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Background:  For life-threatening or uncontrollable bleeding in association with the thrombin inhibitor dabigatran, the monoclonal antibody fragment idarucizumab is available, and for bleeding in association with the direct factor Xa inhibitors rivaroxaban or apixaban, the modified recombinant FXa protein andexanet is available for reversal. These antidotes represent emergency drugs that are typically used only after performing guideline-compliant multimodal measures., Methods:  An interdisciplinary group of experienced experts in the fields of angiology, hematology, internal medicine, clinical pharmacology, laboratory medicine, transfusion medicine, anesthesiology, intensive care, and hemostaseology developed recommendations relevant to daily clinical practice based on the current scientific evidence., Results:  Reversal of oral anticoagulants should be considered for severe bleeding in the following situations: (1) life-threatening bleeding or refractory hemorrhagic shock, (2) intracerebral bleeding, or (3) endoscopically unstoppable gastrointestinal bleeding. After successful hemostasis, anticoagulation (e.g., direct oral anticoagulant, vitamin K antagonist, and heparin) should be resumed promptly, taking into account individual bleeding and thromboembolic risk., Discussion:  This article aims to facilitate the management of patients with andexanet by all medical disciplines involved, thereby ensuring optimal care of patients during bleeding episodes., Competing Interests: Dieses Manuskript fasst die wesentlichen Diskussionspunkte eines interdisziplinären Expertentreffens im August 2022 mit Vertreter*innen aus der Angiologie, Hämatologie, Innerer Medizin, klinischer Pharmakologie, Labormedizin, Transfusionsmedizin Intensivmedizin und Hämostaseologie zusammen, in dem die Bedeutung und die möglichen Einsatzgebiete von spezifischen Antidots zur Antagonisierung der neuen/direkten orale Antikoagulantien (DOAK) bei schweren und lebensbedrohlichen Blutungen diskutiert und herausgearbeitet wurde. Dieses Expertentreffen wurde durch die Fa. AstraZeneca finanziell unterstützt., (Thieme. All rights reserved.)

Venous thromboembolism (VTE) is a major cause of maternal morbidity during pregnancy and the postpartum period. Because there is a lack of adequate study data, management strategies for the prevention of VTE during pregnancy have mainly been deduced from case-control and observational studies and extrapolated from recommendations for non-pregnant patients. The decision for or against pharmacologic thromboprophylaxis must be made on an individual basis weighing the risk of VTE against the risk of adverse side effects such as severe bleeding complications. A comprehensive, multidisciplinary approach is often essential as the clinical scenario is made more complex by the specific obstetric context, especially in the peripartum period. As members of the Working Group in Women's Health of the Society of Thrombosis and Haemostasis (GTH), we summarize the evidence from the available literature and aim to establish a more uniform strategy for VTE risk assessment and thromboprophylaxis in pregnancy and the puerperium. In this document, we focus on women with hereditary thrombophilia, prior VTE and the use of anticoagulants that can safely be applied during pregnancy and the lactation period., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Unlabelled: Dabigatran, an oral, reversible direct factor IIa inhibitor, is approved in Europe for stroke prevention in atrial fibrillation and for the prevention of venous thromboembolism after elective hip and knee replacement. In contrast to vitamin K antagonists, a routine coagulation monitoring during the treatment with dabigatran etexilate is not necessary. However, in specific clinical situations such as invasive emergency procedures or serious haemorrhage, the actual anticoagulant status of dabigatran may be of importance for the treating clinician and can be assessed by clotting tests (aPTT, TT, ECT). The diluted thrombin time test (Hemoclot®), which is specifically calibrated for dabigatran, is useful for quantitative determination of the dabigatran serum concentration. In general, discontinuation of dabigatran etexilate 24 hours before standard elective surgery is sufficient to normalise the bleeding risk in patients with normal renal function. In patients with renal impairment and/or in the case of a high bleeding risk procedure the recommended duration of discontinuation is prolonged. If a bleeding episode occurs in a patient on dabigatran, further treatment should be based on the severity and localisation of the bleeding. A distinct feature of dabigatran is the possibility of effectively removing dabigatran from the circulation by haemodialysis., Recommendation: In the case of clinically minor bleedings, a delay in the administration of the next dabigatran etexilate dose is recommended. The length of the delay is based on the patient's individual thromboembolic risk. In minor bleedings the use of prothrombin complex concentrates is not indicated. In the case of moderate or major bleedings the main focus should be on stabilising the circulation by using fluids and blood products and, if a lesion can be identified, the local treatment thereof. If time and infrastructure is available, dialysis offers an effective and fast option to remove dabigatran out of the circulation. In the incidence of severe and life threatening bleedings, an additional, more complex haemostasis management is required. Besides haemodynamic stabilisation of the circulation, administration of prothrombin complex concentrates should not be delayed. It has to be kept in mind that standard laboratory coagulation parameters may not accurately reflect the effect of prothrombin complex concentrates in patients on dabigatran. Hence the effect of the prothrombin complex concentrate should be monitored clinically and adjusted by means of onset of coagulation in vivo.

Prevention of deep vein thrombosis has become standard of care in surgical and orthopaedic patients and it is gaining in attention in medical patients. However, there are still open questions related to its indication, to type and extent of prophylaxis and how to improve its efficacy and safety. In order to facilitate decision making to provide or to withhold prophylaxis, clinical risk assessment considering exposing and predisposing risk factors has proved to be of value. The exposing risk is characterised by type and extent of surgery or trauma, respectively, whereas the predisposing risk is determined by patient related risk factors. This has also been acknowledged in national and international guidelines. The choice of prophylactic modalities should be based on the combination of exposing and predisposing risk factors. Physical and pharmacological methods are available for primary prevention of VTE. The cornerstones of pharmacological prophylaxis have been subcutaneous injections of low molecular weight heparins or fondaparinux. Recently, also oral direct thrombin- and factor Xa-inhibitors have become available for patients undergoing hip or knee replacement surgery who always are at high risk for VTE complications.

There is sound evidence, that low molecular weight heparin (LMWH) administered subcutaneously is at least as effective and safe as an i.v. infusion of unfractionated heparin. Thus, with LMWH out-patient treatment of deep vein thrombosis (DVT) becomes feasible. According to the current guidelines, an objective diagnosis of DVT is required before the anticoagulation with heparin is initiated. Close monitoring is also required during the subsequent initiation of treatment with vitamin K antagonist. Contraindications and comorbid conditions need to be identified and may necessitate hospital treatment. A checklist may assist in the decision for or against out-patient treatment, but an individual assessment for the individual patient is always a requisite.

The percutaneous transluminal angioplasty of stenosis and short occlusions of the femoral artery is a well established, safe and effective treatment option. The additional placement of stents during angioplasty is associated with frequent and rapid restenosis due to intimal hyperplasia. Therefore, stent placement of the femoral artery is commonly recommended only for special circumstances, including PTA-induced dissection of the vessel wall, elastic recoil, and eccentric stenosis. Placement of stents near joints, e. g. in the common femoral artery or the popliteal artery should be avoided as it may lead to structural damage of the stents. The current angiological statement concerning stent implantation in the femoral artery may be revised if effective measures to inhibit intimal hyperplasia such as brachytherapy or sirolimus coated stents become available.