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Background: Coronavirus 2019 (COVID-19) patients are at risk of thrombosis. Literature that compares the effectiveness of enoxaparin to unfractionated heparin (UFH) in COVID-19 patients is scarce. Objective: We aimed to evaluate the effectiveness and safety of enoxaparin compared with UFH when used at their standard/intermediate dosing in COVID-19 patients. Methods: This was a retrospective study conducted at a large COVID-19 center located in Eastern Province, Saudi Arabia. Confirmed COVID-19 cases (≥18 years old) admitted between January and December 2020 were randomly screened for inclusion. Exclusion criteria were patients receiving therapeutic anticoagulation, on chronic anticoagulation, had active bleeding, a platelet count 9/L, or an incomplete electronic file. The primary endpoint was the occurrence of any thrombotic event (pulmonary embolism, deep venous thrombosis, stroke, or myocardial infarction) or mortality. Secondary endpoints were major or minor bleeding. We applied inverse propensity score weighting (IPTW) with survival analysis to analyze the primary endpoint. Logistic regression was used for the secondary endpoint. Results: A total of 980 patients were included (enoxaparin, n = 470 and UFH, n = 510) with a mean age (±SD) of 47.7 (± 12.3) for the enoxaparin arm and 52 (±13.9) for the UFH arm. There was a statistically significant difference in the primary endpoint with an adjusted hazard ratio (aHR) of 0.46 (95%CI: 0.22 to 0.96, P = 0.039) in favor of the enoxaparin arm. There was no statistically significant difference in major or minor bleeding rates between the two arms. Conclusion and Relevance: When compared with UFH, enoxaparin was associated with a significant reduction in thrombotic events or mortality among COVID-19 patients. The results need confirmation from randomized controlled trials.

This study aimed to evaluate the effectiveness of tocilizumab in mechanically ventilated patients with coronavirus disease 2019 (COVID-19). This retrospective multicenter study included adults (≥18 years) diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by real-time polymerase chain reaction (RT-PCR) from nasopharyngeal swab, and requiring invasive mechanical ventilation during admission. Survival analyses with inverse propensity score treatment weighting (IPTW) and propensity score matching (PSM) were conducted. To account for immortal bias, we used Cox proportional modeling with time-dependent covariance. Competing risk analysis was performed for the extubation endpoint. A total of 556 (tocilizumab = 193, control = 363) patients were included. Males constituted the majority of the participants (69.2% in tocilizumab arm,74.1% in control arm). Tocilizumab was not associated with a reduction in mortality with hazard ratio [(HR) = 0.82,95% confidence interval (95%CI): 0.62–1.10] in the Inverse propensity score weighting (IPTW) analysis and (HR = 0.86,95% CI: 0.64–1.16) in the PSM analysis. However, tocilizumab was associated with an increased rate of extubation (33.6%) compared to the control arm (11.9%); subdistributional hazards (SHR) = 3.1, 95% CI: 1.86–5.16). Although tocilizumab was not found to be effective in reducing mortality, extubation rate while on mechanical ventilation was higher among tocilizumab treated group.

Background Behçet's disease (BD) is a multisystem vasculitis characterized by exacerbations and remissions with unknown etiology. Males are more affected than females with the usual onset in the third decade. Vascular involvement can occur in up to 40% of cases of BD. BD is unique among the vasculitides that it may involve all sizes and types of vessels. Objectives 1. To study the pattern of vascular involvement of Behçet's disease (BD) in the Saudi population; use of anticoagulation and its duration, thromboembolic, and major bleeding complications during anticoagulant therapy. 2. The effect of combined immunosuppression and anticoagulation treatment approach in reducing the risk of venous and arterial thromboembolism. 3. The role of vascular surgery for peripheral arterial and abdominal aortic aneurysms (AAA), and the role of immunosuppression in the treatment of pulmonary artery aneurysm (PAA) without the need for surgical intervention. Methods Twenty-three patients with confirmed vasculo-BD attending the thrombosis clinics at our tertiary care center between 2010 and 2015 were studied retrospectively and analyzed through descriptive statistics SPSS version 22. Results Demographics and pattern of vascular involvement are shown in tables 1 and 2. HLA-typing was performed for 13 patients, and HLA- B51 was positive in 7 (54%) patients tested. The acute phase reactants (ESR and CRP) were high in all 23 (100%). Hereditary and acquired thrombophilia workup was performed for all patients and only 1 (4.3%) was positive for antiphospholipid antibodies. Oral ulcers were present in all the patients, genital ulcers in 12 (52%), ocular involvement in 8 (35%), skin manifestations in 3 (13%), and arthritis in 1 (4.3%). Lower extremity vein thrombosis is the most frequent manifestation of Vasculo-BD in Saudi Arabia, followed by CVT, PAI, SVT/Budd-Chiari syndrome, IVC thrombosis, peripheral artery aneurysms, and AAA. Peripheral arterial and abdominal aortic aneurysms in 3 (13.6%), all of whom had successful vascular surgery for aneurysm repair. Inferior vena cava filter was inserted in 3 (13.6%). One patient was admitted to the intensive care unit with fulminant hepatic failure due to bilateral hepatic vein thrombosis and subsequently died. The vascular thrombosis recurrence was in 11 patients (48%, all venous) despite adherence to the prescribed anticoagulant therapy and lack of any provocation. These patients were initially treated with anticoagulant monotherapy. After combining immunosuppressive therapy to the pre-existing anticoagulant therapy, none had thrombosis recurrence. There was a complete resolution of the two patients with PAA with mono-immunosuppressant therapy and no surgical intervention. The most commonly prescribed initiation anticoagulant therapy was low molecular weight heparin (87%). Conclusion BD with vascular involvement continues to pose a major diagnostic and therapeutic challenge to physicians due to the heterogeneity of the clinical presentation and lack of the diagnostic laboratory test. Therefore, we must have a low threshold for BD in any patient with vascular thrombosis or aneurysm. Combined immunosuppressive therapy is essential in suppressing and preventing the venous and arterial recurrence attacks. Disclosures No relevant conflicts of interest to declare.

Background: Cerebral venous thrombosis (CVT) is an uncommon cause of stroke that mainly affects young adults and children. Initial treatment with heparin followed by wafarin is the mainstay of treatment. Only insufficient experience is available for direct oral anticoagulants (DOACs). Aims: The study aims to demonstrate the efficacy and safety of DOACs such as (Rivaroxaban and Dabigatran) in patients with objectively confirmed CVT. Methods: Data of 46 cases of CVT collected using a standardized case report form. Inclusion criteria were patients diagnosed with CVT, confirmed by CT or MRI imaging. Results: The total number of patients was 46 (9 males and 37 females). The mean age of the patients was 35.2± 5 years. The most common clinical manifestations among our patients were headache followed by seizure. 52% of cases were unprovoked, while 48% were provoked by pregnancy and oral contraceptive pills. Superior sagittal sinus (55%) and transverse sinus (44.9%) were the most common sites. Involvement of more than three venous sinuses was 34.8%. Thrombophilic abnormality was detected in 21.7% of patients. Initiation of anticoagulation (AC) was mostly low molecular weight heparin (LMWH) (80%), followed by unfractionated heparin (UFH) (17.7%) and fondaparinex (2%). Maintenance AC with Rivaroxaban after heparin (LMWH/UFH) was in 63% of our patients, the rest were switched from Warfarin to Rivaroxaban (34.8%), and one was treated by Dabigatran (2%). CVT recurrence was observed in one patient. Major bleeding (according to ISTH criteria) was not reported in our case series. Conclusions: DOACs demonstrated good safety and efficacy profile and can potentially replace warfarin in CVT patients. Disclosures No relevant conflicts of interest to declare.

Background Splanchnic vein thrombosis (SVT) is an uncommon, but potentially life-threatening disease. Aims The aim was to gather more information on most common clinical presentations, risk factors, and treatment outcomes with anticoagulant therapy of SVT patients. Methods A retrospective study for 100 patients diagnosed with SVT confirmed by radiological imaging. Variables about demographics and history, signs and symptoms, risk factors, and treatment were collected from patients medical charts. Results The age group and the age of diagnosis of the patients was mainly 26-40 (40% and 46% respectively). 19% of patients had positive family history. The most affected veins were multiple veins (42%), followed by portal vein (34%), and then the superior mesenteric vein (11%). Recurrence was seen in 12% of patients. SVT was unprovoked in 48% of our patients and provoked in 52% commonly associated with significant trauma (29%), surgery (18%) in which bariatric surgery was the main culprit (11%) followed by colon/small intestine surgery (9%). 56% of the patients presented with abdominal pain, and 21% had abdominal distension, 9% had melena and 9% had splenomegaly. Thrombophilia was seen in 19% of the patients. Maintenance of anticoagulation was mostly by Warfarin (89%) and Rivaroxaban (9%). Duration of anticoagulation was extended (more than one year) in 72% of patients. 12% of patients had mesenteric ischemia and required bowel resection. Conclusions Anticoagulant therapy, in addition to surgery, showed excellent outcome in most patients with SVT. The most common provoking factors were trauma and bariatric surgery. Rivaroxiban demonstrated good safety and efficacy profile and can offer an alternative to traditional therapy in SVT patients. Disclosures No relevant conflicts of interest to declare.

Background Antiphospholipid Syndrome (APS) is defined by thrombosis and/or pregnancy morbidity in patients with antiphospholipid antibodies (aPL). There remains a pressing need for identification of clinical and laboratory parameters that define patients at most considerable risk for APS-related events on Direct oral anticoagulants (DOACs). Aims To demonstrate the efficacy and safety of DOAC (Rivaroxaban) compared with Warfarin (Vitamin K Antagonist) in patients with thrombotic APS. Methods A retrospective cohort study of thrombotic APS patients who were started on anticoagulant therapy, either VKA or DOAC, from 2010 -2016. Results We investigated 73 patients diagnosed with APS. 83.5% of the patients were female. The age range at diagnosis was between 26-40 (52%). 67% of the cases were diagnosed in the form of DVT while the rest had arterial or unusual site venous thrombosis. 43% of the patients had systemic lupus disease. 28% of the cases had a single-positive aPL profile, 23% had double-positive, and 49% had triple-positive aPL. 68.5% of the cases were treated with warfarin, while 31.5% of the cases were switched from warfarin to Rivaroxaban. 15% of patients had major and clinically relevant non-major bleeding (2 patients had major bleeding in the warfarin group, and four patients in the rivaroxaban group). Recurrence of thrombosis (arterial and venous) was 43% with Rivaroxaban and 30% with warfarin. The average duration from starting Rivaroxaban to development of complications such as bleeding and thromboembolic events was mostly after 1-2 years (70%). Conclusions Rivaroxaban should be used with extreme caution in APS patients, especially patients with a full positive aPL profile and arterial thrombosis. Disclosures No relevant conflicts of interest to declare.