Bleeding, Thrombosis and Vascular Biology
Bleeding, Thrombosis and Vascular Biology studies problems related to blood coagulation, fibrinolysis, hemostasis, physiopathology and therapy of hemorrhagic and thrombotic diseases. It encourages and promotes clinical and laboratory research on thrombosis and hemostasis, also through the institution of research awards and "travel grants" for young researchers to participate in Italian or international congresses. It develops and supports the organization of scientific congresses, conferences and educational courses on the themes of hemostasis and thrombosis, promoting the exchange of knowledge. It promotes, protects and disseminates the results of research carried out by its members, and raises awareness of these issues in the scientific world. It transfers and summarizes developments in international research in the field of hemostasis and thrombosis through the preparation of guidelines for the diagnosis and treatment of thrombotic or hemorrhagic diseases, encouraging the application of scientific data to clinical practice. Submitting articles in our journal is free of charge; even the article publication fee is not required, since the costs are covered by private funds (SISET). <!-- Editorial Rome, a summer evening, on a terrace with a few Brazilian friends, nuns, escaped during the Seventies from the military dictatorship in that Country, which did not appreciate their teaching activities. It is a prayer vigil, the eve of Pentecost. Each of us has a torch that enlightens, with its flame, the starry sky. At the end, the nuns invite us not to blow out the flame of the torches, but to put them all together in a central brazier, already rich with burning fire. We are astonished: fire on fire? Weren’t either the torches or the brazier enough? “The Spirit is fire – Paula whispers to me – it is always new and it is never enough!”. This event came back to my mind after President Paolo Gresele informed me – to my surprise – of the SISET decision to found a new journal on haemostasis and thrombosis. Yet another journal, I thought immediately, aren’t there already too many around? But the surprise was even bigger when the President asked me – on behalf of the Executive Council of the Society – if I wanted to be the Editor in Chief of the new journal. I scoff, trying to go around the question, I thank… Bleeding, Thrombosis and Vascular Biology, BTVB, it sounds like a nice acronym. We choose it at the first meeting, on Lake Maggiore, with President Gresele, the six Section Editors and the editorial manager. And here I am, trying to write my first Editorial. But didn’t we say already everything about bleeding, embolism, thrombosis, endothelial cells? Don’t we risk to be late on the market, when all the fresh fish has been already sold out? But no, it's not like that. I recall the poet Hikmet suggesting that I am wrong: The most beautiful of the seas is the one we have not sailed yet, the most beautiful of our children has not been born yet, and the newest thing I would like to say, I have not said it yet. Let’s therefore ask scientists working all around with platelets, fibrinogen, fibrinolysis or micro-circulation to open their horizons towards a larger and multidisciplinary perspective, looking for mechanisms common to apparently different phenotypes. BTVB intends to host papers that build bridges, instead of erecting walls (physiological, methodological or clinical). Haemorrhage and thrombosis are the two traditional plates of the haemostatic scale, but the pin supporting them goes in a transversal way, from genetic to nutrition, from inflammation to environment, from artificial intelligence to big data, going through gender differences, socio-economic disparities, lifestyles. The central pivot of the haemostatic scale is made up of a huge amount of people, little studied, because they are considered normal. BTVB intends to host the care (“I care”) of healthy people, an attentive and systematic exploration of the big part below the iceberg, we usually neglect, in relation to the upper part, which is small but visible. Blood circulates everywhere, it is well known, but it is not the same everywhere, also because it meets different environments. We should ‘geo-localise’ those environments in order to better understand mechanisms and events that still escape to our attention. Paraphrasing Terenzio, the ancient Roman poet, each specialist of an organ or a disease should say nihil haemostaticum a me alienum puto, I do not consider anything of hemostasis far from me. Cardiologists, neurologists, obstetricians, pharmacologists, surgeons, rehabilitators and many others can consider themselves welcome on the pages of BTVB. Let’s start a trip, old and new, with the anxiety, the curiosity and the joyfulness of a long joint experience, with the astonishment and the unpredictability of those young scientists at their first scientific adventure. Good luck to all, on behalf of SISET, Section Editors, the Editorial Board, and myself, for the attention and the cooperation the scientific community will provide us. Giovanni de Gaetano Editor-in-chief -->
PAGEPress Scientific Publications, Pavia, Italy
When a feminist platelet went to the convention of prostaglandins and thromboxanes
A satirical monologue presented in Italian at the XXVIII Meeting of the Italian Society for Haemostasis and Thrombosis, Rome, November 2024.
Copyright (c) 2025 The Author(s) https://creativecommons.org/licenses/by-nc/4.0
The landscape of rare coagulation factor deficiency management in Italy: a national hemophilia center survey
Background: Rare bleeding disorders (RBDs) are a group of inherited conditions caused by deficiencies in specific coagulation factors, excluding hemophilia A/B and von Willebrand disease. Individually rare, they pose a significant challenge for diagnosis and management due to diverse clinical presentations and low awareness. This study aimed to provide an overview of RBDs. Methods: An online survey was sent to Italian hemophilia treatment centers. Results: Nineteen centers responded. The diagnostic approach was tiring, but key definitions showed significant variability. This included defect severity, target hemostatic levels for surgery, eligibility thresholds for rare disease exemptions. The use of prophylaxis varied, although favored in severe FII, FVII, FX, and FXIII defects. Treatment primarily involved factor-specific concentrates and tranexamic acid. While inhibitor development was considered uncommon, it was a recognized risk. Bleeding management during dental procedures, pregnancy, and delivery also showed variability. Additionally, normal factor levels in neonates differed across centers. Conclusions: This study highlights a good consensus for managing certain RBDs (FII, FVII, FX, FXIII) in Italy. However, significant heterogeneity persists, emphasizing the need for greater standardization and further research in several key areas.
The key to fibrinolysis and thrombolysis
This narrative review was written at the occasion of the "Verstraete Centennial Memorial Lecture" organized on September 15, 2025 at NEUROMED (Pozzilli, Italy) by Giovanni de Gaetano and Maria Benedetta Donati. It represents a historical account of contributions by the Center for Molecular and Vascular Biology (CMVB), KU Leuven, Belgium, founded by Marc Verstraete, to our understanding of the regulation of fibrinolysis and the development of thrombolytic therapy. This review covers the long trajectory of events which, over almost half a century, have led from basic biochemical discoveries to the development of recombinant tissue-type plasminogen activator (rt-PA) and other clinically valuable drugs to treat thrombotic diseases.
Still unmet problems with low molecular weight heparin prophylaxis of venous thromboembolism. An Italian survey
Background: a survey was launched to assess the challenges that Italian patients and physicians face with home prophylaxis using low-molecular-weight heparin (LMWH), promoted by the "Arianna Anticoagulazione" Foundation, Bologna, Italy. Methods: conducted between March and October 2024, the survey targeted readers of the "anticoagulazione.it" website, distributed through a newsletter and social media. There were two different surveys, one addressed to patients/caregivers and the other to physicians. Results: the professional survey revealed significant uncertainties about managing chronic patients, with over half of physicians identifying them as a "gray area." A third of clinicians were unsure about the duration and necessity of home prophylaxis for acute patients. Arbitrary suspension of treatment was reported by a significantly lower proportion of patients/caregivers than professionals (4% vs 38%; p<0.0001). Conclusions: home prophylaxis presents challenges, especially for chronic patients, acute patients treated at home, and those with specific conditions (e.g., renal insufficiency or extreme body weight). The lack of clear guidelines and the widespread use of LMWH outside standard recommendations highlights the need for large-scale clinical trials to address these issues. Discrepancy in compliance reported by patients/caregivers and clinicians underline the need for improved professional-patient communication. *Prof. Gualtiero Palareti passed away on August 8, 2025, prior to publication.
Anticoagulation in obese patients: challenges and strategies
Obesity is a chronic complex disease, related to several comorbidities, including cardiovascular diseases, insulin resistance, and venous thromboembolism (VTE). Its rising prevalence, especially among individuals with extreme obesity, poses several management challenges, particularly with regard to anticoagulant therapy. The pharmacokinetics and pharmacodynamics of anticoagulants are altered in obese patients, requiring tailored therapeutic strategies. This review examines the challenges faced when managing anticoagulation in obese individuals, focusing on both parenteral and oral anticoagulants. Obesity influences drug absorption, distribution, metabolism, and elimination, complicating the use of both parenteral agents like low-molecular-weight heparin (LMWH), unfractionated heparin (UFH), and fondaparinux and oral agents, such as vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs). Oral anticoagulant administration represents a great challenge also in patients who undergo bariatric surgery, which further impacts on drug bioavailability by modifying gastrointestinal anatomy. In general, data on the efficacy and safety of DOACs in severely obese individuals, particularly those who have undergone bariatric surgery, remain limited. This review highlights the importance of individualized anticoagulation approaches, especially for high-risk patients, and highlights the need for further research to establish appropriate management strategies for the population of obese patients. Such studies are crucial to improve the safety and efficacy of anticoagulant therapy in this growing population.
29th National Conference of the Italian Society for the Study of Hemostasis and Thrombosis, 2025
The National Conference of the Italian Society for the Study of Hemostasis and Thrombosis was held in Bergamo from October 23 to 25, 2025. This is a training event organized every two years by this Society, with the aim of presenting and discussing the state of the art in the pathophysiology, diagnosis, prevention, and treatment of thromboembolic and hemorrhagic diseases. The course is aimed at all those, members and non-members alike, who share a common interest in these diseases and who wish to update their knowledge, gain a deeper understanding, and exchange ideas with colleagues from different national contexts. The need for continuous updating stems from the epidemiological importance of these diseases and, consequently, from the high number of patients suffering from thromboembolic or hemorrhagic diseases who are admitted to our hospitals on a daily basis or who require long-term outpatient treatment. Secondly, the continuous production of new scientific evidence on diagnostic methodologies, therapeutic strategies, and patient management requires regular updates presented and discussed by the most experienced Italian researchers in the field. The course will open with a session organized by the SISET Youth Group on certain aspects of thrombosis, consolidating the tradition inaugurated in the Society's recent conferences/courses. The course will then be divided into seven sessions: aspects of basic research, venous thromboembolism, arterial thrombosis, congenital bleeding disorders, primary haemostasis disorders and thrombocytopenia, management of medical and surgical emergencies in thrombosis and haemostasis, and haemorrhage and thrombosis in children. In addition to illustrating some updates in basic and translational research and summarizing general knowledge on certain topics (e.g., anticoagulant therapy in venous thromboembolism, cardiovascular risk models, the diagnostic and therapeutic classification of thrombotic microangiopathies), they will focus on innovative aspects in diagnosis and therapy (e.g., VEXAS syndrome or gene therapy for hemophilia) or debated aspects (e.g., measurement of circulating direct oral anticoagulant levels). Some rare clinical situations will be explored in depth (e.g., visceral arterial thrombosis, diagnosis and treatment of rare coagulopathies/thrombocytopathies, use of antithrombotic drugs in patients with congenital coagulopathies or immune thrombocytopenia). Clinical practice aspects will also be prioritized, such as the management of medical and surgical emergencies in patients at high risk of bleeding or the management of hormone therapy in cancer patients. Much attention will also be devoted to gender medicine, with reports on the use of antithrombotic drugs in women, the cardiovascular risk associated with hormone replacement therapy, the management of pregnancy and childbirth in immune thrombocytopenia, and the management of postpartum hemorrhage. Finally, a session will be devoted to hemorrhagic and thrombotic problems in neonates, children, and adolescents. As in the last two editions, the course will last two full working days, i.e., two mornings and one full day. Scientific communications will also be presented, with oral and poster sessions. The best oral communications, selected by a panel of reviewers who worked blind to the authors, will be presented during the plenary sessions.
29th National Congress of the Italian Society for the Study of Hemostasis and Thrombosis
In memoriam of Professor Gualtiero Palareti (1943-2025)
PO96 | Patient management with arteriovenous thrombotic manifestation and hemorrhagic complications
Background: Patient managment with high thrombotic risk on both arterial and venous espury, united with bleeding risk, remains as complex as possible to evaluate in clinical practice. We can think about what the correct therapeutic choise is to safeguard the patient on the arterial and venous side. Methods: Man of 66 years old arrives to optimize his drug therapy. He has a heterozygosis mutation of MTHFR C677T gene and the PAI I 4G/5G gene. Although in genotype not particulary predisposing to thrombotic risk, his medical history reports a subocclusive thrombosis of the splenic vein with intraparenchymal involvement in the 2024, treated with EBPM at the dosage of 6000 UI every 12 hours for about three months, then replaced by Edoxaban at the dosage of 60 mg every 24 hours. During this treatment, the patient has an ischemic accident in the subcortical cortical site in January 2025, following this, the patient interrupts the therapy with edoxaban and starts an anti platelet therapy with Clopidogrel and acetyl salicylic acid ad at the dosage respectively of 75 mg and 100 mg every 24 hours. The patient carries out this more aggressive therapy for a few months, subsequently it is decided to switch to only acetyl salicily acyd at the dosage of 75 mg every 24 hours and to reintroduce edoxaban at the dosage of 60 mg every 24 hours. However, the patient also has a pronunced hemorrhagic phenotype die his metabolic liver disease complicated by portal hypertension and from the presence of gastric varicose veins of degree IGVI, condition in itself with potential bleeding risk. In addition to a recent colonoscopy active bleeding was detected in the intestinal diverticulums. Results: Since there is a marked bleeding risk in the face of the overt thrombotic risk, we procedeed to reconfirm the therapy with acid acetylsalicylic a dose of 75 mg once a day, it is then decided ti replace edoxaban with apixaban at the dose of 2.5 mg twice a day. We proceed with this decision in the face of the numerous studies that prove the lower bleeding risk in the use of Apixaban compared to other DOACs. Conclusions: At follow up carried out after 4 weeks, no bleeding was detected, stable blood chemical values, the patient also performs a virtual colonoscopy resulting in a negative result of acuteness, the thrombotic outcome in the splenic vein remains sographically stable.
PO90 | Acquired hemophilia A with high-titer inhibitor in a patient with cardiovascular and metabolic comorbidities
Background: Acquired hemophilia A (AHA) is a rare autoimmune coagulopathy characterized by the development of neutralizing autoantibodies against factor VIII (FVIII). The clinical presentation can be severe, with spontaneous and recurrent bleeding, often requiring multidisciplinary management, particularly in patients with multiple comorbidities. Case Report: A 74-year-old female patient was referred to our unit for recurrent acute anemia (Hb 3 g/dL) and diffuse mucocutaneous and muscular hematomas, especially in the bilateral subscapular regions with low perfusion. The hemorrhagic picture triggered episodes of sustained ventricular tachyarrhythmia, resulting in activation of a previously implanted single-chamber ICD, placed for dilated hypokinetic cardiomyopathy of hypertensive-valvular origin (moderate mitral regurgitation). Past medical history included insulin-dependent type II diabetes mellitus with stage III chronic kidney disease, non-progressive steatotic hepatomegaly, euthyroid uninodular hyperplasia, and a long-standing calcified uterine fibroid. FVIII inhibitor testing was performed, revealing FVIII activity at 8% and an inhibitor titer of 8 BU/mL, leading to a diagnosis of AHA. The patient received intensive hemostatic treatment with recombinant activated factor VII (rFVIIa), totaling 35 vials (5 mg), which resulted in bleeding control and progressive reduction of transfusion needs (15 units of packed red blood cells). Concurrently, corticosteroid immunosuppressive therapy was initiated at 1 mg/kg, with a complete response achieved: inhibitor eradication and normalization of FVIII levels. At discharge, the patient showed hemodynamic stability, no further arrhythmic episodes, resolution of hematomas, and partial functional recovery. Conclusions: AHA may present acutely and severely, even in patients without overt autoimmune disease. Management requires a multidisciplinary approach, individualized therapy, and close monitoring of comorbidities. This case highlights the complexity of managing AHA in elderly patients with advanced cardiac disease and chronic metabolic disorders. The use of bypassing agents such as rFVIIa proved effective and safe even in a fragile cardiological context, with careful monitoring. Prompt initiation of immunosuppressive therapy was crucial, allowing for hematologic recovery without significant infectious or metabolic complications.
PO63 | Atypical venous thrombosis in young patient with systemic lupus erythematosus and high-risk APL profile: provoked or not?
Background: Antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by venous and arterial thrombosis, recurrent abortion, and thrombocytopenia and the presence of antiphospholipid (aPL) antibodies. APS may exist in its primary form when it occurs in isolation or may be associated with other autoimmune diseases, particularly systemic lupus erythematosus (SLE). We describe a case of secondary APS in young patients with SLE. Case Report: In august 2019, a 14-year-old female patient presented with a 1-week history of bruising bruising on her lower extremities. Her laboratory test showed severe thrombocytopenia (platelet count was 2000/ml), anemia, negative Coombs’s test, normal LDH and normal peripheral smear. The results of hepatitis B surface antigen, anti–hepatitis C virus, cytomegalovirus, and human immunodeficiency virus serology were negative. Anti-nuclear antibodies (ANA), anti- extractable nuclear antigen (ENA) and anti-double stranded deoxyribonuclease (dsDNA) were positive (ANA 1: 320, ENA ++, anti dsDNA+++). C3 and C4 complement factors were low. Activated partial thromboplastin time (aPTT) Ratio was prolonged (1.93 n.v 0.7-1.3) with a positive test for lupus anticoagulant antibodies and negative anticardiolipin antibodies. Total body CT scan with contrast media was negative for thrombosis and for active malignancy. According to the EULAR/ACR-2019 she was diagnosed with SLE without APS but with high- risk aPL profile. She started hydroxychloroquine with a low dose of corticosteroids and belimumab, as biological agent. In March 2025, the patient was admitted to our hospital due to edema and pain in the left arm. Venous Doppler ultrasound revealed thrombosis of the left axillary vein, left subclavian vein and left jugular vein. Total body CT scan with contrast media also showed pulmonary embolism of the left pulmonary artery. It was negative for active malignancy. She had never smoked, and did not take oral contraceptive (COC). She was not pregnant but was overweight and hypertensive. She reported having suffered accidental trauma to her left arm. Fondaparinux at a dosage of 7.5 mg/day started. Anticoagulant protein S, protein C, and Antithrombin were normal. Factor V Leiden and prothrombin G20210A mutation were negative. Her laboratory test confirmed a prolonged of the activated partial thromboplastin time (aPTT) Ratio of 1.95 (0.7-1.3) with a positive test for lupus anticoagulant antibodies and negative anticardiolipin antibodies suggested for secondary post traumatic APS in patient with SLE and high-risk aPL profile. She was discharged with prolonged oral anticoagulant therapy, maintaining an international normalized ratio (INR) between 2 and 3. Conclusions: aPL antibodies occur in 20 % to 30 % of patients with SLE, but their presence does not confirm the diagnosis of APS. They are associated with an increased risk of thrombosis or pregnancy morbidity, depending on aPL characteristics and coexistence of other risk factors. Therefore, it is important to report on the clinical features of patients with SLE associated with risk aPL profile to improve management and therapeutic strategies.
PO17 | Implementation and initial validation of a new teaching and assessment platform for experts in haemostasis and thrombosis
We have developed and tested a new teaching and assessment platform for future experts in haemostasis and thrombosis. Particular attention has been paid to the inter-company guidelines describing the minimum essential skills and knowledge required. Both the clinical and laboratory aspects can be taught, refined and assessed, so as to standardise the training of haemostasis and thrombosis experts, who are increasingly in demand throughout the country.
CS08 | A combination of two rapid immunoassays improves HIT diagnosis
Background and Aim: Heparin induced thrombocytopenia (HIT) is an immune adverse reaction induced by the exposure to heparin which leads to the production of IgG antibodies against heparin-platelet factor 4 (H-PF4) complexes. The diagnosis is suspected based on a clinical evaluation with the 4T pre-test probability score (4Tscore) and required the detection of circulating antibodies bound to H/PF4 complexes by immunological and functional assay. Immunological assays are easy to perform, widely available and show high sensitivity. Functional assays are the gold standard for HIT diagnosis after a positive immunological test. However functional tests are technically demanding, time-consuming and limited to few, expert laboratories. This study aims to evaluate the performance of a combination of two automated rapid immunoassays -LIA and CLIA -with respect to the gold standard: an immunoassay -CLIA- followed by functional test -HIPA- for HIT diagnosis. Methods: This observational retrospective study investigated 100 patients from Azienda Ospedaliera Careggi and other hospitals across or outside Tuscany, for whom clinicians requested H-PF4 antibody detection for HIT suspicion. Citrate whole blood and serum were collected and all samples analysed by CLIA assay at the time of sample submission. Then, we performed HIPA test, LIA and CLIA test on ACL TOP 970 on all 100 samples. Results: CLIA test: 68 patients out of 100 (68%) were negative (<1U/mL) and 32 (32%) were positive (≥1U/mL). As CLIA test was performed by both Acustar™ system and ACL TOP 970 CL, we found concordant results. The functional test confirmed HIT diagnosis in 26/32 patients and excluded HIT in 6/32 patients. Based on these results, CLIA method showed a sensitivity of 93.30% and a specificity of 91.78%, a Positive Predictive Value (PPV) of 81.25% and a Negative Predictive Value (NPV) of 98.53%. LIA test: 64 out of 100 patients (64%) were negative (<1U/mL) and the remaining 36 (36%) were positive (≥1U/mL). The HIPA tested 24/36 positive patients and 12/36 negative patients; only 3/64 LIA negative patients were diagnosed as HIPA positive while 61 patients were confirmed as negative. LIA test displayed a sensitivity of 88.89% and specificity of 83.56%, a PPV of 66.67% and NPV of 95.31%. HIPA functional test was performed on all 100 patients and confirmed HIT diagnosis on a total of 27 patients (27%), 23 patients were positive on both CLIA and LIA test, 1 patient was negative on CLIA and positive on LIA test while 3 patients resulted positive on CLIA and negative on LIA. By combining CLIA and LIA methods, a sensitivity of 100% and a specificity of 82.2% have been achieved. The PPV was 67.5% and NPV 87%. Among the 100 patients, the combination of CLIA and LIA tests allowed us to categorize 27 true positive, 13 false positive, 0 false negative and 60 true negative patients. Conclusions: Based on our results, the combination of CLIA and LIA test improves the diagnosis of HIT by identifying all HIT positive patients and achieving a 100% sensitivity compared to single CLIA and LIA tests.Our study demonstrates how combined LIA/CLIA testing optimizes diagnostic sensitivity, with progressively greater probability of detecting platelet-activating antibodies with higher assay reactivity that reaches 100% when both automated assays yield moderate or strong results.
Primary hemostasis disorders and thrombocytopenia.
CS04 | Association between elevated plasma levels of tissue plasminogen activator and occult cancer risk: a nested case-cohort analysis in 10,294 healthy subjects
Background and Aims: Tissue plasminogen activator (tPA), an enzyme involved in the fibrinolytic system, has been associated with cancer progression, but limited prospective data are available. Therefore, its role in predicting cancer risk is yet undefined. This study aimed to investigate whether circulating tPA levels predict cancer occurrence in a large cohort of healthy subjects, i.e. blood donors enrolled in the prospective HYPERCAN study (ClinicalTrials.gov ID#NCT02622815). Methods: A total of 10,294 blood donors (72% males; mean age 48 years) were enrolled between 2012 and 2022 and followed up every 6 months for cancer incidence, with a follow-up of at least 5 years. Malignancies were identified through clinical records, and tPA levels were measured from baseline blood samples using a commercial ELISA kit. A nested case-cohort design was applied, comparing cancer cases to controls from the same cohort. Statistical analysis was performed with SPSS 21.0. All participants provided written informed consent. Results: Over a median follow-up of 9 years (range 5–11), 300 cancer cases were identified, with 35 early diagnoses (within 6 months) excluded. The final analysis included 980 participants (59% male, mean age 51): 265 cancer cases and 715 controls. Most cases (91%) occurred within 5 years from enrollment. Prostate and breast cancers were the most common in men and women, respectively, followed by gastrointestinal (GI) cancers. Compared to controls, cancer cases were significantly older and more likely to be active smokers and have hypertriglyceridemia (p<0.05). Median tPA levels in the cohort were 4.4 ng/mL (IQR 1.4–7.9), significantly higher in men (6.7 ng/mL) than in women (3.4 ng/mL, p<0.05). Multivariable Cox regression analysis adjusted for age, glucose levels, smoking habits, and alcohol intake showed that elevated tPA (HR 1.04 [1.01–1.07], p=0.003) and cholesterol (HR 1.01 [1.00–1.10], p=0.010) levels independently predicted cancer risk. In particular, tPA levels above 7.85 ng/mL were linked to a higher overall cancer risk (HR 1.78 [1.39–2.29], p<0.001) and GI cancer risk (HR 3.29 [1.70–6.38], p<0.001). Gender-specific analyses using recalculated tPA cut-offs (>8.8 ng/mL in men, >5.66 ng/mL in women) showed that tPA levels also predicted breast cancer risk (HR 2.21 [1.09–4.47], p=0.017) in women, while no association was found with prostate cancer in men. Conclusions: This prospective study demonstrates that elevated tPA levels are associated with increased cancer risk, particularly gastrointestinal tumors, and breast cancer in women. These findings support the potential role of tPA as a predictive biomarker and its integration into future cancer screening strategies in the general population.
CO37 | Assessment of clotting factor activity and sterility in thawed fresh frozen plasma supplied to helicopter emergency medical services for prehospital transfusion
Background: Administration of thawed fresh-frozen plasma (FFP) in the pre-hospital setting during helicopter transport for critically injured patients significantly improves survival rates, especially for those at risk of hemorrhagic shock. It also lowers 30-day mortality rates and reduces the need for subsequent blood transfusions. The Immunohematology and Transfusion Medicine Department at Hospital Papa Giovanni XXIII in Bergamo is distinguished as the first institution in Italy to provide thawed FFP, along with packed red blood cells (RBC), to the Helicopter Emergency Medical Service (HEMS) of Bergamo, ensuring that blood products meet the highest quality standards. Aim: This study aims to evaluate the preservation of thawed FFP quality and safety characteristics during air transport in routine conditions practice. Methods: For HEMS use, a blood bank-validated protocol outlines the packing and storage of blood products. This includes two units of 0 Rh-negative packed RBC and two units of AB thawed FFP with a 5-day shelf life. The units are maintained at 4±2∘C in a golden hour cold box (Crēdo ProMed, Pelican BioThermal). To ensure product viability, the RBC and thawed plasma units are exchanged for fresh stock every 72 hours, and the box itself is replaced daily by a new preconditioned one. Continuous monitoring of the internal bag temperature is performed. As part of the quality assessment, coagulation factor VIII (FVIII), FV, and FVII activity, as well as fibrinogen levels, were measured after four days of storage using a STAR Compact Max 3 analyzer (Stago, Italy). Data on total protein levels and sterility, as detected by the BacT/ALERT microbial detection system, were also collected to identify both aerobic and anaerobic bacteria. To compare FVIII levels, 1,855 plasma units designated for quality control (QC) were tested before freezing and following one month of storage at −30°C. Results: The median FVIII levels in the 1,855 FFP used for QC, measured on fresh samples before storage, were 116% (IQR, 100-145) for plasma obtained from apheresis and 111% (IQR, 93-138) for whole blood-derived plasma. After one month of storage at -30°, the median FVIII levels were 103% (IQR 87-124) for plasma from apheresis, and 99% (IQR 81-122) for whole blood-derived plasma. A total of 101 units of thawed FFP stored in the golden hour box was analyzed. In these units, the median levels of FVIII after 96 hours of storage were 73% (IQR, 61-87), with 59 units retaining median FVIII levels above 70%, 38 units above 50%, and only four units exhibiting levels below 50% (34-48). Median levels for FV, FVII, and fibrinogen were 87% (IQR, 71-95), 74% (IQR, 65-88), and 261 mg/dL (IQR, 234-296), respectively. In these plasma units, we observed reductions in FVIII levels of 34.24% and 26.27% compared to the QC plasmas before storage, and after one month of storage at -30°C, respectively. Importantly, sterility was consistently maintained across all units, and serum levels of albumin and immunoglobulins showed no significant change during the storage. Conclusions: Our data show that thawed FFP retains levels of both stable (FVII and fibrinogen) and labile (FVIII and FV) that meet established reference standards during 96 hours of storage at 2-6°C in the golden hour box, along with other essential proteins.
Congenital and acquired hemorrhagic diseases.
CO03 | Early discharge and home treatment of low-risk pulmonary embolism: a cohort study
Background and Aims: Pulmonary embolism (PE) is a common condition with a wide variety of clinical presentations and severities, making early mortality risk assessment essential to defining the most appropriate management strategy. Guidelines agree on the possibility of early discharge for patients who, based on clinical presentation, imaging, and laboratory data, present a low risk of complications. Despite evidence of efficacy and safety, home management is generally applied in only 7% of patients. The aim of this study is to analyse the characteristics and the management of patients with low-risk PE who received this diagnosis at the Emergency Department (ED) of Ospedale di Circolo (Varese). Methods: This retrospective study evaluates data from patients diagnosed with low-risk pulmonary embolism according to the European Society of Cardiology (ESC) 2014 guidelines between January 1, 2019, and June 30, 2024 at the Emergency Department of Ospedale di Circolo in Varese. We analysed hospitalization and discharge rates, along with safety outcomes such as 7-day and 30-day mortality, recurrent venous thromboembolism (VTE), and major bleeding (MB) within 30 days. Results: We analysed data from 102 patients (21.1% of the total of 483 patients) with a low-risk classification based on Pulmonary Embolism Severity Index (PESI) or simplified PESI when data regarding the PESI score were missing. 65 (63.7%) of these patients were male and the mean age was 57.6 years (±14.9). 26 patients (25.5% of patients classified as low risk according to ESC 2014) were discharged after a maximum 96-hour observation period in the Emergency Department, receiving anticoagulant therapy with Direct Oral Anti-coagulants (DOACs) in 71.1% of cases. Discharged patients had higher values of SpO2 (96,9±1,7%) and lower rates of other acute medical illnesses requiring admission. Applying the ESC 2019 guidelines criteria resulted in a sample of 61 patients (59.8%), which showed no significant differences compared to the original population; 23 (37.7%) of these patients was discharged from the ED. After applying Hestia Criteria to the population of 102 patients, 32 patients (31.4%) had 0 criteria and were therefore suitable for early discharge (Table 1). No deaths, recurrent VTE or MB complications were recorded within 30 days. Among 381 patients not classified at low risk of adverse outcomes according to ESC 2014, 39 (10.2%) were discharged within 96 hours. Of those, 2 patients who were already known as terminally ill experienced death, none had recurrent VTE and 1 patient with colon cancer experienced MB at 30 days. Overall, 65 patients (13.4% of the total number of PE patients) were discharged home within 96 hours. Conclusions: This study demonstrates that early discharge is feasible in low-risk patients without significant adverse events. The adoption of predefined protocols and the development of an extra-hospital care network could further support this management strategy.
CS06 | Patient specific iPSCs-derived sinusoidal endothelial cells for phenotypic correction of haemophilia A
Background and Aims: Hemophilia A (HA) is a rare X-linked recessive bleeding disorder caused by variants in the F8 gene, which encodes coagulation factor VIII (FVIII). It affects approximately one in 6,000 males. The severity of HA is determined by the level of plasma FVIII activity and is classified as severe (<1%), moderate (1%–5%), or mild (5%–40%). In patients with HA, increasing FVIII activity to above 2–5% can significantly improve quality of life. The aim of this study was to restore FVIII levels to prevent spontaneous bleeding by correcting FVIII variants using CRISPR-Cas9 base editing in liver sinusoidal endothelial cells (LSECs), which are recognized as a key FVIII producers’ cells. Methods: Peripheral blood mononuclear cells (PBMC) from 3 HA patient and 2 healthy subjects were isolated and reprogrammed into induced pluripotent stem cells (iPSC) after transduction in a feeder-free culture with a non-integrative system with Sendai virus. The clones obtained were stabilized using an enzymatic method with EDTA and characterised for their pluripotency markers expression. Gene correction of the HA-iPSCs will be carried out using CRISPR-Cas9 DNA base editing technologies with specially target of FVIII variations. The following gene variants NM_000132.4:c.6593G>T, NM_000132.4:c.4285C>T and NM_000132.4:c.5373+ 1G>A were considered. Subsequently, HA-iPSCs will be differentiated into liver sinusoidal endothelial cells (LSECs) and hepatocyte-like cells (HLCs) using an optimized differentiation protocol involving BMP4 and VEGF and others growth factors. Specific cells markers were analysed and the expression of FVIII, LSEC and HLCS markers, were evaluated using immunofluorescence (IF) and real-time PCR (RT-qPCR). Results: Obtained iPSCs was positive for alkaline phosphatase staining and immunofluorescence showed the expression of stem cells markers (Oct4, SeV, Sox2, Klf4, KOS and cMyc). The LSECs and HLCs differentiated obtained cells were stained positive for the expression of CD31, STAB2 and LYVE1 and cytokeratin 18 respectively. Following RT-qPCR and flow cytometry analysis expression of the above markers confirmed the obtained cells phenotype. Furthermore, the expression of FVIII were assessed by IF and flow cytometry in the HA-patients obtained cells before and after gene editing and the correction was confirmed. Conclusions: In this study, we generated specific iPSCs from HA-patients carrying different F8 gene variants, derived from PBMCs. These iPSCs were then differentiated in vitro into LSECs and HLCs using optimized protocols. CRISPR-Cas9 mediated gene correction enabled us to demonstrate that specific disease-causing variants can be effectively repaired, resulting in the restoration of FVIII expression. The LSECs and HLCs obtained through these protocols represent a useful in vitro model for evaluating FVIII restoration in HA-patients with different F8 gene variants. Given the limitations of current treatments, new strategies for a definitive cure are urgently needed. Gene and cell therapies offer promising avenues and could provide a powerful, personalized therapeutic approach to optimize treatment for each individual HA-patient.
CO02 | Hepatic fibrosis as predictor of cancer-associated thrombosis in patients with intrahepatic cholangiocarcinoma
Background and Aims: Cholangiocarcinoma (CCA) is an aggressive malignancy with a steadily increasing incidence worldwide, particularly of the intrahepatic variant (iCCA). Consequently, identifying factors that may modify the natural history of this disease has become the focus of interest in multiple studies. While the relationship between hepatic fibrosis and the development of CCA has been previously explored, the contribution of fibrosis-induced coagulation imbalance to disease progression remains unclear. This study aimed at investigating the relationship between advanced liver fibrosis, hemostasis activation, and occurrence of cancer-associated thrombosis (CAT) in patients with iCCA. Methods: Fifty iCCA patients who underwent curative liver surgery were studied. Graft wedge biopsies served as controls (n=10). Histological evaluation was performed on archival formalin-fixed, paraffin-embedded samples using the Ishak Fibrosis Score (IFS, 0-6). Immunohistochemical staining was performed to assess tissue factor (TF), FX, fibrinogen and von Willebrand factor (vWF). Portal vein microthrombosis highlighted by fibrin deposition within the vessel lumen was quantified using Martius Scarlet Blue (MSB) staining. Immunofluorescence (IF) analysis for TF and FX was performed on patient-derived organoids (PDOs, n=10). Extracellular vesicles (EVs) isolated from iCCA-PDO media were analyzed by flow cytometry (FACS) using Calcein-AM, EpCAM-PE, and Annexin V markers. EV-induced platelet activation was evaluated by FACS using CD41, CD62P, and Annexin V markers. Results: iCCA patients showed a procoagulant profile with increased coagulation activation and impaired fibrinolysis compared to controls. In iCCA, patients with advanced fibrosis (IFS 4–5, n=16) showed a more prominent expression of TF, FX, vWF, and fibrinogen than patients with fibrosis stages ≤3 (n=34). Furthermore, the degree of fibrosis correlated with either TF expression by malignant bile ducts or the number of portal vein microthrombosis (p<0.05). IF analysis in iCCA-PDOs confirmed a marked TF and FX upregulation, whereas EVs from iCCA-PDO media promoted platelet activation. Conclusions: Hepatic fibrosis is closely linked to CAT occurrence in iCCA patients, and associated with increased expression of TF and platelet activation by malignant cholangiocytes. This fibrosis-coagulation interplay underscores the need to unravel the mechanisms promoting CAT development in CCA progression.
CS05 | Joint ultrasound follow-up in pediatric patients with haemophilia: a 12-year prospective single-center experience
Introduction: Periodic monitoring of joints status in patients with haemophilia (PwH) is recommended to identify and prevent the arthropathies. Ultrasound (US) is able to detect and quantify markers of disease activity and degenerative damage. The “Haemophilia Early Arthropathy Detection with Ultrasound” (HEAD-US) scoring scale is an accurate imaging method for identifying joint damage. Nevertheless, data on large cohorts of pediatric PwH, are still lacking. Aim: To describe the joint status of 61 pediatric PwH assessed by US, using the HEAD-US protocol and analyse the efficacy of primary prophylaxis on the severe subset. Materials and Methods: We prospectively analyzed 61 pediatric PwH (severe hemophilia A=29, B=7; moderate A=8, B=2; mild A=7, B=8), referred to the “Haemophilia Centre, Regina Margherita Hospital, Turin, Italy” and collected data on joints status using the HEAD-US protocol, from November 2012 to November 2024. The Haemophilia Joint Health Score (HJHS) was performed in 44 patients and compared with the HEAD-US score. Results: In total we performed 276 US exams, with a median of 4 exams per patient. Sorting our cohort into 3 age groups (early childhood: 1-5 years; school age: 6-14 years; adolescence and young adult age: 15-18 years) we found that in early childhood patients, the mean HEAD-US score was 0, in scholar age 0.56 (SD±1.17) and in adolescent and young adult patients was 1.76 (SD±2.22). Focusing the analysis on 31 patients with severe haemophilia treated with primary prophylaxis, we found that in early childhood patients mean HEAD-US score was 0, in scholar age 0.24 (SD±0.73) and in adolescent and young adult patients was 0.91 (SD ±1.38). In case of discordance between the HEAD-US and the HJHS scores (27%, HJHS=0 and HEAD-US>0), the HEAD-US score detected subclinical synovitis in 83% of cases. Conclusions: Our data show that pediatric PwH treated with primary prophylaxis, show less joint damages compared to the same age patients, comprehending those not treated with primary prophylaxis. The HEAD-US score is a feasible and efficient clinical tool in pediatric PwH and, in our setting, it resulted even more sensitive in detecting subclinical joint damage, compared to the HJHS score.
CS03 | Khorana risk score and genomic profiling for prediction of venous thromboembolism in ovarian cancer
Introduction: Ovarian cancer (OC) carries a high thromboembolic risk, with VTE incidence up to 13.3%. We conducted a retrospective cohort study to assess Khorana Risk Score (KRS) performance and explore mutational differences between patients with OC with and without VTE. Methods: We included patients with OC consecutively enrolled in the Comprehensive Genomic Profiling (CGP) program (NCT 06020625) at Gemelli University Polyclinic Foundation IRCCS between March 2022 and December 2023. Informed consent was obtained prior to CGP. VTE events within 12 months from chemotherapy start were recorded. KRS was calculated at the time of genomic profiling, before chemotherapy initiation. KRS was dichotomized as low (1) or intermediate-high (≥2) risk. Somatic mutations with a variant allele frequency ≥0.05, classified as oncogenic or likely oncogenic according to OncoKB, were included in the analysis. Results: Of 667 profiled patients, 413 with at least 12 months follow-up were analyzed. Most had high-grade serous OC (84%) and advanced-stage disease (86%). VTE occurred in 20% (n=84) of patients. Age, histology, and stage showed no significant differences between those with and without VTE. KRS showed a sensitivity of 87% and a specificity of 17% (72% accuracy), with no significant association with VTE (p=0.54). In patients with VTE, we observed a significantly higher proportion of mutations in FGFR2 (OR 11.7, p=0.03), NFE2L2 (OR 11.7, p=0.03), and KEAP1 (OR 5.3, p=0.03) (Figure 1a). Among patients with at least one of these mutations, VTE event rate was 67% (Figure 1b). In these patients, significant enrichment was observed in pathways related to cellular response to oxidative stress and chemical stress, as well as fluid shear and atherosclerosis, driven by NFE2L2 and KEAP1 (Figure 1c). Conclusions: Our study showed a limited predictive role of KRS in OC. Our mutational findings suggest a potential role for KEAP1 and NFE2L2 in VTE development, warranting further investigation through multiomic approach. Figure 1. Evaluation of the predictive role of genomic mutations in patients with ovarian cancer. a. Volcano plot of gene mutations odds ratio. b. VTE distribution among patients with at least one of mutations in FGFR2, NFE2L2 or KEAP1. c. Enrich pathway analysis. VTE: Venous Thromboembolism.
CO01 | Statin therapy for the prevention of venous thromboembolism in cancer patients: a systematic review and meta-analysis
Background and Aims: Venous thromboembolism (VTE) in cancer patients might produce severe clinical consequences such as anticancer therapies delay, hospitalization, and increased risk of both thrombotic recurrence and bleeding during anticoagulant therapy; moreover, in these patients, VTE is the second leading cause of death after cancer itself, reducing overall survival rates. If previous studies already suggested a potential role of statins in preventing VTE in the general population, there is still paucity of evidence concerning statins’ effect in the prevention of cancer-associated thrombosis. This systematic review and meta-analysis aims at filling this gap, by evaluating statins’ role in VTE prevention in cancer patients. Methods: We systematically searched PubMed, Embase and Cochrane Library from inception to May 2024, for randomized controlled trials (RCTs) and observational studies including patients treated with statins (compared to either placebo or non-statin treatment), reporting on the incidence of VTE during follow-up. Information on study characteristics and incidence of VTE were extracted. Estimates were pooled using random-effects meta-analysis. Results: We identified 111 potential studies, 12 were included in the analysis, 2 RCTs and 10 observational studies, for a total of 186.726 patients. Statins were associated with a 30% reduction of the risk of VTE (RR: 0.70; 95%CI: 0.50–0.87), compared to no statin treatment (Fig. 1). A significant heterogeneity was found among the included studies (I2 = 70). Conclusions: According to our preliminary results, treatment with statins in cancer patients seems to reduce the incidence of VTE events. High quality prospective studies are strongly needed in order to better establish statins’ role in this subset of patients.
CS02 | Functional and structural impairments of the cerebral microcirculation in a mouse model of hemophilia A
Background and Aims: Hemophilia A (HA) is an X-linked bleeding disease resulting from mutations in the coagulation factor VIII (FVIII). The main clinical manifestations are prolonged bleeding episodes, including hemarthroses and intracranial hemorrhages (ICH), which are among the most severe and life-threatening complications, especially in pediatric patients. The triggers of hemorrhagic events remain unclear, occurring spontaneously or following minimal trauma. Standard replacement therapies fail to prevent ICH, suggesting that mechanisms beyond FVIII deficiency may contribute to cerebrovascular fragility. Moreover, based on the recent findings on the role of FVIII in the maintenance of endothelial cells (ECs) functionality, within this study we aimed to evaluate both quantitative and functional differences in the cerebral microcirculation in a murine model of HA (C57BL/6-HA) compared to wild-type mice (C57BL/6-WT). Methods: Brains were collected from HA and WT mice at 3, 8, 24, and 52 weeks of age. Quantitative analysis of the cerebral microvasculature was performed by immunofluorescence staining for mCD31, followed by image acquisition and vessel density quantification using ImageJ software. WT and HA mice at 8 weeks of age were retro-orbitally injected, with two fluorescent dextran molecules with different molecular weight (4 e 150 kDa) and different wavelength to assess vascular permeability and evaluate baseline extravasation under physiological conditions. Finally, 8 weeks WT and HA mice were retro-orbitally injected with 1% DMSO to induce vascular stress, and to evaluate the vascular leakage 5-, 10-, and 15-minutes post-injection. Results: Quantitative analysis revealed that HA mice exhibited consistently lower microvascular density compared to age-matched WT mice across all time points, suggesting a lifelong impairment in vascular development or maintenance. In addition to a lower number of vessels, HA mice also displayed significantly shorter average vessel length relative to WT mice, indicating not only a numerical deficit but also a less complex microvascular network. Longitudinal analysis showed that WT mice exhibited significant dynamic variation in vessel number across developmental stages, by contrast HA mice showed no significant changes in microvascular parameters over time. Under physiological conditions, both HA and WT mice showed comparable levels of dextran extravasation, indicating preserved baseline vascular integrity. However, following DMSO-induced stress, HA mice displayed a significant increase in dextran leakage from cerebral vessels at all timepoints analyzed, on the contrary WT mice maintained a preserved vascular integrity comparable to baseline. Conclusions: These findings highlight the presence of endothelial fragility of the HA cerebral microvasculature led to permeability alterations in response to injury. Our study suggests that HA mice are associated with both a reduced cerebral microvascular density and an increased susceptibility to vascular leakage under stress conditions, despite the preservation of baseline vascular integrity. This dual vulnerability—quantitative insufficiency and qualitative fragility—suggests that cerebral microcirculation in HA is profoundly impaired, potentially driving the heightened risk of intracranial hemorrhage observed in HA patients reinforcing the critical need for further investigation into therapeutic strategies aimed at strengthening vascular resilience in HA.
Haemostasis and Thrombosis: Basic Aspects
CO27 | Intracerebral hemorrhage in hemophilia A and B: a 10-year prospective multicenter study in Italy (2012–2022)
Background and Aims: Intracerebral hemorrhage (ICH) is a severe and life-threatening complication in patients with hemophilia, often resulting in high mortality and long-term neurological impairment. Despite its clinical importance, prospective data on ICH incidence, associated risk factors, and outcomes in hemophilia A and B remain scarce. This study aimed to evaluate the prevalence, clinical features, risk factors, and long-term outcomes of ICH in a cohort of patients with hemophilia A and B over a 10-year period. Methods: This was a prospective, multicenter study conducted in Italian hemophilia centers between 2012 and 2022. All patients with hemophilia A or B (any severity) who experienced at least one ICH during this period were included. Data collected included demographic and clinical characteristics, type and severity of hemophilia, prophylaxis vs. on-demand treatment, cardiovascular risk factors (e.g., hypertension), comorbid infections (e.g., HCV), neuroimaging findings (CT/MRI), and neurological sequelae. Survival was evaluated using Kaplan-Meier analysis, and group comparisons were conducted with appropriate statistical tests. Results: Thirty-two patients were enrolled: 26 with hemophilia A and 6 with hemophilia B; 21 had severe and 11 mild hemophilia. Adults represented 75% of the cohort, with a mean age of 45.46±7.58 years. Patients on regular prophylaxis had significantly fewer ICH events compared to those on on-demand therapy (81.2% vs. 18.8%, p <0.05). Hypertension was present in 14 of 24 adults (58.3%) and was more common in mild hemophilia (9/10). Patients with mild hemophilia were significantly older (median 61.3 vs. 42.4 years, p=0.018) and heavier (median 76 vs. 58 kg, p=0.010) than those with severe forms. No significant differences were found in platelet counts (median 214 vs. 219, p=0.938), hemophilia type (A vs. B), or presence of inhibitors. Traumatic ICH was more frequent in severe hemophilia (40% vs. 9.1%, p=0.106). Kaplan-Meier survival analysis showed survival >75% in both groups up to 60 months, with a steeper decline in severe cases thereafter, though this was not statistically significant (p=0.57, log-rank test) (Figure 1). Conclusions: Regular prophylaxis significantly reduces the risk of ICH in patients with hemophilia. Mild hemophilia patients were older and more often hypertensive, suggesting that comorbidities related to aging contribute to ICH risk. Although trauma-related ICH was more frequent in severe hemophilia, survival did not differ significantly by disease severity. Continuous monitoring and individualized prevention strategies are essential to reduce ICH-related morbidity and mortality in this population.
CO26 | Relationship between SMAD3 variants and non-aortic cardiovascular features
Background and Aims: SMAD3 gene encodes a component of the TGFβ-signaling system and is associated with Loeys-Dietz syndrome (LDS) and natural history for aortic dissection at smaller aortic diameter and arterial aneurysms. In this study we have explored the relationship between rare genetic variants identified in SMAD3 gene and non-aortic cardiovascular features in subjects attending the Regional Referral Centre for Marfan Syndrome and Related Disorders (Careggi Hospital, Florence) for differential diagnosis. Methods: A targeted Next Generation Sequencing (NGS) approach using at least 17 genes associated with aortopathy was performed using the SureSelectQXT library preparation kit (Agilent Technologies) on the MiSeq Illumina platform. Segregation analyses of variants identified in available family members have been carried out through Sanger technology. Results: Among 172 patients [mean age (standard deviation) 46.42 (±17.84) years, 129 males and 43 females] attending the Regional Referral Centre for Marfan Syndrome and Related Disorders (Careggi Hospital, Florence) for differential diagnosis of aortopathy-related conditions and undergoing targeted high-throughput sequencing, six rare variants in SMAD3 gene have been identified in 6 index cases (4 males and 2 females, mean age 57.5 years). Three variants were found in exons 6 and 8, both encoding the MH2 domain, in three subjects; among these, subject P014 had a short-term cardiac arrest and subject P010 a haemorrhagic stroke. Patient P016, which had a truncated variant, displayed heart failure with reduced ejection fraction. Among other subjects, P020 had a splicing variant in intron 7 (c. 1009+2T>C) and underwent mitral valvuloplasty for mitral cord rupture. The last subject in whom a SMAD3 variant has been identified is a subject with a missense variant located in the MH1 domain, who clinically presented dilated cardiomyopathy and heart failure. The segregation analysis in family members has evidenced that the variant in SMAD3 has been transmitted to daughters who have mitral valve prolapse with mitral ring disjunction (MAD) associated with arrhythmia and cardiomyopathy, thus supporting the segregation of SMAD3 variant with the clinical phenotype. Correlation between pathogenic variants in SMAD3 and heart failure has already been described in the literature (Julie De Backer et al, 2018) Conclusions: Obtained results highlight the relevance of molecular characterisation in subjects with Loeys-Dietz syndrome type III in order to provide diagnosis definition, risk stratification, and to establish an appropriate therapeutic management in patients. In individuals with LDS3, aortopathy (diseases of the aorta) is the primary concern. However, it’s important not to overlook that these patients can also develop other, albeit less common, non-aortic cardiovascular issues.
CS01 | Elucidating the evil relationship of metabolic dysfunction–associated fatty liver disease with cardiovascular comorbidities: the complex interplay among hypercoagulability, inflammation and liver fibrosis
Background and aims: Metabolic dysfunction–associated fatty liver disease (MAFLD) represents an increasingly significant public health issue. The clinical course of MAFLD can be severe, with increased risk not only of liver-related morbidity and mortality, but also of cardiovascular (CV) diseases, the leading cause of death in these patients. This study aimed to assess the overall CV risk profile using clinical, laboratory, and ultrasound parameters in a cohort of MAFLD patients stratified by liver stiffness. The project is funded by the European Union–Next Generation EU–NRRP M6C2–Investment 2.1. Methods: Consecutive patients with confirmed MAFLD (i.e., hepatic steatosis and at least one of the following: overweight/obesity, type 2 diabetes, or normal weight with ≥2 metabolic abnormalities) were enrolled. The presence and severity of hepatic steatosis were assessed using transient elastography (FibroScan). Patients were excluded if they had recent (<1 year) arterial or venous thrombotic events, were receiving full-dose anticoagulation, had acute infection (<3 months), active cancer, or documented alcohol consumption. All patients underwent ultrasound evaluation to detect early atherosclerosis (carotid intima-media thickness [IMT], ankle-brachial index [ABI], and aortic diameter). Laboratory assessments included thromboelastometry, whole blood aggregation, and systemic inflammation via high-sensitivity C-reactive protein (hs-CRP). The primary outcome was to compare CV risk profile, early atherosclerosis, hypercoagulability, and inflammation across fibrosis stages. Results: 268 patients with MAFLD (mean age 58 ± 13 years; 64% male) were enrolled. The mean body mass index was 29 ± 4 kg/m², and the mean waist circumference was 101 ± 14 cm. Obesity was present in 40% of patients, hypertension in 54%, dyslipidemia in 55%, and type 2 diabetes in 28%. Notably, 15% of patients had a history of arterial thrombosis, and 7.8% had experienced a previous venous thrombotic event. Fibrosis staging revealed that 93 patients (35%) had F0 fibrosis, 125 (46%) had F1, 29 (11%) had F2, 5 (2%) had F3, and 16 (6%) had F4. Patients with more advanced fibrosis (F2–F4) showed a significantly higher prevalence of carotid plaque (p = 0.0028), a trend toward lower ankle-brachial index (ABI) values (1.08 [1.00–1.15] vs. 1.11 [1.00–1.19]), and a non-significant increase in aortic diameter (19 [16.5–20] mm vs. 17.5 [16–19] mm). No significant differences in thromboelastometry or whole blood aggregometry parameters were observed across fibrosis stages. Moreover, hs-CRP levels showed a strong correlation with clot stability, as measured by maximum clot firmness (MCF) in FIBTEM, EXTEM, and INTEM assays (r = 0.59, p = 0.001). A history of thrombosis was also associated with increased FIBTEM MCF (r = 0.27, p = 0.01). Conversely, hs-CRP levels did not correlate with early atherosclerosis parameters. Conclusions: More advanced liver fibrosis was associated with an increased prevalence of carotid atherosclerosis and a trend toward peripheral arterial impairment. While no differences in coagulation parameters were observed across fibrosis stages, inflammation was significantly associated with both fibrosis severity and clot stability. A history of venous thrombosis correlated with liver fibrosis and procoagulant profiles. These findings highlight the complex interplay between liver disease, inflammation, and thrombosis in MAFLD.
PO52 | Comprehensive assessment of variables affecting spontaneous platelet aggregation
Background and Aims: Platelets in citrate-plasma from some subjects aggregate in light transmission aggregometer (LTA) without stimulation by exogenous agonists («spontaneous platelet aggregation», SPA). Although SPA has been associated with cardiovascular risk, its clinical use is hampered by concerns about potential artifacts stemming from the use of citrate anticoagulant or platelet activation during incorrect blood samples collection/processing. In this study, we aimed to comprehensively assess SPA in a large cohort of subjects without cardiovascular disease, exploring multiple variables including anticoagulants, platelet aggregation measurement methods, and individual factors such as age, sex, and platelet count, in order to clarify the nature and clinical relevance of SPA. To this end, we collected blood samples in different anticoagulants and measured SPA using both the traditional LTA and the more sensitive Optical Density Fluctuations Aggregometer (ODFA), capable of detecting small aggregates of 2-3 platelets. Importantly, all procedures were performed in strict adherence to international recommendations to minimize untoward in vitro platelet activation, thereby ensuring the reliability of the findings. Methods: We measured SPA in platelet-rich plasma (PRP) in citrate, hirudin or citrate+hirudin from 100 subjects. Citrate-PRP was tested also in presence of aspirin (100 µM), to inhibit potential thromboxane-A2 synthesis by aggregating platelets in low Ca2+ medium. SPA was evaluated using both LTA and ODFA, and platelet aggregate size was assessed by ODFA. Results: SPA was detectable in most citrate-PRP samples using both LTA and ODFA. Median SPA values, expressed as percent increase in light transmission, were significantly higher when measured by LTA compared to ODFA [4.4% (3.0-6.0) vs. 3.3% (2.1-5.0), P<0.0001]. In contrast, SPA was undetectable in hirudin-PRP samples by LTA, except in four subjects, while it was detectable in most subjects by ODFA [0.0% (0.0-0.0) vs. 0.8% (0.1-1.3), P<0.0001]. The mean size of platelet aggregates, which is measurable only by ODFA, was significantly higher in citrate-PRP compared to hirudin-PRP [1.8 RU (1.3-2.2) vs. 1.1 RU (1.0-1.2), P<0.0001]. SPA in citrate+hirudin-PRP were comparable to those in citrate alone [2.1% (1.5-4.3) vs. 2.0% (1.1-4.1); P=0.0513], indicating that formation of trace amounts of thrombin is not responsible for the generation of SPA in citrate-PRP. The in vitro addition of aspirin to citrate-PRP samples marginally reduced the median extent of SPA both in LTA [4.4% (2.9-6.0) vs. 4.0% (2.5-6.2), P=0.0004] and ODFA [3.3% (2.1-5.0) vs. 2.8% (1.7-4.4), P<0.0001]. This effect was mainly attributable to the inhibition of secondary waves of platelet aggregation, while primary aggregation remained largely unaffected. Age, sex and platelet count affected SPA in citrate-PRP but not in hirudin-PRP. Conclusions: SPA is not a mere artifact due to in vitro platelet activation by inappropriate sample processing, formation of trace-amounts of thrombin in citrate PRP or other effects of citrate, which only amplifies it, making it detectable also by the lower-sensitivity LTA. Our results demonstrate that SPA occurs to variable extents in most individuals without cardiovascular events and is influenced by individual variables. ODFA, a more sensitive detection method than LTA, allows the detection of SPA also in hirudin-PRP.
PO53 | Effectiveness and safety of DOACS in patients with renal transplantation
Background and Aims: Kidney transplantation is a critical therapeutic option for patients with end-stage chronic kidney disease. Despite advancements in surgical techniques and immunosuppressive therapies, the procedure is associated with a high risk of potentially fatal thromboembolic complications, such as deep vein thrombosis (DVT) and pulmonary embolism (PE). These complications are multifactorial, with contributing factors including postoperative immobility, immunosuppressive drug use, graft dysfunction, and comorbidities like obesity and cardiovascular disease. The use of direct oral anticoagulants (DOACs) in kidney transplant recipients, particularly those requiring long-term anticoa-gulation due to previous thrombotic events, has generated increasing interest. This study aims to examine the effectiveness and safety of DOACs in kidney transplant recipients, focusing on drug interactions with calcineurin inhibitors (CNI) and evaluating clinical outcomes in terms of both safety and efficacy. Methods: A literature review was conducted to analyze existing studies on the use of DOACs in kidney transplant recipients, with a focus on pharmacological interactions with CNIs. In addition, clinical data from a monocentric cohort of 5 kidney transplant patients treated with DOACs were reviewed. Data sources included clinical files from the Hemostasis and Thrombosis Center of AOU Dulbecco, relevant published studies, and safety reports from pharmacovigi-lance databases. Results: The reviewed literature indicates that DOACs, such as apixaban, rivaroxaban, edoxaban and dabigatran, may be safe and effective for preventing thromboembolic events in kidney transplant patients, particularly those with moderate renal dysfunction. However, concerns persist regarding the interactions between DOACs and immunosuppressive drugs, such as tacrolimus and cyclosporine. Clinical outcomes in our cohort showed no major thrombotic or hemorrhagic events during follow-up. The patients have undergone a mean follow-up of 8.8 months (median 11, range 1-13 months). Although the follow-up is relatively short, no adverse events of a bleeding or thrombotic nature have been recorded for any of the patients so far. Conclusions: The use of DOACs in kidney transplant recipients shows promise in preventing thromboembolic events, with a favorable safety profile compared to traditional anticoagulants. However, their use requires careful monitoring, particularly regarding renal function and drug interactions.
PO54 | Resolvin response in bronchial asthma patients: endotype and clinical severity
Background and Aims: Asthma is a chronic inflammatory condition characterized by distinct endotypes. The most common is type 2 asthma, which is allergic and/or eosinophilic in nature. In contrast, non-type 2 asthma—typically neutrophilic or paucigranulocytic—often has a later onset and is more strongly associated with risk factors such as smoking, pollution, and obesity. Resolvins (Rv) are lipid mediators derived from omega-3 fatty acids, primarily eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), that can promote the resolution of inflammation in asthma. This study aims to determine resolvin levels in asthma patients in relation to endotype and clinical severity. Methods: In a observational study, we enrolled thirty-nine patients with varying degrees of bronchial asthma severity (steps 3+4 and 5). Patients were also classified according to inflammatory endotype: type 2 allergic (GT2A, n=20), type 2 non-allergic (GT2NA, n=13), and non-type 2 (GNT2, n=6). A control group (GC, n=12) was also included. All participants underwent clinical assessment and lipidomic analysis focusing on D-series resolvins. Results: Step 5 asthma patients showed significantly lower levels of RvD1 (step 3+4 vs. step 5, p=0.018) and 17(R)-RvD1 (step 3+4 vs. step 5, p=0.045) (Figure 1). Patients treated with the highest doses of inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) had lower levels of 17(R)-RvD1. No significant differences were observed for RvD2 and RvD3, (Figure 1). The type 2 non-allergic group exhibited higher levels of RvD2 compared to both the type 2 allergic group (p=0.040) and the non-type 2 group (p=0.057), (Figure 2). Conclusions: Pro-resolving mediators are produced during asthma; however, their biosynthesis appears reduced in severe and uncontrolled disease. The lower levels of RvD1 and 17(R)-RvD1 observed in patients with higher clinical severity and reduced therapy responsiveness suggest that persistent and adaptive airway inflammation may be due, at least in part, to impaired resolution mechanisms. RvD2 is known to regulate type 2 inflammatory responses, promoting resolution in murine models through RvD2–DRV2 receptor interaction. Our findings support the pro-resolving role of RvD2, highlighting its potential as a key mediator in eosinophil recruitment and activation in the type 2 endotype. Large-scale studies are warranted to further elucidate the role of resolvins in asthma pathogenesis and their potential utility as biomarkers.
PO55 | Evaluation of safety and efficacy of emicizumab prophylaxis in pediatric patients with hemophilia A – a single centre experience
Background and Aims: Hemophilia A (HA) is an hereditary X-linked bleeding disorder secondary to deficiency of the clotting factor VIII (FVIII), that, if not properly treated, is associated with debilitating joint damage due to recurrent hemarthroses as well as life-threatening bleeds including intracranial hemorrhage The introduction of prophylaxis therapy with emicizumab, a monoclonal antibody that replaces the function of the activated FVIII and prevents bleeding, has changed the burden and improved the quality of life of haemophilic patients, mainly in the pediatric population. However, there is a scarcity of data about its use in patients with HA. We aimed to evaluate the safety and efficacy of emicizumab prophylaxis in pediatric patients with severe HA. Methods: Patients with severe HA were enrolled at our hospital. They take emicizumab weekly (3 mg/kg) for a month and then went into a maintenance period with a different dosing regimen. Breakthrough bleeding episodes and the annualized bleeding rate (ABR) were reported for all patients before and after emicizumab prophylaxis. Also, all adverse events during prophylaxis were documented to evaluate the safety of emicizumab. Result: In total, 28 pediatric patients with severe HA were enrolled in this study, from 2018-2019. Emicizumab prophylaxis was started in 2018-2019 in patients with inhibitor and, subsequently, from 2020 also in patients without inhibitor. The median patients’ age was 7, 5(1-15) years. Before starting therapy with emicizumab median annualized bleeding rate was 1.195. After switching to emicizumab, median annualized bleeding was 0. Six patients received their first dose within the first hours of life, among these five never had a bleeding episode. No serious side effects were reported among patients, only reactions at the infusion site. Conclusions: Prophylaxis using emicizumab was associated with a significantly lower bleeding rate in HA patients. The majority of patients had zero bleeds with emicizumab prophylaxis. Therefore, Emicizumab is efficacious and well tolerated in infants, due to a less invasive administration route which increases compliance by the patient and parents and solves the problem of difficult venous accessibility in pediatric patients. Furthermore, emicizumab improve quality of life in children and caregivers, by reducing pain and bleeding and, as a consequence, needing for factor replacement and lower treatment burden for family. Morever, this type of prophylaxis is associated with better emotional well-being, less anxiety over bleeds, fewer missed school days, changing the daily life for these patients and their families.
PO56 | Safety of anticoagulant treatment in patients with splanchnic vein thrombosis and history of portal hypertension-related bleeding
Background and Aims: Splanchnic vein thrombosis (SVT) can be associated to liver cirrhosis, or prothrombotic conditions, including myeloproliferative disorders, intra-abdominal inflammation, solid cancers, or surgery. While anticoagulation therapy improves outcomes in non-cirrhotic patients and reduces all-cause mortality in cirrhotic populations, its safety in patients with a history of portal hypertension (PH)-related bleeding is less clear. This systematic review examines the impact of anticoagulant therapy on re-bleeding risk in SVT patients with a history of PH-related bleeding. Methods: A systematic review and meta-analysis were conducted according to PRISMA guidelines. A comprehensive search of PubMed, Web of Science, and Scopus was performed for studies published up to September 2024. Studies were included if they compared SVT patients with a history of PH-related bleeding receiving anticoagulant therapy versus those not receiving anticoagulants. The primary outcome was the cumulative incidence of PH-related re-bleedings. Results: Of 2,853 identified studies, five (186 participants) met the inclusion criteria: two randomized controlled trials (RCTs) and three observational studies. The cumulative incidence of PH-related re-bleeding was significantly lower in the anticoagulant group at 17.10% [95% CI 17.02, 17.19] compared to the control group at 40.00% [95% CI 39.90, 40.09]. The overall odds ratio (OR) from observational studies was 0.15 [95% CI 0.04, 0.52], indicating a reduced bleeding risk, while the OR from RCTs was 0.84 [95% CI 0.31, 2.32], showing a non-significant trend. Conclusions: Anticoagulant therapy may reduce re-bleeding risk in SVT patients with a history of PH-related bleeding, but further high-quality studies are needed.
PO57 | Direct oral anticoagulant determination in urine samples compared to plasma concentrations in outpatients with atrial fibrillation and obesity
Background: With atrial fibrillation (AF) and high thromboembolic risk need anticoagulant therapy. Few data are available on direct anticoagulants (DOACs) in this population and a point-of-care method has been validated to support rapid clinical decisions and to identify on-off threshold plasma concentrations. The aim of the present study was to evaluate the sensitivity, specificity, positive and negative predictive values (PPV and NPV) of testing for DOACs from urine samples of obese patients taking DOACs for AF. Methods: Cross-sectional study on obese AF outpatients referring to Policlinico Umberto I of Rome. Inclusion criteria were patients of both sexes, aged ≥18 years, Body Mass Index (BMI) ≥30 Kg/m² and receiving a DOAC for AF over at least 7 days. Exclusion criteria were denial of written informed consent, inability to provide a spontaneous urine sample, any contraindication to the administration of DOACs and conditions with known haematuria and blood components such as urobilinogen, which alter the colour of urine and may compromise the interpretation of pad colours of DOAC dipstick. patients were consecutevly enrolled from 2022 to 2024. Trough and peak plasma concentrations and urinary Dipstick were assessed, which determines separate pads for factor Xa (FXA-i) and thrombin inhibitor (THR-i) DOACs. Study endpoints were the sensitivity, specificity, positive and negative predictive values (PPV and NPV) of DOAC Dipstick compared to plasma concentrations. Sub-analysis according to obesity severity and type of DOAC was performed. The study was approved by the local ethic committee of Sapienza University (No. 0234/2022) and was conducted according to the 1975 Declaration of Helsinki. Results: 320 paired plasma and urine samples were available from 160 enrolled patients (mean age 73.2±9.1 years). Comparing to trough plasma concentrations, DOAC Dipstick showed a sensitivity (mean, 95% confidence interval, CI) of 99.24% (95.82-99.98), specificity of 6.89% (0.85-22.76), PPV 82.80% (81.32-84.18), NPV 66.67% (15.79-95.52). On the other hand, comparing to peak plasma concentrations, DOAC Dipstick showed a sensitivity of 97.8% (93.7-99.5), specificity of 0% (0.0-15.4), PPV of 85.9% (85.6-86.2). Urinary Dipstick showed a sensitivity of 99.10% (95.4-100.0), specificity of 4.70% (0.60-16.20) and a PPV and NPV of 74.50% (73.2-75.8) and 66.70 (15.7-95.6), compared to plasma thresholds >30 ng/mL of FXA-I and THR-I. Sub analyses showed similar results between FXA-I and THR-i. Conclusions: The urine point-of-care has high sensitivity, acceptable PPV, but low specificity and NPV in AF obese patients.