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Perioperative anticoagulation management is a common and complex clinical challenge. In this episode of CLOT Conversations, Drs. James Douketis and Joseph Shaw discuss new ISTH guidance on surgical and procedural bleed risk stratification in anticoagulated patients.

The discussion explores why updated guidance was needed, addressing inconsistencies in prior schemas, and introduces a more detailed, procedure-specific framework. The authors outline a three-tier classification—minimal, low/moderate, and high bleed risk—and its implications for anticoagulation management.

The episode focuses on real-world application, including patient-specific factors, procedural variability, and interdisciplinary communication. It also highlights evidence gaps and ongoing research such as PAUSE2 and ACE-HIGH.

https://www.jthjournal.org/article/S1538-7836(26)00055-3/abstract [Subscription required for full paper]

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Which DOAC bleeds less in acute VTE?

In this episode, we explore the COBRRA trial comparing apixaban vs rivaroxaban and what it means for clinical practice.

The COBRRA trial provides the first direct, randomized comparison of apixaban and rivaroxaban for the treatment of acute venous thromboembolism (VTE).

In this episode of CLOT Conversations, Dr. Lana Castellucci discusses findings from this landmark study and how they should influence anticoagulant selection.

Key insights include:

• Apixaban reduced clinically relevant bleeding by more than 50% compared to rivaroxaban
• Differences in bleeding risk emerged early and persisted over the 3-month treatment period
• Recurrent VTE and mortality rates were similar between groups
• Dosing strategies and early treatment phase appear to play a key role

We also explore real-world considerations, including medication adherence, patient preference, and how to approach populations not included in the trial, such as cancer-associated thrombosis and higher body weight.

This episode provides practical, evidence-based guidance for clinicians managing acute DVT and pulmonary embolism.

Listen now to learn how the COBRRA trial may change your approach to DOAC selection.

Access the publication here:

Castellucci LA, Chen VM, Kovacs MJ, Lazo-Langner A, Greenstreet P, Kahn S, Côté B, Schulman S, De Wit K, Douketis J, Suryanarayan D. Bleeding risk with apixaban vs. rivaroxaban in acute venous thromboembolism. New England Journal of Medicine. 2026 Mar 12;394(11):1051-60.

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Major bleeding remains the principal complication of oral anticoagulation. In patients with device-detected subclinical atrial fibrillation, the decision to anticoagulate requires careful balancing of stroke prevention against bleeding risk.

In this episode of CLOT Conversations, Dr. Deborah Siegal discusses a prespecified subanalysis of the ARTESiA randomized clinical trial, recently published in JAMA Cardiology. ARTESiA demonstrated a 37% reduction in stroke and systemic embolism with apixaban compared to aspirin — but at the cost of increased major bleeding.

This subanalysis goes deeper, examining the site, severity, and clinical course of bleeding events. Most bleeding was gastrointestinal and non-critical. Rates of intracranial and fatal bleeding were low and similar between treatment arms. The majority of events were not clinical emergencies, and many were defined by hemoglobin decline rather than catastrophic presentation.

We explore what these findings mean for individualized risk assessment, the importance of modifiable bleeding risk factors such as NSAID use, and how physicians and patients can approach shared decision-making in subclinical AF.

Abstract (subscription required for full paper):

Siegal DM, Sticherling C, Healey JS, McIntyre WF, Christensen LS, Parkash R, Vanassche T, Conen D, Gold M, Granger CB, Nielsen JC. Major Bleeding With Apixaban vs Aspirin: A Subanalysis of the ARTESiA Randomized Clinical Trial. JAMA cardiology. 2025 Dec;10(12):1305-14.

https://jamanetwork.com/journals/jamacardiology/fullarticle/2841075

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Obesity presents a persistent challenge in the management of cancer-associated thrombosis, particularly when prescribing low molecular weight heparin beyond standard dose caps.

In this episode of CLOT Conversations, host Dr. Jameel Abdulrehman is joined by Dr. Tzu-Fei Wang and Dr. Grégoire Le Gal to discuss findings from the WAVe study, a multicenter prospective cohort study evaluating weight-adjusted dalteparin dosing in patients over 90 kg with acute cancer-associated venous thromboembolism.

The conversation examines bleeding and thrombotic outcomes, mortality, and trough anti-Xa levels, including insights into bioaccumulation and twice-daily versus once-daily dosing. The guests also address study limitations, dose capping in patients with very high body weight, and how WAVe fits into current practice amid increasing DOAC use.

This episode provides practical, evidence-informed guidance for clinicians navigating anticoagulation decisions in obese patients with cancer.

To access the full publication: https://onlinelibrary.wiley.com/doi/full/10.1002/ajh.70127

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In this episode of CLOT Conversations, co-hosts Dr. Jamil Abdul-Rahman and Dr. Maha Othman have an in-depth discussion with leading thrombosis expert Dr. Jeff Weitz. Together, they unpack new findings from The Lancet on RGN-9933 and RGN-7508, two investigational factor XI inhibitors evaluated in the ROXI-VTE I and II phase-2 trials. These studies examine how targeted inhibition of factor XI may reduce post-operative venous thromboembolism with potentially lower bleeding risk than current anticoagulants.

Dr. Weitz explains the distinct mechanisms of the two antibodies, the role of factor XII-mediated activation in post-operative VTE, key efficacy and safety outcomes, and how these early-phase studies set the stage for ongoing phase-2 and phase-3 trials—including ROXI-CATH, ROXI-Aspirin, and emerging AF and stroke-prevention research.

This episode is essential listening for clinicians interested in the rapidly evolving landscape of anticoagulation and next-generation therapies that may offer safer options for patients undergoing orthopedic surgery and beyond.

Read the full Lancet publication by clicking on the link below and explore more thrombosis resources at thrombosiscanada.ca.

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https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(25)02097-5/abstract [Note: full access requires a subscription]

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Diagnosing recurrent venous thromboembolism (VTE) remains one of the biggest clinical challenges in thrombosis medicine. In this episode, Dr. Vicky Mai and Dr. Grégoire Le Gal join us to discuss the international PREDICTORS study (JTH, 2025), which evaluated the performance of commonly used clinical decision rules (Wells and Geneva scores) in patients with suspected recurrent VTE. They share why symptoms can be misleading, how residual clots complicate imaging, and what their findings mean for the safe use of D-dimer and anticoagulation status in clinical practice.

Reference:

Mai, V., Martens, E. S., Righini, M., Schulman, S., Thiruganasambandamoorthy, V., Kahn, S. R., ... & Le Gal, G. (2025). Performance of clinical decision rules in patients presenting with suspected recurrent venous thromboembolism: a multicenter prospective cohort study. Journal of Thrombosis and Haemostasis.

https://www.sciencedirect.com/science/article/abs/pii/S1538783625004088

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This episode reviews findings from a cross-sectional study at SickKids on health literacy in pediatric VTE patients and caregivers (Res Pract Thromb Haemost, 2025). Among 101 participants, 74% of adolescents and 59% of parents/caregivers demonstrated low general health literacy using REALM, HAS-A, and eHEALS instruments. Communication with providers was the most affected domain, and fewer than half of participants were satisfied with their thrombosis knowledge. Adolescents frequently overestimated their understanding, underscoring the need for simplified educational resources and a “universal precautions” approach to health literacy in pediatric thrombosis care.

AboutKidsHealth Thrombosis Hub: https://www.aboutkidshealth.ca/thrombosis

Bastas, D., Mancini, A., Wong, G., Brandão, L. R., Mukaj, S., Vincelli, J., ... & Avila, L. (2025). Health literacy in pediatric thrombosis: a landscape analysis. Research and Practice in Thrombosis and Haemostasis, 9(1), 102653.

Publication Link: https://www.rpthjournal.org/article/S2475-0379%2824%2900348-0/fulltext

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In this episode, Dr. Laura Avila and Jennifer Vincelli discuss their Blood publication on long-term outcomes of pediatric pulmonary embolism. Among 150 patients, ~30% had incomplete PE resolution and 9% experienced recurrence, but persistent sequelae were rare. True post-PE syndrome occurred in <9%, with only one case of CTEPH. The findings highlight the value of structured follow-up, attention to underlying conditions, and promoting physical activity to counter deconditioning.

To access the publication use this URL: https://thrombosiscan.info/CLOT-CONVO-46

Support the show

https://thrombosiscanada.ca

Take a look at our healthcare professional and patient resources, videos and publications on thrombosis from the expert members of Thrombosis Canada