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PubMed2006

Quantifying the effect of antiplatelet therapy: a comparison of the platelet function analyzer (PFA-100) and modified thromboelastography (mTEG) with light transmission platelet aggregometry.

BACKGROUND: Antiplatelet therapy with aspirin and clopidogrel is known to confer protection against ischemic events. Increasing numbers of patients are presenting for surgery while taking these drugs. This may lead to an increase in perioperative blood loss, particularly in those who have a heightened response to the drugs. Identifying these patients preoperatively would allow us to plan appropriate management. METHODS: The antiplatelet effect of aspirin and/or clopidogrel was measured using two point-of-care monitors: the platelet function analyzer (PFA-100; Dade, Miami, FL) and the modified thromboelastograph (mTEG; Haemoscope Corp., Niles, IL). This was compared with optical light transmission aggregometry. RESULTS: All people taking aspirin displayed a definitive aspirin effect on aggregometry (n = 20). Ninety percent of these were identified by modified thromboelastography (n = 18). Seventy percent were identified by the platelet function analyzer (n = 14). Fifty percent of people taking clopidogrel displayed a definitive response to the drug on aggregometry. Seventy percent of these were identified on modified thromboelastography (n = 7). None were identified by the platelet function analyzer. There was good agreement between the results of the aggregometry and modified thromboelastography in clopidogrel patients (kappa = 0.81). CONCLUSION: The search for a point-of-care monitor of platelet function has been the focus of much research. This study has shown that the modified thromboelastograph can be used for monitoring the effect of clopidogrel as well as aspirin. It potentially has a wide scope to be used for the monitoring of effectiveness of therapy as well as a possible predictor of perioperative bleeding.

Adult↗

PubMed2005

Thromboelastography maximum amplitude predicts postoperative thrombotic complications including myocardial infarction.

Postoperative thrombotic complications increase hospital length of stay and health care costs. Given the potential for thrombotic complications to result from hypercoagulable states, we sought to determine whether postoperative blood analysis using thromboelastography could predict the occurrence of thrombotic complications, including myocardial infarction (MI). We prospectively enrolled 240 patients undergoing a wide variety of surgical procedures. A cardiac risk score was assigned to each patient using the established revised Goldman risk index. Thromboelastography was performed immediately after surgery and maximum amplitude (MA), representing clot strength, was determined. Postoperative thrombotic complications requiring confirmation by a diagnostic test were assessed by a blinded observer. Ten patients (4.2%) suffered a total of 12 postoperative thrombotic complications. The incidence of thrombotic complications with increased MA (8 of 95 = 8.4%) was significantly (P = 0.0157) more frequent than that of patients with MA < or =68 (2 of 145 = 1.4%). Furthermore, the percentage suffering postoperative MI in the increased MA group (6 of 95 = 6.3%) was significantly larger than that in the MA < or =68 group (0 of 145 = 0%) (P = 0.0035). In a multivariate analysis, increased MA (P = 0.013; odds ratio, 1.16; 95% confidence interval, 1.03-1.20) and Goldman risk score (P = 0.046; odds ratio, 2.39; 95% confidence interval, 1.02-5.61) both independently predicted postoperative MI. A postoperative hypercoagulable state as determined by thromboelastography is associated with postoperative thrombotic complications, including MI, in a diverse group of surgical patients.

Adult↗

PubMed2004

[Thromboelastography in liver transplantation, a comparison with conventional laboratory tests].

BACKGROUND: The aim of our study was to compare the results of conventional tests and thromboelastography during liver transplantation and to determine their importance for blood loss. METHODS AND RESULTS: Thromboelastography and conventional laboratory tests were undertaken in 25 patients at the end of the anhepatic phase. Transfusion requirements correlated significantly only with prothrombin time and reaction time, R. These two tests likewise correlated significantly one with the other. CONCLUSIONS: Lowered plasma levels of coagulation factors of the prothrombin complex influenced the blood losses in our patients. While not replacing conventional tests, thromboelastography can serve as an additional test for monitoring acute changes in hemostasis.

Adolescent↗

PubMedDate not supplied

Essential thrombocythemia and epidural analgesia in the parturient. Does thromboelastography help?

BACKGROUND AND OBJECTIVES: It is often considered that essential thrombocythemia contraindicates placement of an epidural catheter because of the danger of epidural hematoma. Thromboelastography offers a possible means of determining the appropriateness of epidural analgesia in a patient with this disorder. METHODS: A pregnant woman with essential thrombocythemia and a history of spontaneous abortions was evaluated by thromboelastography at 38 weeks of gestation to determine the safety of using epidural analgesia for labor pain management. On the basis of the thermoelastography findings, the patient was given epidural analgesia with bupivacaine and fentanyl during her labor. RESULTS: The patient experienced good pain relief, delivered a healthy infant vaginally, and suffered no complications. CONCLUSIONS: Thromboelastography may be a useful diagnostic test in determining the suitability of regional techniques for labor analgesia in parturients with essential thrombocythemia. However, success in one patient does not prove the general safety of this approach.

Adult↗

PubMed2001

Analysis of coagulation changes associated with supraceliac aortic crossclamping using thromboelastography.

INTRODUCTION: The etiology of the coagulation changes seen with supraceliac (SC) aortic crossclamping (AXC) remains controversial; both primary fibrinolysis and clotting factor consumption have been implicated. The cause of these changes was investigated with thromboelastography (TEG), a test that measures the viscoelastic properties of thrombus to dynamically assess coagulation and fibrinolysis. METHODS: Eight pigs underwent SC AXC for 30 min; 5 pigs undergoing 30 min of infrarenal (IR) aortic clamping served as controls. Blood was drawn before AXC, before unclamping, and 5 and 60 min after unclamping. Thromboelastography and standard coagulation tests [prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, and platelet count] were performed. Measured TEG parameters included fibrinolytic index (a measure of fibrinolysis), r value (a reflection of intrinsic coagulation cascade activity), and the alpha angle and K values (measures of the speed of solid clot formation). Repeated measures ANOVA and t test were used for statistical analysis. RESULTS: There was no difference in the fibrinolytic index at any time point between the two groups. Increased activity of the intrinsic coagulation cascade during SC clamping was reflected by a lower R value just before unclamping (12.6 +/- 3.0 vs 20.0 +/- 3.0, P = 0.048) compared to IR AXC. Decreased speed of solid clot formation was noted 5 min after unclamping in the SC group but not the IR group [as defined by an increased K value (ANOVA, P = 0.010) and a decreased alpha angle value (ANOVA, P = 0.005)]. Fibrinogen levels were lower in the SC than in the IR group 5 (P = 0.013) and 60 min after unclamping (P = 0.02), but PT, PTT, and platelets did not differ between the groups at any time points. CONCLUSIONS: Thirty minutes of SC AXC does not result in fibrinolysis. There is increased clotting activity during SC clamping followed by decreased speed of clot formation and decreased fibrinogen levels after unclamping. These changes are consistent with clotting factor consumption.

Animals↗

PubMed1998

The usefulness of celite-activated thromboelastography for evaluation of fibrinolysis.

PURPOSE: Although thromboelastography is useful for measuring both coagulability and fibrinolysis, it takes about two hours to measure all parameters including fibrinolytic rate. The present study aimed to investigate the usefulness of celite-activated thromboelastography (TEGc) to evaluate fibrinolytic status in non-cardiac surgery. METHODS: Whole blood samples were obtained from 30 patients for non-cardiac surgery, and used for measurements of both native TEG (TEGn) and TEGc. The final concentration of 1% (w/v) celite was used for TEGc. RESULTS: Time for measurement of the fibrinolytic rate (FR) of TEGc in patients (56.7 +/- 4.0 min) was less than half that of FR of TEGn (123.3 +/- 15.6 min) (P < 0.05), suggesting a more rapid assessment of fibrinolytic status. A linear relationship was observed between FR values of TEGc and those of TEGn (r = 0.93, P < 0.0001), suggesting the usefulness of the fibrinolytic parameter of TEGc. CONCLUSION: TEGc is a useful technique for a more rapid assessment of fibrinolytic status.

Adult↗

PubMed1997

Platelet concentrate effects on thromboelastography.

OBJECTIVE: This study evaluated platelet effects on thromboelastography to determine how morphologically abnormal platelets affected native whole blood analysis. DESIGN: Prospective, controlled comparison. SETTING: Tertiary care university hospital. PARTICIPANTS: Volunteer cardiac surgery patients. INTERVENTIONS: Fresh platelets were obtained from volunteers and were either treated normally or cryodisrupted with liquid nitrogen. Fresh platelets, liquid nitrogen-treated platelets, or an equivalent quantity of the patient's blood were added to whole blood samples obtained from cardiac surgery patients before heparinization. Thromboelastographic parameters sensitive to platelet effects were measured in each of the three groups. MEASUREMENTS AND MAIN RESULTS: Maximum amplitude and alpha-angle significantly increased in the two groups receiving added platelets. There were no differences between the fresh platelet and the liquid nitrogen-treated platelet groups (Student's paired t-test). The R-time decreased significantly in both platelet-treated groups compared with the group that did not receive additional platelets. CONCLUSIONS: Viscoelastic changes in whole blood coagulation after the addition of platelet concentrates are not dependent on morphologically intact or functionally normal platelets. This in vitro study predicts that transfusion of poorly preserved platelet concentrates as well as fresh platelets would increase clot strength on thromboelastography if the recipient's blood were tested immediately after administration.

Blood Coagulation↗

PubMed2003

The effects of hydroxyethyl starch solutions on thromboelastography in preoperative male patients.

BACKGROUND: Hydroxyethyl starches (HES) have been shown to decrease clot strength and to increase coagulation times assessed by thromboelastography (TEG). HES with minimal anticoagulant side-effects is beneficial for plasma volume expansion in the perioperative setting. A comparison of the in vivo effects of high, middle and low molecular weight HES solutions on TEG variables has not been performed so far. METHODS: Blood was obtained before and after intravenous infusion (10 ml kg-1) of either saline, HES 70/0.5/4 (molecular weight in kDa/degree of substitution/C2:C6 ratio), HES 130/0.4/9, HES 200/0.6/9.4, or HES 450/0.7/4.6 in 50 otherwise healthy patients. Thromboelastography was performed in 360 micro l of 1% celite activated citrated whole blood after recalcification. RESULTS: HES 450/0.7/4.6 prolonged reaction time indicating impairment of the plasmatic coagulation system. TEG parameters indicative for platelet function, including angle alpha, maximum amplitude and coagulation time, deteriorated after infusion of HES 450/0.7/4.6 and HES 70/0.5/4. HES 200/0.6/9.4 and HES 130/0.4/9 impaired platelet contribution to hemostasis only partially, decreasing two or one TEG platelet parameters, respectively. CONCLUSION: Infusion of HES 450/0.7/4.6 compromises TEG parameters more than the other solutions tested, whereas HES 130/0.4/9 has the smallest effect. Further outcome-related studies are needed in order to assess the clinical relevance of our findings.

Adult↗

PubMed2000

Evaluation of the contribution of platelets to clot strength by thromboelastography in rabbits: the role of tissue factor and cytochalasin D.

UNLABELLED: The contribution of platelets and soluble clotting components to clot strength has been the focus of several clinical studies using thromboelastography; it would, therefore, be beneficial to develop an animal model with which to mechanistically approach hemostatic disorders. Thus, we proposed to determine if the contribution of platelet function (G(P), dyne/cm(2)) and soluble components of the coagulation pathway to total clot strength (G(T)) in rabbits were similar to those in humans. Blood was sampled from the ear arteries of conscious rabbits (n = 12); 350 microL of the blood was placed in a thromboelastograph. Ten microliters of normal saline, cytochalasin D (an inhibitor of microtubule function, 10 microM final concentration), or tissue factor (a potent stimulator of platelet function, 0.00625% final concentration) was added to the blood sample, and thromboelastography performed for 1 h. The G(T) (mean +/- SD) was significantly (P < 0.001) different among samples exposed to normal saline, cytochalasin D, or tissue factor, with G(T) values of 7238 +/- 1432, 937 +/- 372, and 16,556 +/- 3314, respectively. G(P) was responsible for 87% and 94% of G(T) in the absence or presence of tissue factor, respectively. G(P) did not significantly correlate with platelet concentration in the absence or presence of tissue factor. The contribution of G(P) to G(T) is similar to that observed in humans. IMPLICATIONS: Rabbits may serve as a model of hemostasis that closely approximates human situations to mechanistically determine the etiology of coagulopathy. The contribution of platelet function to total clot strength is similar to that observed in humans.

Animals↗

PubMed1995

Effects of the platelet-activating factor receptor antagonist WEB 2086 on whole blood coagulation and fibrinolysis in a thromboelastography assay.

The effects of WEB 2086 on human blood coagulation and fibrinolysis were studied in vitro using computerized thromboelastography and native whole blood. WEB 2086 (3.0, 30, 150, and 300 microM) had no apparent effect on the split point (SP), reaction time (R) and lysis of the clot. The biKoatugulierung time (K) was prolonged, the angle (alpha) and maximum amplitude (MA) were diminished, and the overall coagulation index (TEG index) was smaller. SP and R indicate onset of coagulation with the formation of fibrin strands, suggesting that WEB 2086 had no effect on the plasma factors. Since the Lysis parameter reflects fibrinolysis, WEB 2086 had no demonstrable fibrinolytic activity. K, alpha and MA involve platelet function and the integrity of fibrin; the fact that these factors were affected to the exclusion of SP and R suggests an effect largely on platelets. There was lack of a dose-response relationship at this concentration range (3.0-300 microM), probably due to saturation of PAF receptors even at the lowest effective concentration. These findings are consistent with the known effects of WEB 2086 on platelet function and suggest that thromboelastography may be a useful tool in the study of the activity of PAF receptor antagonists on coagulation profiles. Furthermore, since WEB 2086 is a highly specific PAF receptor antagonist devoid of intrinsic activity, and the samples used were not treated with exogenous PAF, these results suggest that endogenous PAF may play a significant role in the normal clotting mechanism.

Azepines↗

PubMed2005

An evaluation of the procoagulant action of recombinant activated factor VII in cord whole blood versus adult whole blood using thromboelastography.

Recombinant activated factor VII (rFVIIa) has been reported to be effective in adult patients in various clinical situations and might be beneficial in neonates with bleeding tendency. In the present study we compared the procoagulant action of increasing amounts of rFVIIa in both cord whole blood and adult whole blood with respect to changes in the values of the clotting time, clot formation time, and maximum clot firmness by means of thromboelastography. Thromboelastography allows evaluation of the effects of rFVIIa on haemostasis in whole blood. When increasing amounts of rFVIIa were added in vitro to whole blood samples, significant decreases in the values of the clotting time and clot formation time and a significant increase in the maximum clot firmness were observed. Cord whole blood was significantly more sensitive to rFVIIa addition than adult whole blood, an effect probably attributable to the low anticoagulant capacity of the neonatal plasma. Maximum clot firmness values were significantly lower in cord whole blood than in adult whole blood, an effect mainly attributable to the hypofunctional state of neonatal platelets. Since cord whole blood exerted a significantly higher sensitivity to addition of rFVIIa, we speculate that lower doses of rFVIIa might be required to treat neonates with bleeding tendency compared with the adult rFVIIa administration strategy.

Adult↗

PubMed1997

In vitro evaluation of the effect of profound haemodilution with hydroxyethyl starch 6%, modified fluid gelatin 4% and dextran 40 10% on coagulation profile measured by thromboelastography.

Synthetic colloids have been implicated as a cause of coagulopathy when administered in large quantities. The effect of profound haemodilution (50%) on coagulation profile was measured in vitro by thromboelastography. Blood samples were taken from 11 ASA grade 1 patients prior to induction of anaesthesia for elective surgery. Each sample was simultaneously tested in four different preparations: undiluted blood (control sample); blood diluted with hydroxyethyl starch 6%; blood diluted with modified fluid gelatin 4%; blood diluted with dextran 40 10%. There was a significant decrease in reaction time in the preparations treated with hydroxyethyl starch 6% and modified fluid gelatin 4%, reflecting activation of initial fibrin formation. A significant increase in clot formation time was noted in the hydroxyethyl starch 6%-treated preparations. There was also a significant decrease in clot formation rate and maximum amplitude in the hydroxyethyl starch 6% group. Clot formation time, clot formation rate and maximum amplitude did not change in the modified fluid gelatin 4% group. Profound haemodilution with dextran 40 10% exerted extreme effects on the measured variables, very often resulting in a straight line on the thromboelastography profile.

Blood Coagulation↗

PubMed2005

Effect of amniotic fluid on coagulation and platelet function in pregnancy: an evaluation using thromboelastography.

Amniotic fluid embolism is a rare obstetric complication. The exact pathogenesis of this syndrome remains unknown and significant controversy exists whether coagulopathy should always be present. We used thromboelastography to assess the effect of amniotic fluid on coagulation and platelet function in pregnant women. Different volumes of amniotic fluid (10-60 microl) were added to blood (330 microl) from pregnant women and thromboelastography variables determined. There were three important findings. R time, reflecting time to first clot formation, was significantly decreased with the addition of 10 microl amniotic fluid; platelet function, as determined by Reopro-TEG technique, was increased with the addition of 30 microl of amniotic fluid; and there was no evidence of fibrinolysis in any samples studied. In conclusion, our study substantiates the hypothesis that coagulation profile changes are invariable accompaniments of amniotic fluid embolism.

Adult↗

PubMed2005

Urokinase induced fibrinolysis in thromboelastography: a model for studying fibrinolysis and coagulation in whole blood.

BACKGROUND: The contact system (CS) proteins, factor XII and prekallikrein are thought to have roles in blood coagulation and fibrinolysis. Recent research has suggested that the CS proteins might be more important in fibrinolysis and cell function than in coagulation. Most studies on fibrinolysis have used plasma or euglobulin assays, ignoring the influence of cellular elements of blood on the fibrinolytic process. OBJECTIVE AND METHODS: In order to study both coagulation and fibrinolysis in whole blood (WB), we have developed a thromboelastography (TEG) assay to investigate both coagulation and fibrinolysis in the same blood sample. In this assay, named urokinase (UK) induced fibrinolysis in thromboelastography (UKIFTEG), TEG is performed on recalcified citrated WB in the presence of UK. Large variations in Ly60 (percentage lysis 60 min after clot formation) were obtained between different donors with the same UK concentration. The UKIFTEG assay was therefore performed using UK concentrations that gave Ly60 values in the approximate range of 20-40%. RESULTS: The effect of CS activation was investigated in the presence or absence of celite (10 mg mL(-1) blood). Celite shortened the clotting time (CT), and increased Ly60 values. Factor XIIa (FXIIa) and plasma kallikrein (KK) produced concentration dependent reductions in CT (significant at concentrations of 1303 and 2600 ng mL(-1) blood, respectively) and increased Ly60 values (significant at concentrations of 652 and 1300 ng mL(-1) blood, respectively). CONCLUSIONS: Our results show that CS activation and both FXIIa and KK produce reductions in clotting time and enhanced fibrinolysis in UKIFTEG.

Blood Coagulation↗

PubMed1998

Preoperative evaluation and postoperative prediction of hemostatic function with thromboelastography in patients undergoing redo cardiac surgery.

BACKGROUND: Patients who receive cardiac procedures, in particular "redo" ones, often suffer complications from massive bleeding, largely due to bypass-induced coagulopathies. Cardiopulmonary bypass (CPB) may cause damage of the blood components, both in terms of quality and quantity. In order to investigate the qualitative changes of blood constituents with special regard to coagulation resulting from the complex insult of previous cardiac surgery, thromboelastography (TEG) was used to analyze the whole clotting process. METHODS: Seventy-four patients who underwent cardiac surgery with CPB were prospectively studied. Of them, 32 patients received "redo" cardiac surgery. Blood samples for routine laboratory coagulation tests (RCT) and TEG examination were drawn before and after cardiopulmonary bypass. Clinically significant bleeding was defined if the chest tube drainage was greater than 100 ml/h for 3 consecutive h or greater than 300 ml in 1 h during the first 8 h after surgery. Prebypass and postbypass coagulation parameters were compared and the percentage of accuracy, false positive and false negative rate were deduced from calculation. RESULTS: In the TEG tracings, preoperative alpha angle and maximum amplitude were significantly decreased in the "redo" group when compared with primary group, indicating less competent platelet function and platelet-fibrin interaction. Lower platelet count was also found by conventional coagulation tests in "redo" patients. Postoperatively, higher percentage of excessive hemorrhage was also noted in the "redo" group (42.8% vs. 27.5% in primary group). However, a much lower predictive accuracy was found in "redo" patients in comparison with primary cardiac patients (53.5% vs. 90%). CONCLUSIONS: We concluded that thromboelastography failed to predict postoperative hemorrhage in "redo" cardiac patients and the graphic recordings derived could not be treated as a guide of transfusion therapy. We thought that inferior preoperative hemostatic status and severer coagulopathy might be responsible for the differences between "redo" and primary cardiac patients.

Adult↗

PubMed2002

The effect of anesthetic techniques on hemostatic function in arthroscopic surgery: evaluation by thromboelastography.

BACKGROUND: Anesthetic techniques are known to affect blood hemostasis, which may be responsible for the pathogenesis of postoperative venous thromboembolism. The purpose of this study was to evaluate the effect of general and spinal anesthesias on blood hemostasis using thromboelastography. METHODS: Forty patients undergoing arthroscopic knee surgery were enrolled for study and randomly allocated to one of two groups, to receive either general (GA; n = 20) or spinal anesthesia (SA; n = 20). In addition to thromboelastography, prothrombin and activated partial-thromboplastin time, and haematocrit and platelet count were also examined concurrently. Blood was sampled and examined before anesthesia to provide the baseline data (Time 1). Three more evaluations were performed at different time, i.e., twenty minutes after induction of anesthesia and just prior to skin incision (Time 2), thirty minutes after skin incision (Time 3), and three hours after surgery (Time 4). RESULTS: There were no intra- or inter-group differences noted as comparing the measured parameters obtained prior to, during, or three hours after surgery. CONCLUSIONS: From the present study, we do not find any individual anesthetic technique which would have effect on the hemostasis of patients who received diagnostic arthroscopic surgery.

Anesthesia, General↗

PubMed1992

[Analysis of blood coagulation and fibrinolysis in rheumatoid arthritis using the urokinase activated thromboelastography].

The urokinase activated thromboelastography is useful for the analysis of blood coagulation and fibrinolysis in rheumatoid arthritis (RA). In 43 RA patients without extraarticular symptoms (mean year old +/- SD = 50.3 +/- 10.9) and 20 healthy control subjects (mean year old +/- SD = 49.5 +/- 13.8, which is not significant), we have examined reaction time (r), coagulation time (k), r+k, maximal amplitude (ma), lysis time (LT) of the urokinase (final density = 85U/ml) activated platelet rich plasma thromboelastography. In RA patients r, k, r+k are shorter, ma is larger, LT is longer than in control subjects. Especially, k, ma and LT are remarkably statistically significant. these findings suggest that most of RA patients have hypercoagulability and/or prolongation of lysis time simultaneously, k, ma and LT are pathophysiologically important.

Adult↗

PubMed2006

The influence of fibrin polymerization and platelet-mediated contractile forces on citrated whole blood thromboelastography profile.

Thromboelastography analysis providing a global assessment of coagulation is gaining new interest in clinical practice. MinimalTF triggered whole blood thromboelastography provides a valuable tool for studying the kinetics of clot formation (expressed by the parameters R, K and alpha-angle) and the physical characteristics of the clot, such as its firmness and the elastic modulus shear (expressed by the parameters maximal amplitude MA and G). We studied the influence of fibrin polymerization and platelet functional status on each parameter of thromboelastographic trace obtained by minimalTF activation inWB by employing increasing concentrations of a fibrin polymerization inhibitors (the tetrapeptide Gly-Pro-Arg-Pro-OH.AcOH; Pefabloc-FG) and an inhibitor of actin polymerization (Cytochalasin D). Pefabloc-FG at concentrations higher than 5 mg/ml prolonged the R and K times and decreased the alpha-angle in a concentration-dependent manner but it did not modify MA and G parameters. At the concentration of 5 mg/ml, Pefabloc-FG completely inhibited clot formation. Cytochalasin D had no effect on R time but decreased the alpha-angle, MA and G parameters by reaching a plateau at the concentration of 5 microM. The effect of cytochalasin D was more pronounced on MA and G than on the alpha-angle. A combination of both Pefabloc-FG (0.5 mg/ml) and cytochalasin D (50 microM) significantly decreased alpha-angle compared to control as well as their single effect. However, G value was dramatically reduced in the presence of cytochalasin D exposure, without any additional effect when both inhibitors were combined. This study confirms the importance of fibrin polymerisation on the kinetics of thrombus formation and demonstrates the close association between the quality of the thrombus and the functional status of platelets. Normal platelet contractile forces are of major importance for the maximum amplitude of TEG which is related to the strength and elastic modulus of the thrombus.

Biomechanical Phenomena↗