Abstract 4399

Introduction:

The purpose of our study was to evaluate the peri-procedure management of patients on chronic vitamin K antagonists (VKA) and to assess adherence to the 2008 American College of Chest Physicians (ACCP) guidelines.

Methods:

We retrospectively reviewed the electronic medical records of patients on chronic VKA who required temporary discontinuation of anticoagulation due to an invasive or surgical procedure at New York Presbyterian Hospital from January 2006 to June 2010. Dermatological or oral procedures were excluded. Demographics, indications of VKA, underlying thrombophilia, cancer or inflammatory bowel disease, type of invasive or surgical procedure, method of bridge therapy and complications were recorded. When the ACCP guidelines were published, we compared our previous practice and modified our management accordingly.

Results:

A total of 48 procedures where performed in 34 patients. The demographic and clinical characteristics of these patients are shown in Table 1. The type of procedure, anticoagulant bridge therapy and complications are shown in Table 2. The majority of the procedures were managed using bridge therapy with low molecular heparin (LMWH) treatment dose. There were no thrombotic episodes, however there were 3 bleeding complications. All occurred prior to the publication of the 2008 ACCP guidelines. The patients who had bleeding complications were on therapeutic dose LMWH/Fondaparinux bridge therapy. One patient with the antiphospholipid syndrome developed severe thrombocytopenia after surgery that responded to intravenous gamma globulin.

Table 1.

Demographics, Indications for Vitamin K Antagonists and Clinical Characteristics

Episodes n= 48 
Patients n= 34 
Gender:  
Females n= 21 
Males n=13 
Age (yr):  
Mean 53 
Range: 21–81 
Ethnicity:  
White n= 31 
Hispanic n= 1 
Indian n= 1 
Other n= 1 
Indications for vitamin K antagonists (VKA):  
Primary prevention of arterial thrombosis (AT) n= 1 
Secondary prevention of AT n= 8 
Secondary prevention of venous thrombosis (VT) n= 22 
Secondary prevention of AT + VT n= 3 
Thrombophilia:  
Antithrombin deficiency n= 3 
Factor V Leiden n= 3 (1 homozygote) 
Prothrombin gene mutation n= 3 
Factor V Leiden + Prothrombin gene mutation n= 2 
Antiphospholipid antibodies n= 6 
Antiphospholipid antibodies + PGM n= 1 
History of heparin induced thrombocytopenia (HIT) n= 2 
Cancer n= 2 
Inflammatory Bowel Disease n= 2 
Episodes n= 48 
Patients n= 34 
Gender:  
Females n= 21 
Males n=13 
Age (yr):  
Mean 53 
Range: 21–81 
Ethnicity:  
White n= 31 
Hispanic n= 1 
Indian n= 1 
Other n= 1 
Indications for vitamin K antagonists (VKA):  
Primary prevention of arterial thrombosis (AT) n= 1 
Secondary prevention of AT n= 8 
Secondary prevention of venous thrombosis (VT) n= 22 
Secondary prevention of AT + VT n= 3 
Thrombophilia:  
Antithrombin deficiency n= 3 
Factor V Leiden n= 3 (1 homozygote) 
Prothrombin gene mutation n= 3 
Factor V Leiden + Prothrombin gene mutation n= 2 
Antiphospholipid antibodies n= 6 
Antiphospholipid antibodies + PGM n= 1 
History of heparin induced thrombocytopenia (HIT) n= 2 
Cancer n= 2 
Inflammatory Bowel Disease n= 2 
Table 2.

Type of Procedure, Anticoagulant Bridge Therapy and Complications

Surgical procedures:  
Gynecological n= 5 
Gastrointestinal n= 7 
Urological n= 2 
Bariatric surgery n= 3 
Orthopedic n= 4 
Cosmetic n= 3 
Vascular n= 2 
Sinus surgery n= 1 
Laser capsulotomy n= 1 
Invasive procedures:  
Gynecological n= 2 
Gastrointestinal n= 7 
Urological n= 2 
Epidural injection n= 1 
Thyroid biopsy n= 4 
Inferior Vena Cava (IVC) filter removal n= 3 
Toe Nail Avulsion n= 1 
Anticoagulant Bridge Therapy:  
LMWH therapeutic dose n=23 
Fondaparinux therapeutic dose n= 2 
LMWH (combined treatment and prophylactic dose) n= 7 
LMWH/unfractionated heparin (UFH) n= 1 
LMWH prophylactic dose n= 9 
Fondaparinux (prophylactic dose) n= 2 
No bridge therapy n= 4 
Complications:  
Bleeding  
Major n= 2 
Clinically significant n= 1 
Minor n= 1 
Thrombosis n= 0 
Surgical procedures:  
Gynecological n= 5 
Gastrointestinal n= 7 
Urological n= 2 
Bariatric surgery n= 3 
Orthopedic n= 4 
Cosmetic n= 3 
Vascular n= 2 
Sinus surgery n= 1 
Laser capsulotomy n= 1 
Invasive procedures:  
Gynecological n= 2 
Gastrointestinal n= 7 
Urological n= 2 
Epidural injection n= 1 
Thyroid biopsy n= 4 
Inferior Vena Cava (IVC) filter removal n= 3 
Toe Nail Avulsion n= 1 
Anticoagulant Bridge Therapy:  
LMWH therapeutic dose n=23 
Fondaparinux therapeutic dose n= 2 
LMWH (combined treatment and prophylactic dose) n= 7 
LMWH/unfractionated heparin (UFH) n= 1 
LMWH prophylactic dose n= 9 
Fondaparinux (prophylactic dose) n= 2 
No bridge therapy n= 4 
Complications:  
Bleeding  
Major n= 2 
Clinically significant n= 1 
Minor n= 1 
Thrombosis n= 0 
Conclusion:

Adherence to the ACCP guidelines for the perioperative management of anticoagulation minimizes bleeding complications and improves patient outcomes.

Disclosures:

No relevant conflicts of interest to declare.

Author notes

*

Asterisk with author names denotes non-ASH members.