Bridging therapy for oral anticoagulation increases the risk for bleeding-related complications in total joint arthroplasty.

Martijn Haighton,Louis N. Marting,Remmelt M R Veen,Nienke Wolterbeek,Diederik H R Kempen,Martijn van Dijk

doi:10.1186/s13018-015-0285-6

Martijn Haighton, Louis N. Marting + Show 4 more

Open Access

https://doi.org/10.1186/s13018-015-0285-6

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Abstract

BackgroundPatients scheduled for elective surgery with a high risk of thromboembolism require anticoagulation bridging therapy perioperatively. The purpose of this study was to assess the risk of thromboembolic events and bleeding-related complications after total hip and knee arthroplasty in patients requiring bridging therapy for anticoagulants.MethodsA retrospective cohort study of all patients with primary total hip or total knee replacement in a 4-year period was performed. Outcome measures were blood loss, thromboembolic and bleeding-related complications and hospital stay.ResultsBridged patients had more blood loss and higher complication rates than the control group. Most complications were bleeding-related, and there were no thromboembolic events. Seven of the 14 (50 %) total hip patients bridged with unfractioned heparin required reoperation (three patients with ischial neuropraxia due to hematoma). There were two bleeding-related deaths in total hip patients bridged with low-molecular-weight heparin. Mean hospital stay was significantly longer in unfractioned heparin bridging.ConclusionIn this study, there was a significant increase in bleeding-related complications in total joint replacement with bridging therapy compared to prophylaxis. This risk was highest in patients with total hip arthroplasty. There were no thromboembolic events in bridged patients.

Highlights

Patients scheduled for elective surgery with a high risk of thromboembolism require anticoagulation bridging therapy perioperatively
In one patient with deep venous thrombosis (DVT) and pulmonary embolism (PE) after previous contralateral total knee arthroplasty (TKA) and one patient with postoperative atrial fibrillation (AF), immediate postoperative therapeutic low-molecular-weight heparin (LMWH) was started. These patients did not receive oral anticoagulation (OAC) preoperatively, they were included in the LMWH bridging TKA group
OAC use was significantly higher and antiaggregants use significantly lower in bridging groups compared to the prophylaxis group

Summary

Introduction

Patients scheduled for elective surgery with a high risk of thromboembolism require anticoagulation bridging therapy perioperatively. The purpose of this study was to assess the risk of thromboembolic events and bleeding-related complications after total hip and knee arthroplasty in patients requiring bridging therapy for anticoagulants. Patients with conditions causing a high risk for thromboembolism (atrial fibrillation, mechanical heart valves or recurrent venous thromboembolism) require long-term oral anticoagulation (OAC) therapy with vitamin K antagonists. Whereas interruption of OAC increases the risk of thromboembolic events, continuing results in a risk of bleeding-related complications. To balance these risks, OAC can be interrupted to obtain normal coagulation during surgery and. In recent prospective observational studies, LMWH was shown to be as safe as UFH in selective procedures with low thromboembolic event rates of 0.6–3.6 % and major bleeding rates of 0.5–11.3 %

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