Three-month cumulative incidence of thromboembolism and bleeding after periprocedural anticoagulation management of arterial vascular bypass patients

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The objective of this study was to determine 3-month cumulative incidence of peri-procedural thromboembolism (TE) including graft occlusion, and peri-procedural bleeding for chronically anticoagulated vascular bypass graft (BG) patients requiring temporary warfarin interruption for an invasive procedure. Appropriate peri-procedural management of patients receiving chronic warfarin therapy to preserve lower extremity arterial BG patency is unknown. In a protocol driven, cohort study design, all BG patients referred to the Mayo Clinic Thrombophilia Center for peri-procedural anticoagulation (1997-2007) were followed forward in time to estimate the 3-month cumulative incidence of TE and bleeding. Decisions to provide "bridging" low molecular weight heparin (LMWH) were individualized based on estimated risk of TE and bleeding. There were 78 BG patients (69 ± 10 years; 38% women), of whom 73% had a distal autogenous and 53% had prosthetic BG; 45% received antiplatelet therapy. Peri-procedural LMWH was prescribed for 77% of patients and did not vary by BG distal anastomosis location or type. The 3-month cumulative incidence of TE was 5.1% (95% CI 1.4-12.6), including two BG occlusions, one DVT, and one myocardial infarction. Major bleeding occurred in 1 patient (1.28%, 95% CI 0.0-6.94). One patient died due to heart failure. TE and bleeding did not differ by bridging status. The 3-month cumulative incidence of TE among BG patients in whom warfarin is temporarily interrupted for an invasive procedure may be higher than in other "bridging" populations (atrial fibrillation, prosthetic heart valve, venous thromboembolism). This finding underscores the often tenuous nature of distal bypass grafts necessitating an aggressive approach to peri-procedural anticoagulation management.