Perioperative Bridging Research Articles

Impact of perioperative low-molecular-weight heparin therapy on clinical events of elderly patients with prior coronary stents implanted > 12 months undergoing non-cardiac surgery: a randomized, placebo-controlled trial

BackgroundLittle is known about the safety and efficacy of discontinuing antiplatelet therapy via LMWH bridging therapy in elderly patients with coronary stents implanted for > 12 months undergoing non-cardiac surgery. This randomized trial was designed to compare the clinical benefits and risks of antiplatelet drug discontinuation via LMWH bridging therapy.MethodsPatients were randomized 1:1 to receive subcutaneous injections of either dalteparin sodium or placebo. The primary efficacy endpoint was cardiac or cerebrovascular events. The primary safety endpoint was major bleeding.ResultsAmong 2476 randomized patients, the variables (sex, age, body mass index, comorbidities, medications, and procedural characteristics) and percutaneous coronary intervention information were not significantly different between the bridging and non-bridging groups. During the follow-up period, the rate of the combined endpoint in the bridging group was significantly lower than in the non-bridging group (5.79% vs. 8.42%, p = 0.012). The incidence of myocardial injury in the bridging group was significantly lower than in the non-bridging group (3.14% vs. 5.19%, p = 0.011). Deep vein thrombosis occurred more frequently in the non-bridging group (1.21% vs. 0.4%, p = 0.024), and there was a trend toward a higher rate of pulmonary embolism (0.32% vs. 0.08%, p = 0.177). There was no significant difference between the groups in the rates of acute myocardial infarction (0.81% vs. 1.38%), cardiac death (0.24% vs. 0.41%), stroke (0.16% vs. 0.24%), or major bleeding (1.22% vs. 1.45%). Multivariable analysis showed that LMWH bridging, creatinine clearance < 30 mL/min, preoperative hemoglobin < 10 g/dL, and diabetes mellitus were independent predictors of ischemic events. LMWH bridging and a preoperative platelet count of < 70 × 109/L were independent predictors of minor bleeding events.ConclusionsThis study showed the safety and efficacy of perioperative LMWH bridging therapy in elderly patients with coronary stents implanted > 12 months undergoing non-cardiac surgery. An alternative approach might be the use of bridging therapy with half-dose LMWH.Trial registrationISRCTN65203415.

Perioperative bridging anticoagulation in patients receiving oral anticoagulants (OACs) undergoing elective surgery/procedures at King Chulalongkorn Memorial Hospital (KCMH), Thailand

Perioperative bridging anticoagulation in patients receiving oral anticoagulants (OACs) undergoing elective surgery/procedures at King Chulalongkorn Memorial Hospital (KCMH), Thailand

Compliance to perioperative anticoagulation protocols in elderly patients undergoing elective orthopedic procedures: a retrospective observational cohort study on 548 patients

BackgroundCompliance with perioperative anticoagulation guidelines is essential to minimize bleeding and thromboembolic risks in patients undergoing surgery. Compared to vitamin-K antagonists (VKAs), perioperative management of direct oral anticoagulants (DOACs) contains fewer steps. Therefore, we hypothesized that noncompliance with guidelines in VKA users is higher than in DOAC users. The primary aim of our study was to investigate the difference in noncompliance to perioperative anticoagulant management guidelines between elderly patients using VKAs versus those using DOACs. The secondary aim was to determine the difference in occurrence of conflicting information communicated to the patients and the difference in incidence of coagulation-related adverse events.MethodsThis retrospective non-controlled observational cohort study examined elderly patients undergoing elective orthopedic surgery in a teaching hospital in the Netherlands. All patients undergoing elective orthopedic surgery between 1 May 2016 and 1 January 2020, aged 70 years and over, using VKAs or DOACs were selected. Nonelective surgeries were excluded. The primary outcome was the noncompliance to perioperative anticoagulant management guidelines. Secondary outcomes were missing or conflicting information on anticoagulation management communicated to the patient and coagulation-related adverse events. For continuous data, the unpaired T-test was used and for categorical data, the chi-square test.ResultsIn patients using VKAs, noncompliance to one of the steps of perioperative anticoagulation management was 81%, compared to 55% in patients using DOACs (p < 0.001). In most cases, VKAs or DOACs were interrupted for longer than recommended. In 13% of patients using a VKA with perioperative bridging, bridging was not conducted as recommended in the guidelines. In 13% of patients using a DOAC, a low-molecular-weight heparin (LMWH) was prescribed while a DOAC had already been restarted postoperatively. VKA users received conflicting information about perioperative anticoagulation management more often than DOAC users (33% versus 20%; p < 0.001). No difference was seen in postoperative coagulation-related complications.ConclusionGuidelines compliance in DOAC users is higher than in VKA users. Clinical decision support to help in selecting the right interruption interval in DOAC users, simplified standardized perioperative management, good coordination of instructions given to patients, and familiarity with updated guidelines are important in reducing noncompliance.

Midterm results on a new self-expandable covered stent combined with branched stent grafts: Insights from a multicenter Italian registry

ObjectiveTo investigate the technical periprocedural and midterm outcomes of endovascular repairs with multibranched endovascular repair or iliac branch devices combined with a new self-expanding covered stent. MethodsThe COvera in BRAnch registry is a physician-initiated, multicenter, ambispective, observational registry (ClinicalTrials.gov Identifier: NCT04598802) enrolling patients receiving a multibranched endovascular repair or iliac branch devices procedure mated with Bard Covera Plus (Tempe, AZ) covered stent, designed to evaluate the outcomes of the covered stent mated with patient-specific and off-the-shelf branched stent graft. Primary end points were technical success, branch instability, and freedom from aortic and branch-related reintervention within 30 days and at follow-up. Preoperative characteristics, comorbidities, and outcomes definitions were graded according to the Society for Vascular Surgery reporting standards. ResultsTwo hundred eighty-four patients (76 years; range, 70-80 years; 79% males) in 24 centers were enrolled for a total of 708 target vessels treated. The covered stents were mated with an off-the-shelf graft in 556 vessels (79%) and a custom-made graft in 152 (21%). Three hundred seven adjunctive relining stents in 277 vessels (39%) were deployed, of which 116 (38%) were proximal, 66 (21%) intrastent, and 125 (41%) distal. Adjunctive relining stent placement was more frequent when landing in a vessel branch instead of the main trunk (59% vs 39%; P = .031), performing a percutaneous access (49% vs 35%; P < .001), using a stent with a diameter of 8 mm or greater (44% vs 36%; P = .032) and a length of 80 mm or greater (65% vs 55%; P = .005), when a post-dilatation was not performed (45% vs 29%; P < .001) and when an inner branch configuration was used (55% vs 35%; P < .001). Perioperative technical bridging success was 98%. Eight patients (3%) died in the perioperative period. Two deaths (1%) were associated with renal branch occlusion followed by acute kidney injury and paraplegia. Follow-up data were available for 638 vessels (90%) at a median of 32 months (Q1, Q3, 21, 46). Branch instability was reported in 1% of branches. Forty-six patients (17%) died during follow-up, nine (3%) of them owing to aortic-related causes. Primary patency rates at 1, 2, and 3 years were 99% (581/587), 99% (404/411), and 97% (272/279), respectively. Branch instability was associated with patient-specific devices (9% vs 4%; P = .014) and intrastent adjunctive stent placement (12% vs 2%; P = .003), especially when a bare metal balloon-expandable stent was used (25% vs 3%; P < .001). ConclusionsThe use of this new self-expanding covered stent mated with branched endografts proved to be safe and feasible with high technical procedural success rates. Low rates of branch instability were observed at midterm follow-up. Comparative studies with other commercially available covered stents are warranted.

Risk-adjusted perioperative bridging anticoagulation reduces bleeding complications without increasing thromboembolic events in general and visceral surgery

BackgroundPerioperative bridging of oral anticoagulation increases the risk of bleeding complications after elective general and visceral surgery. The aim of this study was to explore, whether an individual risk-adjusted bridging regimen can reduce bleeding events, while still protecting against thromboembolic events.MethodsWe performed a quality improvement study comparing bridging parameters and postoperative outcomes before (period 1) and after implementation (period 2) of a new risk-adjusted bridging regimen. The primary endpoint of the study was overall incidence of postoperative bleeding complications during 30 days postoperatively. Secondary endpoints were major postoperative bleeding, minor bleeding, thromboembolic events, postoperative red blood cell transfusion, perioperative length-of-stay (LOS) and in-hospital mortality.ResultsA total of 263 patients during period 1 and 271 patients during period 2 were compared. The included elective operations covered the entire field of general and visceral surgery. The overall incidence of bleeding complications declined from 22.1% during period 1 to 10.3% in period 2 (p < 0.001). This reduction affected both major as well as minor bleeding events (8.4% vs. 4.1%; p = 0.039; 13.7% vs. 6.3%; p = 0.004). The incidence of thromboembolic events remained low (0.8% vs. 1.1%). No changes in mortality or length-of-stay were observed.ConclusionIt is important to balance the individual thromboembolic and bleeding risks in perioperative bridging management. The risk adjusted bridging regimen reduces bleeding events in general and visceral surgery while the risk of thromboembolism remains comparably low.

Comparison of the Recent Updates to the ACC/AHA and ESC Guidelines for the Management of Valvular Heart Disease: Similarities and Differences.

There have been several advances in the diagnosis and management of valvular heart disease (VHD) over the last decade. These have been reflected in the latest European and North American guidelines, although both contain significant similarities and differences. In this review, we highlight the important overlaps and variations between the updated guidelines and their previous versions to help guide the general cardiologist. There has been extensive revision on the use of percutaneous treatments, the indications for intervention in asymptomatic VHD, and perioperative bridging therapies. The updated guidelines provide new recommendations in many aspects of VHD; however, there remain significant gaps in the role of biomarkers in VHD and the long-term outcomes of novel oral anticoagulants (NOACs) and transcatheter therapies.

Perioperative management in chronically anticoagulated children undergoing tonsillectomy.

Tonsillectomy is a common procedure in children. Patients at high risk for thrombosis who require chronic anticoagulation therapy pose a special challenge when undergoing tonsillectomy, as bleeding may occur up to two weeks after surgery. Due to a lack of evidence-based data, there is no consensus on the best management for such patients. The objective of our manuscript is to review perioperative anticoagulation bridging strategies in children undergoing tonsillectomy. Retrospective case series of chronically anticoagulated patients at high risk for a thromboembolic event, who underwent tonsillectomy from 2010 to 2021. Patients whose anticoagulation treatment was discontinued due to a low risk of thromboembolic events were excluded. Four patients met inclusion criteria (age range 1.5-16.1 years). All patients were admitted prior to surgery for bridging therapy with intravenous unfractionated heparin (UFH) drip titrated to a therapeutic dose until 4-6 hours prior to surgery. The estimated blood loss during surgery was minimal in all surgeries. UFH was readministered per hospital protocol on the night of surgery and titrated to a therapeutic dose. Postoperative warfarin was restarted within 2 days for all patients. High-risk patients were kept in the hospital until postoperative day 6-8 due to concern for delayed bleeding. One patient was noticed to have blood-tinged sputum requiring no intervention, and none of the patients developed early or delayed hematemesis. Our data show that bridging therapy with UFH has been successful. Chronically anticoagulated patients undergoing tonsillectomy require multidisciplinary care for the management of their pre- and postoperative course.

Bridging therapy according to new clinical guidelines: A review

In modern world it is really important to know how to manage patients taking anticoagulant or antiplatelet therapy. There is an increasing number of patients, who have gone through PCI or any other cardiac intervention and who also need another surgery which cannot be postponed till the end of dual antiplatelet therapy. The number of patients who take oral anticoagulant has also increased last years. Algorithms of perioperative bridging therapy and antiplatelet therapy discontinuation can help to decrease both ischemic and hemorrhagic complications. Multidisciplinary risk assessment remains a critical component of perioperative care.

Perioperative bridging anticoagulation in patients with oral cancer surgery: a multicenter retrospective study

The number of patients administered oral antithrombotic drugs who require elective surgery has increased. Perioperative heparin bridging needs to be considered for patients at a high risk of thromboembolism. The present study investigated the effects of perioperative heparin bridging therapy on perioperative complications (postoperative bleeding and thrombotic events) in oral cancer surgery. The medical records of 98 patients who underwent oral cancer surgery with perioperative bridging therapy were retrospectively analyzed. Postoperative hemorrhage occurred in 16 patients (16.3%) and thrombotic events (deep venous thrombosis) in 5 (5.1%), which were higher than in other surgeries. A multivariate analysis identified the administration of prostaglandins as the only significant independent risk factor for postoperative hemorrhage, and a longer duration of postoperative heparin bridging therapy was associated with the incidence of deep venous thrombosis. The present results suggest a higher incidence of thrombotic and bleeding events in patients who underwent oral cancer surgery with heparin bridging, and the nature of surgery (such as revascularization and prolonged bed rest) may be a contributing factor. Future studies are needed to establish whether heparin bridging is effective in oral cancer surgery.

Impact of perioperative antithrombotic strategies on clinical events in non-cardiac surgery.

Antithrombotic therapy including antiplatelet agents and anticoagulants are prescribed for secondary prevention in patients with established cardiovascular disease. Although antithrombotic therapy is often interrupted before non-cardiac surgery with or without perioperative bridging anticoagulation, the impact on thrombotic and bleeding events remains uncertain. A total of 360 patients chronically treated with antithrombotic therapy for secondary prevention underwent elective non-cardiac surgery under general anesthesia, with the complete interruption of antithrombotic agents. The study endpoints included all-cause death, thrombotic events, and major bleeding complications after surgical procedures. Of 360 patients, 190 (52.8%) and 200 (55.6%) received antiplatelet and anticoagulation perioperatively. Atrial fibrillation (32.8%) and coronary artery disease (22.5%) were the major indications for antithrombotic regimens. Antithrombotic therapy was interrupted from 5 [2, 7] days before the surgery to 4 [2, 7] days postoperatively. Perioperative bridging therapy with unfractionated heparin was employed in 113 (31.4%) patients. During the hospitalization, one (0.3%) patient died due to non-cardiovascular causes. Thrombotic events and major bleeding occurred in two (0.6%) and eight (2.2%) patients. Bridging therapy with heparin was significantly associated with an increased risk of bleeding events (5.3% vs. 0.8%, p = 0.02). Pre-operative bridging therapy with heparin and operative duration were significantly associated with bleeding complications. In the present study, complete interruption of antithrombotic therapy resulted in a few thrombotic events in patients undergoing elective non-cardiac surgery. Bridging therapy with heparin and longer operative duration were significantly associated with post-operative bleeding complications.

Impact of perioperative interruption of antithrombotic therapy on thrombotic and bleeding events in non-cardiac surgery

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Antithrombotic therapy including antiplatelet agents and anticoagulants are prescribed for secondary prevention in patients with established cardiovascular disease. Although antithrombotic therapy is often interrupted before non-cardiac surgery with or without perioperative bridging anticoagulation, the impact on thrombotic and bleeding events remains uncertain. Purpose The aim of this study was to clarify the impact of perioperative interruption of anticoagulants on thrombotic and bleeding events in patients with established CVD undergoing elective non-cardiac surgery. Methods A total of 330 patients chronically treated with antithrombotic therapy for secondary prevention underwent elective non-cardiac surgery under general anesthesia, with the complete interruption of antithrombotic agents. The study endpoints included all-cause death, thrombotic events, and major bleeding complications after surgical procedures. Results Of 330 patients, 171 (51.8%) and 159 (48.2%) received antiplatelet agents and anticoagulants perioperatively. Atrial fibrillation (31.8%) and coronary artery disease (20.3%) were the major indications for antithrombotic regimens. Antithrombotic therapy was interrupted from 5 [2, 7] days before the surgery to 4 [2, 7] days postoperatively. Perioperative bridging therapy with unfractionated heparin was employed in 99 (30.0%) patients. During the hospitalization, 3 (0.9%) patients died due to non-cardiovascular causes. Thrombotic events and major bleeding occurred in 2 (0.6%) and 9 (2.7%) patients. Bridging therapy with heparin was non-significantly associated with an increased risk of bleeding events (5.1% vs. 1.7%, p = 0.09). In univariable and multivariable analyses, pre-operative hemoglobin level and operative duration were significantly associated with bleeding complications. Conclusions In the present study, complete interruption of antithrombotic therapy resulted in a few thrombotic events with a numerically higher rate of bleeding events in patients undergoing elective non-cardiac surgery. Pre-operative hemoglobin level and operative duration were significantly associated with post-operative bleeding complications.

Management of anticoagulated patients in dentoalveolar surgery: a retrospective study comparing bridging with heparin versus unpaused vitamin K antagonist medication

BackgroundThe aim of this study was to investigate the occurrence of postoperative bleeding following dentoalveolar surgery in patients with either continued vitamin K antagonist medication or perioperative bridging using heparin.MethodsA retrospective study was performed analyzing patients who underwent tooth extraction between 2012 and 2017. Patients were retrospectively allocated into two comparative groups: un-paused vitamin K antagonist medication versus bridging using heparin. A healthy, non-anticoagulated cohort with equivalent surgery served as a control group. Main outcome measures were: the occurrence and frequency of postoperative bleeding, the number of removed teeth, the surgical technique of tooth removal (extraction/osteotomy/combined extraction and osteotomy) and the prothrombin time.Results In total, 475 patients were included in the study with 170 patients in the group of un-paused vitamin K antagonist medication VG, 135 patients in the Bridging group BG and 170 patients in the control group CG. Postoperative bleeding was significant: CG versus VG p = 0.004; CG versus BG p < 0.001, BG versus VG p < 0.001. A significant correlation of number of the extracted teeth in the BG (p = 0.014) and no significance in VG (p = 0.298) and CG (p = 0.210) and in the BG versus VG and CG with p < 0.001 in terms of surgical intervention extraction. No difference observed in terms of prothrombin time.ConclusionsBridging with heparin increases the risk for bleeding compared to un-paused vitamin K antagonist medication. The perioperative management of anticoagulated patients requires a well-coordinated interdisciplinary teamwork to minimize or at best avoid both: postoperative bleeding and thromboembolic incidences.

Safety of Hepatobiliary and Pancreatic Surgery in Patients Receiving Direct Oral Anticoaulants (DOACs)

Introduction: The safety and optimal perioperative management of patients receiving direct oral anticoagulants (DOACs) during hepatobiliary and pancreatic (HBP) surgery is still controversial. Methods: Between 2012 and 2018, 115 anticoagulant-prescribed patients who underwent elective HBP surgery (65 benign and 50 malignant diseases, 69 laparoscopic and 46 open-fashioned operations) in our department were enrolled in this study. Patients undergoing emergency operations were excluded from the study. The patients were divided into two groups; patients receiving DOACs (DOAC group, n = 35) and patients undergoing warfarin therapy (WF group, n = 80). Background characteristics, surgical blood loss, and postoperative complications, including bleeding and thrombotic complications, were compared between the groups. Results: In the DOAC group, dabigatran, apixaban, rivaroxaban, and edoxaban were used in 10, 8, 10, and 7 patients, respectively, and only 11 patients (31.4%) received perioperative heparin bridging. There were no differences in patients´ background characteristics and mode of surgery (open or laparoscopic). The duration of operation (p = 0.148), surgical blood loss (p = 0.782), and the rate of intraoperative red blood cell transfusion (p = 1.000) were similar between the groups. Overall, any thromboembolic complications were not observed in the current cohort, and only 1 patient (2.9%) suffered from postoperative bleeding complication in the DOAC group. The mortality was zero, and the length of postoperative stay was also identical between the groups (p = 0.998). Conclusion: HBP surgery is safely performed in patients receiving DOAC therapy, without increase in bleeding or thromboembolic complications compared with warfarin therapy.

Markedly increased risk of postoperative bleeding complications during perioperative bridging anticoagulation in general and visceral surgery

BackgroundIncreasing numbers of patients receiving oral anticoagulants are undergoing elective surgery. Low molecular weight heparin (LMWH) is frequently applied as bridging therapy during perioperative interruption of anticoagulation. The aim of this study was to explore the postoperative bleeding risk of patients receiving surgery under bridging anticoagulation.MethodsWe performed a monocentric retrospective two-arm matched cohort study. Patients that received perioperative bridging anticoagulation were compared to a matched control group with identical surgical procedure, age, and sex. Emergency and vascular operations were excluded. The primary endpoint was the incidence of major postoperative bleeding. Secondary endpoints were minor postoperative bleeding, thromboembolic events, length of stay, and in-hospital mortality. Multivariate analysis explored risk factors of major postoperative bleeding.ResultsA total of 263 patients in each study arm were analyzed. The patient cohort included the entire field of general and visceral surgery including a large proportion of major oncological resections. Bridging anticoagulation increased the postoperative incidence of major bleeding events (8% vs. 1%; p < 0.001) as well as minor bleeding events (14% vs. 5%; p < 0.001). Thromboembolic events were equally rare in both groups (1% vs. 2%; p = 0.45). No effect on mortality was observed (1.5% vs. 1.9%). Independent risk factors of major postoperative bleeding were full-therapeutic dose of LMWH, renal insufficiency, and the procedure-specific bleeding risk.ConclusionPerioperative bridging anticoagulation, especially full-therapeutic dose LMWH, markedly increases the risk of postoperative bleeding complications in general and visceral surgery. Surgeons should carefully consider the practice of routine bridging.

Efficacy and Safety of Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation Undergoing Elective Surgical Procedures: A Meta-analysis.

Objective: The study objective was to determine if peri-operative bridging anticoagulation in patients with atrial fibrillation is beneficial or harmful.Design: Systematic review and meta-analysis.Setting: Inpatient or in-hospital setting.Participants: Adults with atrial fibrillation having a CHADS2 score >1 undergoing elective surgical procedure on anticoagulation.Methods: A systemic search of multiple databases (Cochrane, Medline, PubMed) was performed regarding studies conducted on efficacy and safety of perioperative bridging anticoagulation in patients with atrial fibrillation. Studies identified were reviewed by two authors individually before inclusion. The results were then pooled using Review Manager to determine the combined effect. Stroke/systemic embolism was considered as the primary efficacy outcome. Major bleeding was the primary safety outcome.Results: The systematic search revealed 108 potential articles. The full texts of 28 articles were retrieved for assessment of eligibility. After full text review, 25 articles were excluded. Three articles met inclusion criteria. No significant difference in stroke/systemic embolism with bridging anticoagulation was noted (risk ratio, 1.25-95% confidence interval [CI], 0.55-2.85). Bridging was associated with significantly higher risk of major bleeding (risk ratio, 3.29-95% CI, 2.25-4.81).Conclusion: An individualized approach is required when initiating peri-operative bridging anticoagulation. There is certainly a higher risk of bleeding with bridging anticoagulation and no difference in stroke/systemic embolism. However, the results cannot be extrapolated to patients who have valvular atrial fibrillation or CHADS2 score of 5 or greater.

Antiplatelet Therapy with Cangrelor in Patients Undergoing Surgery after Coronary Stent Implantation: A Real-World Bridging Protocol Experience.

Objective The aim of the study is to describe the real-world use of the P2Y 12 inhibitor cangrelor as a bridging strategy in patients at high thrombotic risk after percutaneous coronary intervention (PCI) and referred to surgery requiring perioperative withdrawal of dual antiplatelet therapy (DAPT). Materials and Methods We collected data from nine Italian centers on patients with previous PCI who were still on DAPT and undergoing nondeferrable surgery requiring DAPT discontinuation. A perioperative standardized bridging protocol with cangrelor was used. Results Between December 2017 and April 2019, 24 patients (mean age 72 years; male 79%) were enrolled. All patients were at high thrombotic risk after PCI and required nondeferrable intermediate to high bleeding risk surgery requiring DAPT discontinuation (4.6 ± 1.7 days). Cangrelor infusion was started at a bridging dose (0.75 µg/kg/min) 3 days before planned surgery and was discontinued 6.6 ± 1.5 hours prior to surgical incision. In 55% of patients, cangrelor was resumed at 9 ± 6 hours following surgery for a mean of 39 ± 38 hours. One cardiac death was reported after 3 hours of cangrelor discontinuation prior to surgery. No ischemic outcomes occurred after surgery and up to 30-days follow-up. The mean hemoglobin drop was <2 g/dL; nine patients received blood transfusions consistent with the type of surgery, but no life-threatening or fatal bleeding occurred. Conclusion Perioperative bridging therapy with cangrelor is a feasible approach for stented patients at high thrombotic risk and referred to surgery requiring DAPT discontinuation. Larger studies are warranted to support the safety of this strategy.

Impact of antithrombotic therapy on the outcomes with focus on bleeding and thromboembolic events in patients undergoing pancreticoduodenectomy.

We investigated perioperative outcomes of pancreaticoduodenectomy (PD) in patients receiving antithrombotic therapy (ATT) with a focus on the incidence of perioperative bleeding and thromboembolic complications. A total of 77 patients who underwent PD at our institution between 2013 and 2019 were retrospectively reviewed. Clinical findings and surgical outcomes including bleeding and thromboembolic complications were compared in patients with or without ATT. Interruption of ATT and perioperative heparin bridging were based on our hospital protocol. Among ATT (30) and non-ATT (47) groups, ATT group had a significantly higher age and history of cardiocerebrovascular diseases. No significant difference was observed in intraoperative and post-pancreatectomy haemorrhage (PPH) between the groups. ATT group was associated with a significantly higher rate of post-operative complications, Clavien-Dindo classification ≥II and thromboembolic events. Operative mortality in ATT and non-ATT groups was 2 (6.7%) and 1 (2.1%), respectively. There was no significant association between ATT and excessive intraoperative blood loss (≥1000 mL), PPH (≥grade B) and thromboembolic complications (Clavien-Dindo classification ≥II). In patients with ATT, PD is a feasible procedure with no major impact on intraoperative bleeding or PPH.

Perioperative antithrombotic management of patients who receive direct oral anticoagulants during gastroenterological surgery.

AimWe investigated the effect of perioperative management of direct oral anticoagulants (DOACs) on bleeding and thromboembolic complications during gastroenterological (GE) surgery.MethodsA total of 334 patients receiving anticoagulants and undergoing elective GE surgery between 2012 and 2018 were enrolled. The patients were divided into three groups: patients receiving warfarin (WF, n = 231), patients receiving DOACs with heparin bridging (DOAC‐HB, n = 34), and patients receiving DOAC without heparin bridging (DOAC‐NHB, n = 69). Outcome variables were compared between the groups and the risk factors of postoperative bleeding were assessed using logistic multivariate analysis.ResultsNo significant differences were observed in background characteristics between the groups. There were similarities between the groups in surgical blood loss (P = .772) and rate of intraoperative transfusion (P = .952). Thromboembolic complications only occurred in two patients in the WF group (0.9%), and no thromboembolism occurred in the DOAC groups. The incidence of major postoperative bleeding was significantly higher in DOAC‐HB group than in the other groups (14.7% vs 4.8% vs 1.4%, P = .011). Multivariate analysis showed DOAC with heparin bridging to be the most significant risk factor of major postoperative bleeding (odds ratio = 11.60, P = .028).ConclusionsElective GE surgery can be safely performed in patients receiving DOACs without heparin bridging. Perioperative heparin bridging during DOAC interruption is not recommended even for patients undergoing major GE surgery due to increased postoperative bleeding.

The impact of perioperative heparin bridging therapy in lung cancer surgery.

The impact of perioperative heparin bridging (HB) for lung surgery in patients on anti-clotting drugs remains unclear. We performed a retrospective study to assess its effect on surgical safety by comparing HB and non-HB groups. This study included 274 consecutive patients on anti-clotting drugs who underwent surgery for lung cancer. Of these, 77 received HB and 197 did not. Propensity score matching extracted 124 patients, consisting of 62 patients with HB and 62 patients without HB. Endpoints were surgical safety. There was no statistically significant difference in the outcomes of surgical safety outcomes between the HB and non-HB group after propensity-score matching, operative time (172 vs. 203min, p = 0.131), volume of blood loss (60 vs. 70ml, p = 0.335), need for intraoperative RBC transfusion (3.2 vs. 6.5%, p = 0.680), chest tube drainage volume on the 1st postoperative day (200 vs. 200ml, p = 0.796), and chest tube placement duration (3 vs. 3days, p = 0.606). The influence of perioperative HB on postoperative thromboembolic or bleeding events in lung cancer surgery is not obvious, but its surgical safety appears to be acceptable.

Perioperative Bridging of Anticoagulation - Does Protocol Adherence Improve Outcomes?

Background: Perioperative warfarin management is a clinical challenge as it requires careful assessment of both thrombosis and bleeding risk associated with the planned procedure. In our experience, many clinicians favor bridging over not bridging and often use full dose unfractionated or low molecular weight heparin even when a prophylactic dose would be a reasonable alternative. To improve and standardize the complex decision-making process for anticoagulation management for patients undergoing elective surgery we introduced an evidenced-based perioperative bridging anticoagulation protocol in 2017 based on the 9th edition of American College of Chest Physicians guidelines. The aim of the study was to investigate the impact of the perioperative bridging anticoagulation protocol on postoperative bleeding and thrombotic events in patients undergoing elective surgery at our institution. We hypothesized that adherence to the proposed protocol reduces the incidence of postoperative bleeding complications without an increase in thrombotic risk. Methods: We performed a retrospective chart review for all surgical inpatients who were on long-term anticoagulation with warfarin and who required interruption of warfarin around surgery at Dartmouth-Hitchcock Medical Center from June 2016, when the protocol was introduced, to June 2019. Data were extracted from the electronic medical record for each study subject and included demographics, clinical and radiologic data, indication for long-term anticoagulation (atrial fibrillation, venous thromboembolism, or mechanical heart valve), risk categories for thrombotic events, type of surgery, anticoagulation management before and after surgery including type and dose of short-acting anticoagulation used for bridging, and bleeding and thrombotic complications within 30 days of surgery. We evaluated adherence to the bridging protocol by individual providers and divided subjects into two groups for comparison: 1) subjects who received protocol-directed care and 2) subjects who received non-protocol care. We compared the risk of postoperative bleeding and thrombotic events in the two groups using the R3.5.1. Concordance of bridge protocol and crude associations between discrete variables were assessed by McNemar's and two-tailed Fisher's exact test, respectively. Multivariate logistic regression was used to estimate covariate-adjusted association groups and the outcomes of interest. P &amp;lt; 0.05 was used as the criterion for statistical significance. Results: 194 subjects met entry criteria and were included in the study; 114 subjects were managed according to the protocol (58.8%; 95% CI = 51.5%-65.8%, McNemar's P = 0.034). Clinical characteristics were similar in the protocol-adherent and nonadherent groups. Most patients (50%) were on long-term warfarin for stroke prevention with atrial fibrillation. The incidence of bleeding and thrombotic complications for the entire population was 7.8% and 4.7 %, respectively. Two-thirds of subjects who experienced either bleeding (66.7% vs 33.3%, 95% CI= 0.91-11.93, P = 0.055, two tailed Fischer's exact test) or thrombotic (66.7% vs 33.3%, 95% CI= 0.62-19.19, P = 0.16, two tailed Fischer's exact test) complications were in the protocol-nonadherent group. Controlling for age and sex using multivariate logistic regression, subjects whose anticoagulation was not managed postoperatively in adherence to the protocol were over three times as likely to experience a bleeding complication (adjusted odds ratio=3.36, 95% CI= 1.13-11.40, P = 0.036) and a thrombotic complication (adjusted odds ratio=3.54, 95% CI=0.88-17.77, P=0.088) when compared to patients whose postoperative anticoagulation management was protocol-driven. Discussion: Overall adherence to an evidence-based anticoagulation bridging protocol by providers was only 59%. When adhered to, protocol-based practice helped to reduce bleeding complications by 60% and was associated with a trend toward a lower risk for thrombosis. Our study results emphasize the value of an evidence-based perioperative anticoagulation bridging protocol and the importance of protocol adherence. To improve adherence, we have now embedded the protocol as an order-set in our electronic medical record system and have provided additional education to providers within our institution with a plan to assess improvement in adherence subsequently. Disclosures No relevant conflicts of interest to declare.