Periprocedural Anticoagulation Research Articles

Three‐way stopcock suture technique for hemostasis after ablation for atrial fibrillation

Figure-of-eight sutures (F8S) have emerged as an alternative to the standard practice of manual compression to achieve venous hemostasis after catheter ablation for atrial fibrillation (AF). In lieu of a knot to secure the sutures in place, a three-way stopcock can be used, which can be loosened or tightened as needed to achieve hemostasis and is easier to remove. The safety and effectiveness of this technique, when compared to traditional F8S, are unknown. In this case series, we sought to describe this stopcock closure (SC) technique and compare procedural characteristics and outcomes to the traditional F8S. Charts of consecutive patients who underwent AF radiofrequency at two centers were reviewed for the type of hemostasis (SC or F8S), demographics, periprocedural anticoagulation, groin complications, and procedural duration. A total of 100 patients were included (50 in the F8S group and 50 in the SC group). The two groups were similar in terms of mean age, gender, weight, renal function, oral anticoagulant use, and procedural heparin dosing. There was one groin bleeding complication in each group. The procedural time was shortened in the SC group (220 ± 8 minutes vs 313 ± 8 minutes), and there was more protamine use (25 vs 3 patients) owing to the differences in preferences among two operators. In this proof-of-concept study, a simple stopcock device provided comparable hemostasis to standard F8S after radiofrequency catheter ablation of AF.

410. Nitinol venous stent outcomes in peripartum women following treatment for acute ilio-femoral deep vein thrombosis

Introduction Deep vein thrombosis (DVT) is the leading cause of morbidity and mortality within pregnant and post-partum women. Contemporary management of acute ilio-femoral DVT includes catheter-directed thrombolysis and stenting of an obstructive lesion. Objective This study examines venous stent related outcomes of peripartum women (pregnant or within 6wks post-partum) with acute ilio-femoral DVT. Methods Peripartum women (2012–2017) treated for acute ilio-femoral DVT were included for analysis. Primary patency was defined as a patent stent with Results Of 190 patients treated for acute ilio-femoral DVT, 81 (43%) were women. Cumulative patency was 88% (median follow-up 2.3 yrs; range 30–328 wks). From this group, 9 women were peripartum (11%). Onset of DVT was post-partum for all (mean 4 wks after birth; range 3–6 wks). Two women were treated with catheter-directed thrombolysis alone, and 7 women were also stented. Median age at the time of stent placement was 29yrs (range 22–41 yrs). Primary, primary-assisted, and secondary patency rates were 14%, 43%, and 43%, respectively. Re-intervention was required in 6/7 (86%) peripartum women, with mean time to re-intervention of 9 wks (range 1–33 wks). Venous stenting in peripartum women was associated with a higher risk of re-intervention (HR 6.58; p = 0.0001, 95% CI [2.46, 17.60]), and was a strong predictor of cumulative patency loss (HR 10.71; p = 0.002, 95% CI [2.37, 48.51]). Discussion Peripartum women are significantly more likely to require re-intervention and experience patency loss compared with their non-peripartum counterpart. Thresholds for intervention may need to be higher and periprocedural anticoagulation strategies require more investigation if treatment is to be offered in the peripartum period.

A retrospective analysis of the periprocedural management of oral anticoagulants in patients undergoing interventional radiology procedures.

Limited evidence is available to guide periprocedural management of oral anticoagulants in the setting of interventional radiology (IR) procedures. For direct oral anticoagulants, therapy interruption (TI) is based on medication half-life and procedural bleeding risk. Periprocedural management of warfarin includes INR monitoring, and possible bridging with parenteral anticoagulants. It is unknown if these recommendations apply to IR procedures. To evaluate bleeding complications and thromboembolic events following periprocedural management of the factor Xa (FXa) inhibitors or warfarin in patients undergoing IR procedures. We performed a retrospective, observational study at NYU Langone Health (NYULH) of all adult patients who underwent an IR procedure from January 2015 to July 2017 and were receiving apixaban, rivaroxaban, or warfarin. Patients who were pregnant or who had a mechanical heart valve were excluded. At NYULH, TI is not required for FXa inhibitors, and an INR < 3 is recommended for patients on warfarin undergoing low risk procedures. For moderate/high risk procedures, TI for 48h or 72h with reduced renal function, is recommended for FXa inhibitors, and an INR < 1.5 is recommended for patients on warfarin. We evaluated 350 IR procedures, with a total of 174 low bleeding risk and 176 moderate/high bleeding risk. The 30-day major bleeding rate was 0.9%, clinically relevant non-major bleeding rate was 3%, minor bleeding rate was 1% and thromboembolic event rate was 1%. The periprocedural oral anticoagulation management strategy at NYULH appears safe given the low 30-day incidence of bleeding and thromboembolic events.

Clinical Characteristics, Procedural Factors, and Outcomes of Percutaneous Coronary Intervention in Patients With Mechanical and Bioprosthetic Heart Valves

There is scarcity of evidence regarding antiplatelet and anticoagulant therapy in patients with prosthetic valves undergoing percutaneous coronary intervention (PCI). Our goal was to compare clinical outcomes between patients with mechanical or bioprosthetic valves undergoing PCI. The study population comprised patients with either a bioprosthetic or mechanical heart valve in the aortic and/or mitral position undergoing PCI between January 2003 and July 2017. Demographics, admission, and discharge medications as well as procedural details were documented. Outcomes were postprocedural bleeding, length of stay, and in-hospital deaths. Of 211 patients, we identified 119 and 92 patients with a bioprosthetic or mechanical valve, respectively. Mean age was 75 ± 9 years and 66 ± 12 years in bioprosthetic and mechanical valve patients, respectively. Bare-metal stents were used in 18.2% and 30.1% of bioprosthetic and mechanical valve patients, respectively. Major bleeding was documented in 0.8% and 6.5% of bioprosthetic and mechanical valve patients, respectively (p = 0.04). Use of triple therapy (aspirin AND clopidogrel AND oral vitamin K antagonist) was significantly lower in bioprosthetic valve patients compared with mechanical valve patients (12% vs 68%, p <0.001). Our study shows variation in periprocedural anticoagulation and/or antiplatelet choice exists in this population. Patients with mechanical valves experienced higher rates of major bleeding compared with patients with bioprosthetic valves, which could be due to concomitant anticoagulation and dual antiplatelet therapy.

Nerve root injection cancellations because of incomplete anticoagulation management.

Computed tomography-guided steroid injection is a well-recognized, conservative treatment of localized spinal pain as a result of facet arthropathy and radiculopathy secondary to nerve root compression. An extremely rare complication is the development of an epidural haematoma with potential to cause permanent neurological damage, so anticoagulation at the time of procedure is contraindicated. Routinely injections are performed as an outpatient requiring the referring physician to implement a peri-procedural anticoagulation plan. Anecdotal experience suggested that cancellations were occurring as patients remained on anticoagulation at the time of their appointment. The authors therefore assessed the existing service against expected standards to identify the causes of cancellations and find ways to improve the service. This audit aimed to identify the incidence of cancelled computed tomography-guided nerve root injections secondary to incorrect peri-procedural anticoagulation management, develop an intervention to help reduce the incidence of cancellations and then re-audit to assess the effect of the intervention. The audit standard was that 100% of outpatients attending for computed tomography-guided nerve root and facet injections should have an appropriate anticoagulation plan implemented. Baseline data collection took place prospectively between 1 September and 30 November 2016. The study population was elective computed tomography-guided spinal nerve root and facet injections scheduled on the radiology information system at the authors' trust. Descriptive analysis was completed. The intervention involved a revised electronic request form being implemented with new compulsory fields concerning antiplatelets and anticoagulants. Re-audit post-intervention involved prospective data collection between 1 September and 30 November 2017 using the same methods. Baseline audit found that of three out of 55 (5%) patients had cancellations. On re-audit, there were 0 cancellations out of 93 patients. The new request form prevented 5% of patients referred for computed tomography-guided nerve root injection being cancelled because of incorrect anticoagulation management. Extrapolated over the year the potential savings through preventing lost activity are £3445.56.

Safety and efficacy of nonvitamin K antagonist oral anticoagulants during catheter ablation of atrial fibrillation: A systematic review and meta-analysis.

Catheter ablation for atrial fibrillation (AF) is associated with a transitory increase in the risk of both thromboembolic and bleeding events. Evidence on the use of nonvitamin K antagonist oral anticoagulants (NOACs) in patients undergoing AF ablation mostly comes from small observational studies, underpowered to detect differences in clinical outcomes between NOACs and vitamin K antagonists (VKAs) treated patients. This updated meta-analysis aimed to determine the safety and efficacy of periprocedural anticoagulation with NOACs compared with VKAs in AF patients undergoing catheter ablation. We searched MEDLINE, Cochrane library, and web sources for randomized and observational studies comparing periprocedural treatment with NOACs and VKAs in patients undergoing AF ablation. The primary safety endpoint was major bleeding events, and the primary efficacy endpoint was thromboembolic events (a composite of systemic thromboembolism, transient ischemic attack, and stroke). A total of 29 studies with 12644 patients were included in the meta-analysis. Overall, patients on NOACs had a significantly lower risk of major bleeding compared to VKAs either in observational studies (Peto OR 0.68; 95% CI: 0.48-0.95; P=0.022; I2 =20%) or in RCTs (Peto OR 0.30; 95% CI: 0.14-0.62; P=0.001; I2 =28%). Uninterrupted NOACs reduced the risk of major bleeding when compared to uninterrupted VKAs (Peto OR 0.66; 95% CI: 0.45-0.96; P=0.028; I2 =1%), similarly, interrupted NOACs lowered the risk of major bleeding compared to interrupted VKAs (Peto OR 0.29; 95% CI: 0.13-0.66; P=0.003; I2 =0%; Pinteraction =0.076). The rate of thromboembolic complications was very low and did not significantly differ between the study groups either in observational studies (Peto OR 0.91; 95% CI: 0.49-1.67; P=0.755; I2 =0%) or in RCTs (Peto OR 0.14; 95% CI: 0.01-1.30; P=0.083; I2 =0%). Use of NOACs compared to VKAs significantly reduced the risk of bleeding in patients with AF ablation. Similarly, the risk of bleeding was lower with uninterrupted NOACs than with uninterrupted VKAs, and with interrupted NOACs than with interrupted VKAs. The rate of thromboembolic complications was extremely low in both study groups without any differences.

Safety and efficacy of uninterrupted vs. minimally interrupted periprocedural direct oral anticoagulants for catheter ablation of atrial fibrillation: two sides of the same coin?

Safety and efficacy of uninterrupted vs. minimally interrupted periprocedural direct oral anticoagulants for catheter ablation of atrial fibrillation: two sides of the same coin?

Figure-of-eight sutures for hemostasis result in shorter lab recovery time after ablation for atrial fibrillation.

Ablation for atrial fibrillation (AF) requires multiple venous sheaths and anticoagulation with heparin, both risk factors for bleeding complications. Manual compression (MC) with heparin reversal is the standard method to achieve venous hemostasis postablation; however, temporary figure-of-eight sutures (F8S) are an alternative. While this technique has been shown to be safe and effective, little is known about its effect on postprocedural recovery time. In this retrospective cohort study, consecutive patients who underwent AF radiofrequency ablation over a 23-month period were reviewed for type of hemostasis (manual compression or figure-of-eight suture), demographics, periprocedural anticoagulation, groin complications, and procedural duration. A total of 104 patients were included (42 in the MC group and 62 in the F8S group). The two groups were similar for mean age, gender, weight, oral anticoagulant use, and procedural heparin dosing. Access site complications were 4.76%versus 3.23% (P=0.68). Time from procedure end to sheath removal was lower in the F8S group (16.2 ± 8.47vs 4.25 ± 4.14min, P<0.0001). Overall time from procedure end to hemostasis was 36.1 ± 10.1min in the MC group versus 7.9± 5.6 in the F8S group (P<0.0001). Times to extubation and transport out of the lab were both significantly lower in the F8S group (34.1 ± 14.6vs 13.5 ± 5.4min, and 44 ± 14.6vs 21.9 ± 6.7min, respectively, P<0.0001). Figure-of-eight sutures provided efficient hemostasis following AF ablation, with significantly reduced postprocedure recovery time including time to hemostasis, extubation, and transport out of the lab.

A meta-analysis of randomized controlled trials of uninterrupted periprocedural anticoagulation strategy in patients undergoing atrial fibrillation catheter ablation

BackgroundIn patients undergoing atrial fibrillation (AF) ablation, despite uninterrupted oral anticoagulants (OACs) have been recommended, no consensus has emerged regarding to whether uninterrupted novel oral anticoagulants (NOACs) are superior to uninterrupted vitamin K antagonists (VKAs) for the periprocedural antithrombotic management. This meta-analysis aimed to compare the efficacy and safety of uninterrupted NOACs and uninterrupted VKAs in patients undergoing AF ablation. MethodsDatabases were searched for articles published up to March 20, 2018. Only randomized controlled trials (RCTs) were selected. The data were analyzed with RevMan 5.3 using a fixed-effects method. Results6 RCTs and 1903 patients were included. There was no significant difference between NOACs group and VKAs group in incidence of stroke or TIA (OR = 1.00, 95% CI = 0.23–4.40, P = 1.00), silent cerebral thromboembolic events (OR = 1.09, 95% CI = 0.67–1.75, P = 0.74) or minor bleeding (OR = 1.01, 95% CI = 0.78–1.31, P = 0.93), which were consistent in subgroup analysis of individual NOAC vs. VKAs group. NOACs treatment was associated with reduced risk of major bleeding as compared with VKAs (OR = 0.45, 95% CI = 0.26–0.81, P < 0.01). In the subgroup analyses, only the dabigatran group showed significant lower incidence of major bleeding compared to VKAs group. ConclusionsIn patients undergoing AF ablation, uninterrupted NOACs is as effective as uninterrupted VKAs treatment, uninterrupted dabigatran (150 mg twice daily) may be superior to other uninterrupted OACs strategies.

Periprocedural anticoagulation in atrial fibrillation: Update on electrical cardioversion and ablation.

In this manuscript, we discuss the most important changes in the field of anticoagulant treatment in patients with atrial fibrillation in the setting of electrical cardioversion or catheter ablation. Moreover, we provide practical guidance as well as information on daily practice.

Periprocedural anticoagulation during left atrial ablation: interrupted and uninterrupted vitamin K-antagonists or uninterrupted novel anticoagulants

BackgroundThere is a lack of data on anticoagulation requirements during ablation of atrial fibrillation (AF). This study compares different oral anticoagulation (OAC) strategies to evaluate risk of bleeding and thromboembolic complications.MethodsWe conducted a single-centre study in patients undergoing left atrial ablation of AF. Three groups were defined: 1) bridging: interrupted vitamin-K-antagonists (VKA), INR ≤2, and bridging with heparin; 2) VKA: uninterrupted VKA and INR of > 2; 3) DOAC: uninterrupted direct oral anticoagulants. Bleeding complications, thromboembolic events and peri-procedural heparin doses were assessed.ResultsIn total, 780 patients were documented. At 48 h, major complications were more common in the bridging group compared to uninterrupted VKA and DOAC groups (OR: 3.42, 95% CI: 1.29–9.10 and OR: 3.01, 95% CI: 1.19–7.61), largely driven by differences in major pericardial effusion (OR: 4.86, 95% CI: 1.56–15.99 and OR: 4.466, 95% CI, 1.52–13.67) and major vascular events (OR: 2.92, 95% CI: 0.58–14.67 and OR: 9.72, 95% CI: 1.00–94.43). Uninterrupted VKAs and DOACs resulted in similar odds of major complications (overall OR: 1.14, 95% CI: 0.44–2.92), including cerebrovascular events (OR: 1.21, 95% CI: 0.27–5.45). However, whereas only TIAs were observed in DOAC and bridging groups, strokes also occurred in the VKA group. Rates of minor complications (pericardial effusion, vascular complications, gastrointestinal hemorrhage) and major/minor groin hemorrhage were similar across groups.ConclusionOur dataset illustrates that uninterrupted VKA and DOAC have a better risk-benefit profile than VKA bridging. Bridging was associated with a 4.5× increased risk of complications and should be avoided, if possible.

Periprocedural Complications in Patients Undergoing Catheter Ablation of Atrial Fibrillation Without Discontinuation of a Vitamin K Antagonist and Direct Oral Anticoagulants.

Periprocedural anticoagulation is important in catheter ablation (CA) of atrial fibrillation (AF) and there is increasing evidence that uninterrupted vitamin K antagonist (VKA) therapy is superior to interrupted anticoagulation strategies. Since the emergence of direct oral anticoagulants (DOACs), numerous studies have shown promising results for their use in uninterrupted strategies. However, further studies are needed to further define the efficacy and safety of performing AF ablation with uninterrupted factor XA inhibitors or direct thrombin inhibitors.Methods and Results:We have performed CA of AF without discontinuation of either VKA or DOAC therapy since April 2014. A total of 376 patients with AF underwent CA including pulmonary vein isolation. All of the patients were divided into 2 groups (uninterrupted VKA or uninterrupted DOACs). Anticoagulation with DOACs was associated with fewer complications than uninterrupted VKA therapy (P=0.04). There were significant differences between groups in the rates of congestive heart failure, left ventricular ejection fraction, body weight, and estimated glomerular filtration rate and of the CHADS2, CHA2DS2-VASc and HAS-BLED scores. Therefore, we also analyzed the results using the propensity score-matching method. We found no significant difference in periprocedural complications between uninterrupted VKA or DOACs therapy (P=0.65). CA of AF without discontinuation of DOACs is not inferior to CA without discontinuation of a VKA, with regard to ischemic or hemorrhagic complications.

Periprocedural Management of Direct Oral Anticoagulants Surrounding Cardioversion and Invasive Electrophysiological Procedures.

As direct oral anticoagulants (DOACs) have demonstrated favorable efficacy and safety outcomes compared with vitamin K antagonists for the treatment and prevention of venous thromboembolism and the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, their role in the management of anticoagulation during electrophysiological procedures continues to evolve. At present, guidelines are limited regarding specific recommendations for the use of DOACs in these clinical settings. Here, we review available data regarding the risks and benefits associated with various periprocedural anticoagulation management approaches when patients receiving DOACs undergo electrophysiologic procedures including cardioversion, ablation, and device implantation. This discussion is intended to provide clinicians with an overview of available evidence and best practices to minimize the risk of both thromboembolic and bleeding events in the periprocedural setting.

Risk Mitigation: Identifying and Creating Evidence-Based Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks

As image-guided therapeutic and diagnostic procedures have increased in demand, the specific risk factors for periprocedural complications have been poorly defined. To identify risk factors for bleeding because of interventional radiology procedures and for quality assurance purposes, the staff in the Department of Radiology at Mayo Clinic in Rochester, Minnesota, created a detailed procedural database in 2003. In addition to documentation of baseline demographic characteristics and procedural details, patients were monitored for 3 days to document any postprocedural complications. The data, including patient follow-up, were collected by radiology registered nurses. Analysis of these data has provided opportunity to identify risk factors for bleeding and to create evidence-based periprocedural screening and anticoagulation guidelines in the practice.

Continuous and minimally-interrupted direct oral anticoagulant are both safe compared with vitamin K antagonist for atrial fibrillation ablation: An updated meta-analysis

BackgroundThe appropriate and safe peri-procedural anticoagulation schedule for patients on a direct oral anticoagulant (DOAC) undergoing AF ablation is not known. We aimed to evaluate the safety and efficacy of both continuous and minimally-interrupted novel oral anticoagulant (DOAC) strategies compared with uninterrupted vitamin K antagonist (VKA) for atrial fibrillation (AF) ablation. MethodsWe searched electronic databases for randomized or prospective controlled observational studies comparing DOAC (continuous or interrupted) versus uninterrupted VKA. The primary endpoint was major bleeding. Secondary endpoints were total bleeding (composite of major and minor bleeding) and symptomatic thromboembolism. Data were analyzed by random-effects modeling and sensitivity analyses performed according to study design and peri-procedural DOAC schedule. ResultsThirteen studies (4 randomized, 9 observational) with 5463 patients were included in final analysis (45% on DOAC). DOAC was associated with less major bleeding compared with VKA in pooled randomized studies (odds ratio [OR] 0.27, 95% confidence interval [CI] 0.09–0.80, p = 0.03, I2 = 0%), however there was no difference on overall analyses (OR 0.70, 95% CI 0.39–1.24, p = 0.22, I2 = 27%). When stratified by DOAC dose schedule, there was no difference in major bleeding for continuous DOAC (OR 0.48, 95% CI 0.21–1.11, p = 0.09, I2 = 6%) or minimally-interrupted DOAC (OR 0.81, 95% CI 0.37–1.76, p = 0.60, I2 = 43%) compared with VKA. There was no difference between DOAC and VKA for risk of total bleeding (p = 0.20) or symptomatic thromboembolism (p = 0.78). ConclusionContinuous and minimally-interrupted DOAC are both safe and non-inferior peri-procedural anticoagulation strategies compared with uninterrupted VKA for AF ablation. DOAC in general is associated with reduced major bleeding as demonstrated in pooled randomized studies.

Prevention of Radial Artery Occlusions Following Coronary Procedures: Forward and Backward Steps in Improving Radial Artery Patency Rates.

Radial artery (RA) occlusion (RAO) remains the Achilles heel of transradial coronary procedures. Although of silent nature, RAO is relatively frequent, results in graft shortage for future coronary artery bypass surgery, and may occur even after short-lasting, 5F coronary angiography (CAG). The most frequent predictors of RAO are RA size, body size, female gender, and periprocedural anticoagulation intensity. Methods to detect RAO are variable, of which the Barbeau test and ultrasonography have similar diagnostic accuracy. Data indicate that late RAO recanalization may occur. Meticulous handling of RA and the use of appropriate hemostatic devices and techniques along with sufficient heparin dose appear important measures to reduce RAO rates. Recent contradictory studies indicate that the decreasing incidence of RAO overtime is not as uniform as previously thought. In 2 meta-analyses, the benefit of higher over lower anticoagulation intensity became evident. As "it may all be appropriate anticoagulation" for a simplified approach against RAO, the results of an ongoing trial comparing 100 with 50 IU/kg body weight in transradial CAG are eagerly awaited.

Mind the gap: results of a multispecialty survey on coordination of care for peri-procedural anticoagulation.

To understand how physicians from various specialties perceive coordination of care when managing peri-procedural anticoagulation. Cross-sectional survey of cardiologists, gastroenterologists, and primary care physicians (PCPs) in an integrated health system (N = 251). The survey began with a vignette of a patient with atrial fibrillation co-managed by his PCP, cardiologist, and an anticoagulation clinic who must hold warfarin for a colonoscopy. Respondents' experiences and opinions around responsibilities and institutional support for managing peri-procedural anticoagulation were elicited using multiple choice questions. We examined differences in responses across specialties using Chi square analysis. The response rate was 51% (n = 127). 52% were PCPs, 28% cardiologists, and 21% gastroenterologists. Nearly half (47.2%) of respondents believed that the cardiologist should be primarily responsible for managing peri-procedural anticoagulation, while fewer identified the PCP (25.2%), anticoagulation clinic (21.3%), or gastroenterologist (6.3%; p = 0.09). Respondents across specialties had significantly different approaches to deciding how to manage the clinical case presented (p < 0.001). Most cardiologists (60.0%) would decide whether to offer bridging without consulting with other providers or clinical resources, while most PCPs would decide after consulting clinical resources (57.6%). Gastroenterologists would most often (46.2%) defer the decision to another provider. A majority of all three specialties agreed that their institution could do more to help manage peri-procedural anticoagulation, and there was broad support (88.1%) for anticoagulation clinics' managing all aspects of peri-procedural anticoagulation. Providers across specialties agree that their institution could do more to help manage peri-procedural anticoagulation, and overwhelmingly support anticoagulation clinics' taking responsibility.

Femoral access site closure without prior femoral angiography : Aretrospective analysis.

SummaryAims and backgroundAlthough guideline recommendations have shifted towards a transradial route, femoral puncture is still an established vascular access, especially for complex coronary interventions. The FemoSeal™ vascular closure device (FVCD) helps to reduce femoral compression time and access site complications after removal of the catheter sheath. To ensure safe use, an angiography of the femoral artery prior to FVCD deployment is recommended by the manufacturer. We postulate that omitting this angiography does not relevantly increase the risk for vascular complications.Methods and resultsIn this retrospective analysis of an all-comers population (n = 1923) including patients receiving a percutaneous coronary intervention (PCI), we could show that combined vascular complication rates without femoral angiography were low (primary endpoint 4.6%) and comparable to a randomized clinical trial that did perform angiography of the vascular access site in a cohort of patients receiving diagnostic coronary angiography only. In addition to this analysis, we could demonstrate that patients with an acute coronary syndrome, receiving periprocedural anticoagulation or anti-platelet therapy had an increased risk for the formation of arterial pseudoaneurysms; however, we did not observe any ischemic vascular event after FVCD deployment.ConclusionClosure of the femoral access site after coronary angiography using the FVCD can be safely performed without femoral angiography; however, due to an increased risk for the formation of pseudoaneurysms we recommend the transradial access in situations with increased bleeding risk.

Periprocedural Anticoagulation Management for Atrial Fibrillation Ablation: Current Knowledge and Future Directions.

Catheter ablation (CA) for atrial fibrillation (AF) is an established first-line approach to the management of drug-refractory AF. Although, advancements in procedural techniques and technology have improved the efficacy and safety of CA, thromboembolism (TE) remains one of the most feared periprocedural complications. Minimizing the risk of TE during and after CA requires a multifaceted approach, in which periprocedural anticoagulation plays a central role. The goal of anticoagulation before, during, and after CA is to minimize TE risk without excessively increasing the risk of adverse bleeding. Generally, there are two broad approaches to periprocedural anticoagulation management, "interrupted" or "uninterrupted." Interrupted refers to those patients in whom their oral anticoagulant is stopped before the CA, with or without "bridging" with another anticoagulant, while uninterrupted refers to continuation of oral anticoagulation throughout the periprocedural period. The strongest evidence supports an uninterrupted oral anticoagulation strategy with warfarin, which is currently the standard of care. The introduction of the novel anticoagulants has added some complexity to the decision making. Current data generally supports that these are safe to use and are not associated with any additional procedural risk or adverse events (thromboembolism or bleeding) compared to warfarin. At present, based upon current evidence from randomized trials, dabigatran and rivaroxaban are reasonable alternatives to warfarin for an uninterrupted approach, while further data is needed (and trials are ongoing) for apixaban and edoxaban. In this article, we discuss the different approaches to the management of periprocedural anticoagulation and the data supporting their use.

Continuous and Minimally Interrupted Novel Oral Anticoagulant are Both Safe for Atrial Fibrillation Ablation: An Updated Meta-Analysis

Background: The appropriate periprocedural anticoagulation schedule for patients on NOAC undergoing AF ablation is not known. We aimed to evaluate the safety and efficacy of both continuous and minimally interrupted novel oral anticoagulant (NOAC) strategies for atrial fibrillation (AF) ablation.