Anticoagulation strategies in extracorporeal circulatory devices in adult populations

Abstract

Extracorporeal circulatory devices such as hemodialysis and extracorporeal membrane oxygenation can be lifesaving; however, they are also prone to pathologic events including device failure, venous and arterial thrombosis, hemorrhage, and an accelerated risk for atherosclerotic disease due to interactions between blood components and device surfaces of varying biocompatibility. While extracorporeal devices may be used acutely for limited periods of time (eg, extracorporeal membrane oxygenation, continuous venovenous hemofiltration, therapeutic apheresis), some patients require chronic use of these technologies (eg, intermittent hemodialysis and left ventricular assist devices). Given the substantial thrombotic risks associated with extracorporeal devices, multiple antiplatelet and anticoagulation strategies—including unfractionated heparin, low‐molecular‐weight heparin, citrate, direct thrombin inhibitors, and direct oral anticoagulants, have been used to mitigate the thrombotic milieu within the patient and device. In the following manuscript, we outline the current data on anticoagulation strategies for commonly used extracorporeal circulatory devices, highlighting the potential benefits and complications involved with each.

The Efficacy and Safety of Bivalirudin Versus Heparin in the Anticoagulation Therapy of Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis

“…The consumption of platelet and thrombin may lead to consumption coagulopathy, which causes intravasular and extravascular thrombosis. Additionally, the complexity of pharmacokinetic parameters may increase due to the increase of volume distribution and random adsorption of drugs on different parts of the pump, which requires continuous dose titration of UFH ( Kato et al, 2021 ). Compared with UFH, bivalirudin has a more predictable pharmacokinetic profile, a greater reduction in thrombin, and no associated incidence of HIT ( Netley et al, 2018 ).…”

Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature

“…However, no large studies of sufficient quality are available that investigate the effects of different anticoagulation agents and targets in vvECMO. A review by Kato et al found no differences between strategies [ 167 ]. Moreover, no randomized controlled trials on anticoagulated vs. anticoagulation-free vvECMO in intracranial hemorrhage are available.…”

Massive hemoptysis managed by prolonged anticoagulation-free veno-venous extracorporeal membrane oxygenation with which thoracic surgeries were accompanied: a case report

“…Although we adopted an anticoagulation-free operation of ECMO in an attempt to avoid bleeding risk, it would increase the risk of life-threatening thrombo-coagulopathies such as pulmonary artery thromboembolism. Therefore, other choices which have a potential to circumvent both risks concurrently would have to be considered such as intermittent operation of ECMO and use of direct thrombin inhibitors including argatroban [ 11 ].…”