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

Lock, Johan Friso; Ungeheuer, L.; Borst, P.; Swol, Justyna; Löb, Stefan; Brede, Elmar-Marc; Röder, Daniel; Lengenfelder, Björn; Sauer, Karen Ann; Germer, Christoph‐Thomas

doi:10.1186/s13741-020-00170-4

Cited by 21 publications

(13 citation statements)

References 27 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Prior to elective surgical procedures, the anticoagulative drugs are usually discontinued within an adequate time lag before surgery. However, due to the nature of the conditional limited time frame of deceased organ donation, the timely discontinuation of anticoagulative drugs is often not feasible [ 38 ]. In this context, the optimal timepoint for the postoperative resumption of anticoagulative medication following kidney transplantation is not clear.…”

Section: Discussionmentioning

confidence: 99%

Predictive Value of HAS-BLED Score Regarding Bleeding Events and Graft Survival following Renal Transplantation

Hau

Eckert

Laudi

et al. 2022

JCM

View full text Add to dashboard Cite

Objective: Due to the high prevalence and incidence of cardio- and cerebrovascular diseases among dialysis-dependent patients with end-stage renal disease (ERSD) scheduled for kidney transplantation (KT), the use of antiplatelet therapy (APT) and/or anticoagulant drugs in this patient population is common. However, these patients share a high risk of complications, either due to thromboembolic or bleeding events, which makes adequate peri- and post-transplant anticoagulation management challenging. Predictive clinical models, such as the HAS-BLED score developed for predicting major bleeding events in patients under anticoagulation therapy, could be helpful tools for the optimization of antithrombotic management and could reduce peri- and postoperative morbidity and mortality. Methods: Data from 204 patients undergoing kidney transplantation (KT) between 2011 and 2018 at the University Hospital Leipzig were retrospectively analyzed. Patients were stratified and categorized postoperatively into the prophylaxis group (group A)—patients without pretransplant anticoagulation/antiplatelet therapy and receiving postoperative heparin in prophylactic doses—and into the (sub)therapeutic group (group B)—patients with postoperative continued use of pretransplant antithrombotic medication used (sub)therapeutically. The primary outcome was the incidence of postoperative bleeding events, which was evaluated for a possible association with the use of antithrombotic therapy. Secondary analyses were conducted for the associations of other potential risk factors, specifically the HAS-BLED score, with allograft outcome. Univariate and multivariate logistic regression as well as a Cox proportional hazard model were used to identify risk factors for long-term allograft function, outcome and survival. The calibration and prognostic accuracy of the risk models were evaluated using the Hosmer–Lemshow test (HLT) and the area under the receiver operating characteristic curve (AUC) model. Results: In total, 94 of 204 (47%) patients received (sub)therapeutic antithrombotic therapy after transplantation and 108 (53%) patients received prophylactic antithrombotic therapy. A total of 61 (29%) patients showed signs of postoperative bleeding. The incidence (p < 0.01) and timepoint of bleeding (p < 0.01) varied significantly between the different antithrombotic treatment groups. After applying multivariate analyses, pre-existing cardiovascular disease (CVD) (OR 2.89 (95% CI: 1.02–8.21); p = 0.04), procedure-specific complications (blood loss (OR 1.03 (95% CI: 1.0–1.05); p = 0.014), Clavien–Dindo classification > grade II (OR 1.03 (95% CI: 1.0–1.05); p = 0.018)), HAS-BLED score (OR 1.49 (95% CI: 1.08–2.07); p = 0.018), vit K antagonists (VKA) (OR 5.89 (95% CI: 1.10–31.28); p = 0.037), the combination of APT and therapeutic heparin (OR 5.44 (95% CI: 1.33–22.31); p = 0.018) as well as postoperative therapeutic heparin (OR 3.37 (95% CI: 1.37–8.26); p < 0.01) were independently associated with an increased risk for bleeding. The intraoperative use of heparin, prior antiplatelet therapy and APT in combination with prophylactic heparin was not associated with increased bleeding risk. Higher recipient body mass index (BMI) (OR 0.32 per 10 kg/m2 increase in BMI (95% CI: 0.12–0.91); p = 0.023) as well as living donor KT (OR 0.43 (95% CI: 0.18–0.94); p = 0.036) were associated with a decreased risk for bleeding. Regarding bleeding events and graft failure, the HAS-BLED risk model demonstrated good calibration (bleeding and graft failure: HLT: chi-square: 4.572, p = 0.802, versus chi-square: 6.52, p = 0.18, respectively) and moderate predictive performance (bleeding AUC: 0.72 (0.63–0.79); graft failure: AUC: 0.7 (0.6–0.78)). Conclusions: In our current study, we could demonstrate the HAS-BLED risk score as a helpful tool with acceptable predictive accuracy regarding bleeding events and graft failure following KT. The intensified monitoring and precise stratification/assessment of bleeding risk factors may be helpful in identifying patients at higher risks of bleeding, improved individualized anticoagulation decisions and choices of antithrombotic therapy in order to optimize outcome after kidney transplantation.

show abstract

Section: Discussionmentioning

confidence: 99%

Predictive Value of HAS-BLED Score Regarding Bleeding Events and Graft Survival following Renal Transplantation

Hau

Eckert

Laudi

et al. 2022

JCM

View full text Add to dashboard Cite

show abstract

“…A substantial number of patients with colorectal cancer are already bleeding from the underlying tumour before surgery, and major bleeding complications might increase after major abdominal surgery in patients receiving therapeutic dosing of an anticoagulant. 18 Furthermore, other dosing regiments have already been assessed by TILT (intermediate dosing of tinzaparin 100 IU/kg, once a day for 12 weeks) and NVALT-8 (two weeks of therapeutic dosing then 14 weeks on intermediate dosing) and showed no benefit. 16 17 The PERIOP-01 trial used tinzaparin as an early adjuvant treatment starting from the day of surgery until day 56.…”

Section: Discussionmentioning

confidence: 99%

“…Prophylactic dosing of tinzaparin was used in the PERIOP-01 trial because therapeutic dosing could have a higher risk of bleeding complications in the perioperative setting. A substantial number of patients with colorectal cancer are already bleeding from the underlying tumour before surgery, and major bleeding complications might increase after major abdominal surgery in patients receiving therapeutic dosing of an anticoagulant 18. Furthermore, other dosing regiments have already been assessed by TILT (intermediate dosing of tinzaparin 100 IU/kg, once a day for 12 weeks) and NVALT-8 (two weeks of therapeutic dosing then 14 weeks on intermediate dosing) and showed no benefit 1617.…”

Section: Discussionmentioning

confidence: 99%

Efficacy and safety of extended duration to perioperative thromboprophylaxis with low molecular weight heparin on disease-free survival after surgical resection of colorectal cancer (PERIOP-01): multicentre, open label, randomised controlled trial

Auer

Ott

Karanicolas

et al. 2022

BMJ

View full text Add to dashboard Cite

Objective To determine the efficacy and safety of extended duration perioperative thromboprophylaxis by low molecular weight heparin when assessing disease-free survival in patients undergoing resection for colorectal cancer. Design Multicentre, open label, randomised controlled trial. Settings 12 hospitals in Quebec and Ontario, Canada, between 25 October 2011 and 31 December 2020. Participants 614 adults (age ≥18 years) were eligible with pathologically confirmed invasive adenocarcinoma of the colon or rectum, no evidence of metastatic disease, a haemoglobin concentration of ≥8 g/dL, and were scheduled to undergo surgical resection. Interventions Random assignment to extended duration thromboprophylaxis using daily subcutaneous tinzaparin at 4500 IU, beginning at decision to operate and continuing for 56 days postoperatively, compared with in-patient postoperative thromboprophylaxis only. Main outcome measures Primary outcome was disease-free survival at three years, defined as survival without locoregional recurrence, distant metastases, second primary (same cancer), second primary (other cancer), or death. Secondary outcomes included venous thromboembolism, postoperative major bleeding complications, and five year overall survival. Analyses were done in the intention-to-treat population. Results The trial stopped recruitment prematurely after the interim analysis for futility. The primary outcome occurred in 235 (77%) of 307 patients in the extended duration group and in 243 (79%) of 307 patients in the in-hospital thromboprophylaxis group (hazard ratio 1.1, 95% confidence interval 0.90 to 1.33; P=0.4). Postoperative venous thromboembolism occurred in five patients (2%) in the extended duration group and in four patients (1%) in the in-hospital thromboprophylaxis group (P=0.8). Major surgery related bleeding in the first postoperative week was reported in one person (<1%) in the extended duration and in six people (2%) in the in-hospital thromboprophylaxis group (P=0.1). No difference was noted for overall survival at five years in 272 (89%) patients in the extended duration group and 280 (91%) patients in the in-hospital thromboprophylaxis group (hazard ratio 1.12; 95% confidence interval 0.72 to 1.76; P=0.1). Conclusions Extended duration to perioperative anticoagulation with tinzaparin did not improve disease-free survival or overall survival in patients with colorectal cancer undergoing surgical resection compared with in-patient postoperative thromboprophylaxis alone. The incidences of venous thromboembolism and postoperative major bleeding were low and similar between groups. Trial registration ClinicalTrials.gov NCT01455831 .

show abstract

“…89 Concerns have been expressed on the safety of perioperative bridging for VTE prevention. 90 A recent multicenter trial confirmed that bridging or monitoring preoperative coagulation function is not necessary for those on DOACs undergoing elective surgery. 91 Other studies on geriatric hip fracture patients have also demonstrated that expediting surgery in the presence of DOAC without bridging does not lead to worse outcomes.…”

Section: Uncertainties With Bridging Anticoagulation and Anticoagulan...mentioning

confidence: 99%

Obesity and the Risk of Venous Thromboembolism after Major Lower Limb Orthopaedic Surgery: A Literature Review

et al. 2022

View full text Add to dashboard Cite

The risk of venous thromboembolism following total joint arthroplasty is significantly greater than those of other types of elective orthopaedic procedures. This risk is increased in obesity due to the associated prothrombotic physiological and hematological changes that predispose to embolic events. The prevalence of obesity is increasing in the aging population, which contributes to a further increase in the risk of postoperative thrombosis in the older patients. There is a lack of clear evidence regarding dosing information for thromboprophylaxis medications in patients with obesity. As a result, the currently available thromboprophylaxis guidelines do not provide specific recommendations for this group. Suboptimal dosing regimens for these medications can place these patients at a risk of bleeding or clotting complications postsurgery. Hence any increase in dosage may require intensive surveillance for the residual anticoagulant effects and careful balancing of risks and benefits on an individual basis. Our review discusses the basis for increased thrombotic risk in obesity, the evidence supporting dosage recommendations, and the implications of the current guidelines for pharmacological thromboprophylaxis in patients with obesity undergoing lower limb arthroplasty.

show abstract

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

Cited by 21 publications

References 27 publications

Predictive Value of HAS-BLED Score Regarding Bleeding Events and Graft Survival following Renal Transplantation

Predictive Value of HAS-BLED Score Regarding Bleeding Events and Graft Survival following Renal Transplantation

Efficacy and safety of extended duration to perioperative thromboprophylaxis with low molecular weight heparin on disease-free survival after surgical resection of colorectal cancer (PERIOP-01): multicentre, open label, randomised controlled trial

Obesity and the Risk of Venous Thromboembolism after Major Lower Limb Orthopaedic Surgery: A Literature Review

Contact Info

Product

Resources

About