Periprocedural Bridging in Patients with Venous Thromboembolism: A Systematic Review

Abstract

Periprocedural bridging is widely used in patients with previous venous thromboembolism who require interruption of vitamin K antagonists due to an invasive procedure  This systematic review found that periprocedural bridging in patients with previous venous thromboembolism increases the risk of bleeding without reducing the risk of periprocedural venous thromboembolism  Most patients with venous thromboembolism do not benefit from periprocedural bridging

Perioperative consultative hematology: can you clear my patient for a procedure?

“…The 95% con fi dence inter vals overlapped for VTE and major bleed ing but did not for all bleed ing. 35 • There is no clear answer for this patient. She is at low risk from a purely VTE stand point based on ACCP and ASH guide lines.…”

“…Although bridg ing of war fa rin was once rou tinely employed, ret rospec tive obser va tional evi dence published over the past decade has con sis tently shown bridg ing to be asso ci ated with net harm and sug gests it should be avoided in most cases. 6,[35][36][37] The ran dom ized con trolled Bridging Anticoagulation in Patients Who Require Temporary Interruption of Warfarin Therapy for an Elective Invasive Procedure or Surgery (BRIDGE) trial sought to answer whether fore go ing LMWH bridg ing in atrial fibril la tion patients requir ing war fa rin inter rup tion for a pro ce dure would result in less major bleed ing with out an increase in arterial throm bo em bo lism. Per stan dard ized pro to col, war fa rin was held for 5 days preprocedurally, and patients were ran dom ized to pla cebo or LMWH (dalteparin) with 30-day pri mary out comes of major bleed ing (supe ri or ity) and arte rial throm bo em bolic event (noninferiority).…”

Periprocedural bridging anticoagulation in patients with venous thromboembolism: A registry‐based cohort study

“…Potential underuse of bridging anticoagulation is also a concern among high‐risk patients. Although none of the studies noted previously had significant numbers of high‐risk patients, the meta‐analysis demonstrated very low incidence rates of recurrent VTE both in the overall analysis and in the subgroup of patients at high thromboembolic risk 9 . A randomized trial of bridging is probably warranted in high‐risk populations, including those with recent VTE and/or higher risk thrombophilia.…”

“…A recent meta-analysis of observational studies confirmed the increased rate of bleeding without a reduction in thromboembolism events for patients with VTE who received periprocedural bridging LMWH compared with those who did not. 9 However, that meta-analysis was limited in its ability to distinguish between patients at high and low risk of thromboembolism. Nearly all studies in that meta-analysis included patients enrolled before the 2012 ACCP guidelines were published.…”

“…Although none of the studies noted previously had significant numbers of high-risk patients, the meta-analysis demonstrated very low incidence rates of recurrent VTE both in the overall analysis and in the subgroup of patients at high thromboembolic risk. 9 A randomized trial of bridging is probably warranted in high-risk populations, including those with recent VTE and/or higher risk thrombophilia. Further research is also needed to address optimal periprocedural management of direct oral anticoagulants in patients with VTE.…”