We have read with interest the article by Wilensky et al. on “Outcomes after arterial endovascular procedures performed in patients with an elevated international normalized ratio,”1 reporting on the management of patients under oral anticoagulant therapy (OAT). Although the authors state that no studies were published before their series, the possibility of performing peripheral arterial procedures in patients with OAT was specifically addressed in 2 studies from our institution. Specifically in the articles by Pini et al.2 and Faggioli et al.,3 we have highlighted the results achievable in carotid stenting (CAS) procedures in patients with OAT. In both studies, not only the safety of the procedure was shown, but also the advantages over traditional surgical carotid endarterectomy (CEA) and bridging therapy. In the first paper, we have analyzed specifically 502 CAS performed in a 5-year period with 12 (2.4%) perioperative strokes, 1 (0.2%) death, no myocardial infarctions, and 4 (0.8%) access site bleeding period. Twenty patients (4.0%) under chronic OAT were submitted to CAS without perioperative bridging heparin therapy and no complications. Overall, patients under OAT had no significantly different outcome compared with patients without OAT.2 In the second paper, we have analyzed altogether 1,222 carotid revascularizations, with 711 CEAs (58.1%) and 511 CAS (41.9%). In the CEA group, 31 (4.4%) OAT patients were treated after OAT interruption and bridging heparin therapy. These patients had a significantly higher complication rate compared with patients not receiving OAT, including death, stroke, and hematoma. In CAS, the results were similar in patients receiving OAT (30[5.8%]) and patients not receiving OAT. Patients receiving unsuspended OAT who underwent CAS had better outcomes than OAT patients who underwent CEA after suppression of OAT and bridging therapy.3 As a matter of fact, our current practice includes stenting as a first option in OAT patients needing carotid revascularization. In this sense, although we advocate standard CEA as the gold standard procedure for symptomatic and asymptomatic carotid disease, there are subgroups of patients (i.e., OAT patients and patients with contralateral carotid occlusion) who benefit more from CAS.4
Faggioli, G., Pini, R., Stella, A. (2016). Oral Anticoagulant Therapy and Endovascular Procedures. ANNALS OF VASCULAR SURGERY, 33, 264-265 [10.1016/j.avsg.2016.01.006].
Oral Anticoagulant Therapy and Endovascular Procedures
FAGGIOLI, GIANLUCA;PINI, RODOLFO;STELLA, ANDREA
2016
Abstract
We have read with interest the article by Wilensky et al. on “Outcomes after arterial endovascular procedures performed in patients with an elevated international normalized ratio,”1 reporting on the management of patients under oral anticoagulant therapy (OAT). Although the authors state that no studies were published before their series, the possibility of performing peripheral arterial procedures in patients with OAT was specifically addressed in 2 studies from our institution. Specifically in the articles by Pini et al.2 and Faggioli et al.,3 we have highlighted the results achievable in carotid stenting (CAS) procedures in patients with OAT. In both studies, not only the safety of the procedure was shown, but also the advantages over traditional surgical carotid endarterectomy (CEA) and bridging therapy. In the first paper, we have analyzed specifically 502 CAS performed in a 5-year period with 12 (2.4%) perioperative strokes, 1 (0.2%) death, no myocardial infarctions, and 4 (0.8%) access site bleeding period. Twenty patients (4.0%) under chronic OAT were submitted to CAS without perioperative bridging heparin therapy and no complications. Overall, patients under OAT had no significantly different outcome compared with patients without OAT.2 In the second paper, we have analyzed altogether 1,222 carotid revascularizations, with 711 CEAs (58.1%) and 511 CAS (41.9%). In the CEA group, 31 (4.4%) OAT patients were treated after OAT interruption and bridging heparin therapy. These patients had a significantly higher complication rate compared with patients not receiving OAT, including death, stroke, and hematoma. In CAS, the results were similar in patients receiving OAT (30[5.8%]) and patients not receiving OAT. Patients receiving unsuspended OAT who underwent CAS had better outcomes than OAT patients who underwent CEA after suppression of OAT and bridging therapy.3 As a matter of fact, our current practice includes stenting as a first option in OAT patients needing carotid revascularization. In this sense, although we advocate standard CEA as the gold standard procedure for symptomatic and asymptomatic carotid disease, there are subgroups of patients (i.e., OAT patients and patients with contralateral carotid occlusion) who benefit more from CAS.4I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
