BACKGROUND: Vitamin K antagonists (VKA) are the most widely used anticoagulants, and bridging is commonly administered during periprocedural VKA interruption. Given the unclear benefits and risks of periprocedural bridging in patients with previous venous thromboembolism, we aimed to assess recurrent venous thromboembolism and bleeding outcomes with and without bridging in this population.
METHODS: We performed a systematic review searching the PubMed and Embase databases from inception to December 7, 2017 for randomized and nonrandomized studies that included adults with previous venous thromboembolism requiring VKA interruption to undergo an elective procedure, and that reported venous thromboembolism or bleeding outcomes. Quality of evidence was graded by consensus.
RESULTS: We included 28 cohort studies (20 being single-arm cohorts) with, overall, 6915 procedures for analysis. In 27 studies reporting perioperative venous thromboembolism outcomes, the pooled incidence of recurrent venous thromboembolism with bridging was 0.7% (95% confidence interval [CI], 0.4%-1.2%) and 0.5% (95% CI, 0.3%-0.8%) without bridging. Eighteen studies reported major or nonmajor bleeding outcomes. The pooled incidence of any bleeding was 3.9% (95% CI, 2.0%-7.4%) with bridging and 0.4% (95% CI, 0.1%-1.7%) without bridging. In bridged patients at high thromboembolic risk, the pooled incidence for venous thromboembolism was 0.8% (95% CI, 0.3%-2.5%) and 7.5% (95% CI, 3.1%-17.4%) for any bleeding. Quality of available evidence was very low, primarily due to a high risk of bias of included studies.
CONCLUSIONS: Periprocedural bridging increases the risk of bleeding compared with VKA interruption without bridging, without a significant difference in periprocedural venous thromboembolism rates.
|Hemostasis and Thrombosis|
Periprocedural bridging in patients with venous thromboembolic disease (VTED) likely increases bleeding risk compared with no bridging (no surprise), and statistically does not decrease risk for clotting. This meta-analysis does reveal some surprises: the risk for bleeding over about 5 days is about 1/2 the risk for bleeding during the standard course of therapy for VTED; the risk for clotting may even be increased during bridging (as high as 4.4% in 1 small study); and bleeding in high-risk patients may be as high as 17.1% (much higher than expected). The authors admit the studies overall are of low quality. There is a mixture of high-, moderate-, and low-risk patients, many studies had no events, the duration of bridging varied, the duration of observation varied, some had only pre-procedural bridging and others only post- and some had both. In short, huge variations making comparisons difficult. Bottom line: bridging likely doesn`t help (maybe very high-risk patients?) and may hurt.
Good review and an important topic in clinical practice. Could be practice-changing but not sure whether it applies to all hypercoagulable patients.
In the absence of randomized information, likely the best we will get. Similar to the situation with a-fib as an indication - little to indicate that bridging is useful, at least not in unselected patients.
Despite limitations in strength of evidence, it is still helpful to specifically look at bridging outcomes for venous thromboembolism indications. Similar to results with atrial fibrillation, but it would be helpful to have the risk assessment more consistently applied to allow for identification of an equivalent high-risk group. An RCT of prophylactic vs therapeutic bridging in the high-risk group is necessary to change practice in that group, but data to date is sufficient to support not bridging for low- and moderate-risk thrombosis patients.