Introduction Hemostatic prophylaxis (HP) is recommended for patients with bleeding disorders (PWBD) before invasive procedures. However, evidence‐based guidelines are needed to determine optimal HP strategies. Aim To determine outcomes of HP for PWBD undergoing colonoscopy. Methods We undertook a retrospective cohort study of HP and outcomes of colonoscopy procedures performed between 9 November 1993 and 13 February 2018 for PWBD who received care in the Mayo Clinic Comprehensive Hemophilia Treatment Center. Results During the study period, 73 PWBD (58 with milder phenotypes: haemophilia, von Willebrand disease [subtypes 1 and 2; II, VII and XI deficiency]) underwent 141 procedures. Preprocedural HP was given to 61%, and interventions were performed in 47%. Of the 39% without preprocedural HP, postprocedural HP was given for 11%. One major (0.7%; 6 days postprocedure despite HP) and 10 minor (7%) bleeding complications occurred, which tended to be in patients with severe disease and/or after excision of larger polyps. There was no significant difference in the rate of bleeding complications with or without preprocedural HP (8.1% vs 5.5%, respectively; P = .74, Fisher's exact test). Conclusion The low bleeding rates in our cohort suggest that preprocedure HP may be withheld for patients with mild bleeding disorders who undergo colonoscopy with a low likelihood of requiring an intervention or who require only low‐risk intervention. This strategy may be best used in experienced centres, provided optimal local hemostasis measures are undertaken and postprocedural HP is rapidly available if high‐risk intervention is required. Further studies are needed to determine optimal evidence‐based HP strategies for PWBD undergoing colonoscopy.
3660 Background: Evidence based guidelines for management of acute coronary syndrome (ACS) in patients (pt) with congenital hemophilia A & B (HA/HB) and von Willebrand disease (VWD) are lacking and confined to case reports and expert opinion (Schutgens et al, 2009). Aims: To review the management of ACS in patients with HA/HB and VWD followed at the Mayo Comprehensive Hemophilia Center. Methods: All pt with HA/HB and VWD who presented with symptoms of ACS to our institution between 2000 and 2010 were retrospectively identified using the hemophilia center database. Medical notes were reviewed, focusing on types of intervention and bleeding complications. Results: Ten pt, HA = 3 and VWD=7, experienced 13 ACS or suspected ACS events. Median age at time of event was 74 years (45 – 80 years), with M:F = 7:3. All 13 events presented with chest pain. 6/13 events presented to the emergency department (ED), 4/13 events presented to a Mayo outpatient clinic, 2/13 events occurred in hospitalized pt and 1 event was a direct referral from a non-Mayo outpatient clinic to our Cardiology in-patient service. ED pt received 325 mg aspirin (HD-ASA) in 5/6 events and intravenous unfractionated heparin (UFH) in 4/6 events, per ACS management guidelines. One ED pt did not receive either ASA or UFH due to atrio-venous malformation (AVM)-related gastrointestinal (GI) bleed (Hg 6 g/dL). Of the inpatients, one received HD-ASA while the other was already on daily low-dose aspirin (LD-ASA); neither received UFH. The pt admitted directly to the Cardiology in-patient service received HD-ASA but not UFH. Of the outpatients, one was started on LD-ASA while another was already on LD-ASA; none received UFH as they were considered low-risk for ACS but warranted further diagnostic evaluation. Coronary angiography (CA) via a right femoral arterial approach was performed in 12/13 events; of which 5 received prophylactic factor concentrate prior to CA. One pt (no prior prophylaxis) experienced minor bleeding at the puncture site, requiring factor concentrate replacement post-CA. Another patient continued to receive prophylactic factor concentrate for 4 days post-CA. Major bleeding or bleeding requiring red blood cell (RBC) transfusion did not occur. Following CA, in 2/12 events, pt underwent bare metal stent (BMS) placement and glycoprotein 2b/3a inhibitor infusion, with no bleeding complications. In 4/12 events, pt proceeded to coronary artery bypass grafting (CABG) and received prophylactic factor concentrate; of which one required multiple post-operative RBC transfusions due to ongoing AVM-related GI bleed. The remaining 6 events were managed medically. The 1 pt who did not undergo CA experienced a post-total knee replacement ACS and was medically managed. On discharge, in 5/13 events, pt were started on daily ASA (HD-ASA, n=2; LD-ASA, n=3). 2 of these received a month of clopidogrel, in addition to LD-ASA, due to BMS placement and were not placed on prophylactic factor concentrate for the duration of dual anti-platelet agent therapy; there were no bleeding complications. Daily ASA was continued in 4/13 events (HD-ASA, n=1; LD-ASA, n=3), with 1 patient receiving both LD-ASA and a month of warfarin for DVT prophylaxis post-orthopedic surgery. In the remaining 4 events, pt were dismissed without ASA, due to bleeding complications (n=2) or the perceived risk of bleeding outweighed the benefit (n=2). During long term follow-up, 1 patient had to stop HD-ASA after 2 years due to GI bleed, while another patient stopped LD-ASA due to episodic epistaxis requiring nasal packing. Conclusion: In this small series of patients, outcomes of management of ACS did not result in significant acute bleeding complications. In addition, long-term treatment with anti-platelet agents appears to be safe and should be strongly considered for all patients with coronary artery disease. Disclosures: No relevant conflicts of interest to declare.
Background Based on data from the CDC, over the next 20 years, approximately 12,500 patients (pt) with bleeding disorders will require a screening colonoscopy. For a 75 kg adult receiving an average factor dose of 35 units/kg, this translates into utilization of approximately 30 million units over this time period which will vary with pt weight and disease severity. In the absence of evidence based guidelines, current practice is to provide prophylactic clotting factor concentrates to all such pt. Herein we report our institutional experience. Materials and Methods Retrospective chart review of Mayo Comprehensive Hemophilia Treatment Center pt undergoing colonoscopies. Eligible pt had congenital von Willebrand disease (VWD), hemophilia A (HA) and B (HB). Data collected included pt demographics, factor concentrate and antifibrinolytic agent use, biopsy and polypectomy procedures, and bleeding complications (up to 1 month). Results From 1993-2013, 69 pt underwent 130 colonoscopies, 40/69 (58%) were males. Median (range) age at the time of the procedure was 60 years (3 to 87). The distribution of diagnoses were as follows: HA mild n=13, moderate n=5, severe n=5 and severe with inhibitor n=1; symptomatic carrier of HA n=2; HB mild n=6, severe n=1; VWD types 1: n=23, 2A: n=5, 2B: n=5, 2M: n=2; 3: n=3. 40/69 (58%) pt had one colonoscopy, the remainder 2 to 8 colonoscopies. The procedures were performed as outpatient in 119 (92%) and as inpatient in 11 (8%). Colonoscopy indications included: GI bleeding (49/130, 38%); screening (32/130, 25%); history of polyps (24/130, 18%); iron deficiency anemia (7/130, 6%); Crohn’s disease (5/130, 4%); diarrhea (4/130, 3%); colon cancer followup (3/130, 2%); abnormal imaging (3/130, 2%); family history of colon cancer, diverticulitis, and ulcerative colitis (combined 3/130, 2%). Of the 130 procedures, 25/130 (19%) received no factor or antifibrinolytic treatment, 58/130 (45%) received pre-procedure prophylactic factor only, 1/130 (1%) received post-procedure factor only, 29/130 (22%) received both, 3/130 (2%) received pre-factor and an antifibrinolytic, 3/130 (2%) received post-factor and an antifibrinolytic, 11/130 (8%) received pre and post-procedure factor and an antifibrinolytic. None received an antifibrinolytic alone. Biopsy was performed in only 56/130 (43%) of colonoscopies. Types of biopsies: polyp 37/56 (66%), mucosal 11/56 (20%), mucosal & polyp 5/56 (9%), lesion 1/56 (2%), lesion & polyp 2/56 (4%). Of the pt receiving a biopsy, 39/56 (70%) received pre-procedure factor and 25/56 (45%) received post-procedure factor. The pt most likely to be biopsied were those with an indication of history of polyps 15/56 (27%), GI bleed 13/56 (23%), screening 10/56 (18%), and Crohn’s disease/colon cancer follow up/ diarrhea/iron deficiency anemia each 3/56 (5%). Of the total number of procedures, 39/130 (30%) underwent a polypectomy. Of these, 26/39 (67%) received pre-procedure factor and 17/39 (44%) received post-procedure factor. The average number of polypectomies per patient was 2.3 and the average number of polyps removed per procedure was 3.2. Hemorrhagic complications were noted in 26/130 procedures (13/26 procedural only, 4/26 post-procedure only, 9/26 both), of which 8/26 (31%) were major (requiring hospitalization or RBC transfusion) and 18/26 (69%) were minor (requiring factor or observation). Of all the bleeding complications observed, 15/26 (58%) received factor alone (3/15 major bleeds, 12/15 minor bleeds), 3/26 (11%) received nothing (3/3 minor bleeds), and 8/26 (31%) received a combination of factor concentrate and an antifibrinolytic (5/8 major bleeds, 3/8 minor bleeds). There were 14/56 (25%) pt who underwent a biopsy or polypectomy without receiving any pre/post factor or antifibrinolytic. In 3/14 (21%), there was a minor bleeding complication and in 0/14 (0%), there was a major bleeding complication. No pt experienced colonic perforation. Conclusion In this study, most pt did not receive a biopsy or polypectomy. A risk stratification approach could be taken when deciding on factor concentrate infusions. For low risk pt, factor could be withheld but with post-procedure infusion provided for those undergoing biopsy or polypectomy. For high risk pt, current practices are reasonable. Based on the results presented here and the potential magnitude of impact, this topic deserves further study in a prospective fashion. Disclosures: No relevant conflicts of interest to declare.
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