Comparison between activated clotting time and anti-activated factor X activity for the monitoring of unfractionated heparin therapy in patients with aortic aneurysm undergoing an endovascular procedure

Dieplinger, Benjamin; Egger, Margot; Luft, Christian; Hinterreiter, Franz; Pernerstorfer, Thomas; Haltmayer, Meinhard; Mueller, Thomas

doi:10.1016/j.jvs.2017.11.079

Cited by 20 publications

(20 citation statements)

References 20 publications

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confidence: 60%

“…Our findings suggest that monitoring UFH therapy with anti-Xa during aortic endograft procedures may reduce total UFH use and possibly even improve outcomes. 1 Therefore, the results of our study suggest substitution of the ACT with the anti-Xa activity measurement (with a target range of 0.5-1.0 IU/mL) to monitor UFH therapy during aortic endovascular procedures at vascular medical centers. At our institution, we have anti-Xa activity measurements available in the central laboratory 24 hours a day with an optimized turn-around-time from blood draw to result reporting of 20 minutes.…”

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confidence: 96%

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Dieplinger

Egger

Haltmayer

et al. 2019

Journal of Vascular Surgery

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ReplyWe thank Bellini et al for their comments on our study. 1 We fully agree with the critical statements about the measurement of the activated clotting time (ACT). We also acknowledge that ACT is the only bedside test available 24 hours a day in many hospitals. Furthermore, current guidelines recommend the use of ACT to monitor unfractionated heparin (UFH) therapy during vascular interventions. 2 Nevertheless, many laboratories are now transitioning to monitor actual heparin activity by chromogenic anti-activated factor X (anti-Xa) assay, which is considered the reference method for monitoring heparin therapy. [3][4][5] The data of our comparison between ACT and anti-Xa activity for the monitoring of UFH therapy in patients with aortic aneurysm undergoing an endovascular procedure showed poor agreement between the two methods, and only increased peak anti-Xa activity was an independent predictor of periprocedural bleeding but not increased peak ACT. 1 To further visualize the main message of our study, we show the time course of ACT measurements during UFH treatment and the corresponding anti-Xa values of an exemplary patient with aortic aneurysm during an endovascular procedure (Fig).In our study, after a UFH bolus, further UFH doses were given according to ACT (target range $250 seconds). Repeated UFH dosing was solely based on the ACT measurements. Accordingly, the patient depicted in the Fig received a UFH bolus and two repeated UFH doses to reach the ACT target range. Interestingly, after the UFH bolus, the anti-Xa activity was already at 0.81 IU/mL (indicating therapeutic anticoagulation). Consequently, we speculate that if anti-Xa activity would have been used to monitor UFH therapy in our patients with aortic aneurysm undergoing an endovascular procedure, fewer repeated UFH doses would have been given. Our findings suggest that monitoring UFH therapy with anti-Xa during aortic endograft procedures may reduce total UFH use and possibly even improve outcomes. 1 Therefore, the results of our study suggest substitution of the ACT with the anti-Xa activity measurement (with a target range of 0.5-1.0 IU/mL) to monitor UFH therapy during aortic endovascular procedures at vascular medical centers. At our institution, we have anti-Xa activity measurements available in the central laboratory 24 hours a day with an optimized turn-around-time from blood draw to result reporting of 20 minutes. We are well aware that this setup is not available in many hospitals. Therefore, a point-of-care device to measure anti-Xa activity in the hybrid endovascular room is urgently needed.

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confidence: 96%

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Dieplinger

Egger

Haltmayer

et al. 2019

Journal of Vascular Surgery

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“…Data were collected prospectively in 16 studies 21e 30,32,34,35,38e40 and retrospectively in five. 31,33,36,37,41 None of the included studies was a randomised controlled trial. Eleven studies 21,23e28,32,37,39,40 included open procedures, and 10 studies 22,29e31,33e36,38,41 included endovascular procedures.…”

Section: Study Characteristicsmentioning

confidence: 99%

“…Information included in this section is summarised in Table 5 to facilitate reading. In four of the included studies, 28,33,38,41 the peak ACT levels were correlated with clinical outcomes, including the incidence of ATEC, haemorrhagic complications, and mortality.…”

Section: Association Between Act and Complicationsmentioning

confidence: 99%

“…A separate multivariable logistic model was used, and this analysis also identified an ACT !250 s as an independent predictor of the need of blood transfusion (OR ¼ 1.9, 95% CI ¼ 1.06e3.6, p ¼ .03). Dieplinger et al 41 included 104 patients with aortic endograft procedures and they tested whether ACT measurements were associated with peri-procedural haemorrhagic complications. Thirty-two patients (31%) showed ACT values !…”

Section: Association Between Act and Complicationsmentioning

confidence: 99%

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No Concluding Evidence on Optimal Activated Clotting Time for Non-cardiac Arterial Procedures

Doganer

Wiersema

Scholtes

et al. 2020

European Journal of Vascular and Endovascular Surgery

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WHAT THIS PAPER ADDS Despite a striking lack of evidence on any beneficial effects, heparin has been used worldwide as a prophylactic antithrombotic for 70 years during all non-cardiac arterial procedures (NCAP). The optimal activated clotting time (ACT) and corresponding heparin dose in NCAP is currently unknown. This systematic review sought to assess the optimal level of ACT during NCAP, related to complication rate, and clinically relevant and patient related outcomes. The results show a lack of robust data on optimal target ACT during NCAP. Objectives: Heparin has a non-predictable effect in the individual patient. The activated clotting time (ACT) is used to measure the level of anticoagulation after administration of heparin. To date, appropriate heparin dose protocols and corresponding therapeutic ACT values have not been established in non-cardiac arterial procedures (NCAP). The aim of this review was to study the use of ACT monitoring during NCAP, and whether an optimal ACT could be determined based on the fewest arterial thrombo-embolic complications (ATEC) and bleeding complications. Methods: This systematic review was performed in accordance with the PRISMA Guidelines. A systematic search was conducted in MEDLINE, EMBASE, and the Cochrane database. Any associations were evaluated between periprocedural ACT levels and ATEC and bleeding complications detected during the same admission as the primary procedure or during 30 day follow up. Also, heparin dose protocols, peri-procedural target ACTs, different ACT devices, protamine use and pre-, peri-, and post-procedural anticoagulation therapy were evaluated. Results: In total, 21 studies with 3982 patients were included, on both open and endovascular NCAP. Four studies were primarily designed to correlate peak peri-procedural ACT with clinical outcomes; however, the definitions of the results and the clinical outcomes were too heterogeneous for analysis. There was major variability in all studied aspects of ACT measurement, heparin and protamine use, and in the type of procedures in the included studies. Overall methodological quality of the included studies was poor. No randomised controlled trials were found. Studies were at a high risk of bias. Conclusions: This systematic review demonstrates a lack of data and no consensus in the literature concerning the optimal ACT, and the possible association with haemorrhagic complications and ATEC during NCAP.

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