Management of antithrombotic treatment and bleeding disorders in patients requiring venous access devices: A systematic review and a GAVeCeLT consensus statement

Abstract

Insertion of venous access devices (VAD) is usually considered a procedure with low risk of bleeding. Nonetheless, insertion of some devices is invasive enough to be associated with bleeding, especially in patients with previous coagulopathy or in treatment with antithrombotic drugs for cardiovascular disease. The current practices of platelet/plasma transfusion in coagulopathic patients and of temporary suspension of the antithrombotic treatment before VAD insertion are based on local policies and are often inadequately supported by evidence, since many of the clinical studies on this topic are not recent and are not of high quality. Furthermore, the protocols of antithrombotic treatment have changed during the last decade, after the introduction of new oral anticoagulant drugs. Though some guidelines address some of these issues in relation with specific procedures (port insertion, etc.), no evidence-based document covering all the aspects of this clinical problem is currently available. Thus, the Italian Group of Venous Access Devices (GAVeCeLT) has decided to develop a consensus on the management of antithrombotic treatment and bleeding disorders in patients requiring VADs. After a systematic review of the available evidence, the panel of the consensus (which included vascular access specialists, surgeons, intensivists, anesthetists, cardiologists, vascular medicine experts, nephrologists, infective disease specialists, and thrombotic disease specialists) has structured the final recommendations as detailed answers to three sets of questions: (1) which is an appropriate classification of VAD-related procedures based on the specific bleeding risk? (2) Which is the appropriate management of the patient with bleeding disorders candidate to VAD insertion/removal? (3) Which is the appropriate management of the patient on antithrombotic treatment candidate to VAD insertion/removal? Only statements reaching a complete agreement were included in the final recommendations, and all recommendations were offered in a clear and synthetic list, so to be easily translated into clinical practice.

Life‐threatening airway obstruction due to retropharyngeal and cervicomediastinal hematomas following transjugular intrahepatic portosystemic shunt procedure for acute variceal bleeding in cirrhosis.

“…For patients with platelet count <50 × 10 9 /L, there is no contraindication to minimally invasive procedures; there is relative contraindication to moderately invasive procedures; and there is absolute contraindication to highly invasive procedures. 38 According to the characteristics of transjugular vein catheterization (the size and location of the vein, the diameter of the introducer used, the difficulty of venous cannulation, and the feasibility of compressing maneuvers for reducing the bleeding), TIPS should be considered a highly-invasive venous-access procedure mentioned by the GAVeCeLT consensus statement. This patient had a definite history of hypersplenism caused by liver cirrhosis, aPTT ratio of 1.33 before the TIPS procedure, and the persistent coagulation disorder after the TIPS procedure.…”

“…The GAVeCeLT consensus statement published by the Italian multidisciplinary group for venous access devices in 2022 recommends the following: For patients with disease‐induced coagulopathy with PT/INR >1.5 and/or aPTT ratio >1.3, there is no contraindication to minimally invasive procedures (all peripheral venous access devices, nontunneled peripherally inserted central catheters, nontunneled femorally inserted central catheters at mid‐thigh); there is relative contraindication to moderately invasive procedures (nontunneled central inserted central catheters, nontunneled femorally inserted central catheters at the groin, tunneled peripherally inserted central catheters, nontunneled dialysis catheters); and there is absolute contraindication to highly invasive procedures (tunneled central inserted central catheters, tunneled femorally inserted central catheters, tunneled‐cuffed dialysis catheters, ports and peripherally inserted central catheter‐ports). For patients with platelet count <50 × 10 9 /L, there is no contraindication to minimally invasive procedures; there is relative contraindication to moderately invasive procedures; and there is absolute contraindication to highly invasive procedures 38 . According to the characteristics of transjugular vein catheterization (the size and location of the vein, the diameter of the introducer used, the difficulty of venous cannulation, and the feasibility of compressing maneuvers for reducing the bleeding), TIPS should be considered a highly‐invasive venous‐access procedure mentioned by the GAVeCeLT consensus statement.…”

Peri‐procedure management of antithrombotic agents and thrombocytopenia for common procedures in oncology: Guidance from the SSC of the ISTH

“…24 On the other hand, tunneled catheters and implantable ports are typically categorized as higher bleeding risks due to greater tissue manipulation, and a short interruption of anticoagulation similar to the low bleeding risk category in the Perioperative Management of Patients with Atrial Fibrillation (PAUSE) study (i.e., 1-2 days for DOAC) is typically suggested. 9,24,25 a Aspirin was continued throughout the procedure. Thienopyridines were discontinued for 5 days and replaced with aspirin.…”

“…No studies related to the management of anticoagulation or antiplatelet agents at the time of central line insertion specific to patients with cancer were identified. Central line insertion such as peripheral inserted central catheters is typically viewed as a minor procedure with a low risk of bleeding, for which no change in anticoagulation and/or antiplatelet agents is recommended 24 . On the other hand, tunneled catheters and implantable ports are typically categorized as higher bleeding risks due to greater tissue manipulation, and a short interruption of anticoagulation similar to the low bleeding risk category in the Perioperative Management of Patients with Atrial Fibrillation (PAUSE) study (i.e., 1–2 days for DOAC) is typically suggested 9,24,25 .…”

“…Central line insertion such as peripheral inserted central catheters is typically viewed as a minor procedure with a low risk of bleeding, for which no change in anticoagulation and/or antiplatelet agents is recommended 24 . On the other hand, tunneled catheters and implantable ports are typically categorized as higher bleeding risks due to greater tissue manipulation, and a short interruption of anticoagulation similar to the low bleeding risk category in the Perioperative Management of Patients with Atrial Fibrillation (PAUSE) study (i.e., 1–2 days for DOAC) is typically suggested 9,24,25 . The same guidance applies to non‐tunneled central venous catheter placement in a non‐compressible area such as subclavian, transhepatic, or translumbar veins.…”