Wilensky Joshua A, Ali Ahsan T, Moursi Mohammed M, Escobar Guillermo A, Smeds Matthew R
Department of Vascular and Endovascular Surgery, University of Arkansas for Medical Sciences, Little Rock, AR.
Department of Vascular and Endovascular Surgery, University of Arkansas for Medical Sciences, Little Rock, AR.
Ann Vasc Surg. 2015 Jan;29(1):22-7. doi: 10.1016/j.avsg.2014.05.019. Epub 2014 Jun 12.
Patients treated with anticoagulants frequently require urgent vascular procedures and elevated prothrombin time/international normalized ratio (INR) is traditionally thought to increase access site bleeding complications after sheath removal. We aimed to determine the safety of percutaneous arterial procedures on patients with a high INR in the era of modern ultrasound-guided access and closure device use.
Patients undergoing arterial endovascular procedures at a single institution between October 2010 and November 2012 were reviewed (n = 1,333). We retrospectively analyzed all patients with an INR > 1.5. Venous procedures, lysis checks, and cases with no documented INR within 24 hr were excluded. Sixty-five patients with 91 punctures were identified. A comparison group was then generated from the last 91 patients intervened on with INR < 1.6. Demographics, intraoperative data, and postoperative complications were compared.
The demographics were similar. More Coumadin use and higher INR were found in the study group (71/91 and 0/91, P = 0.001; 2.3 and 1.1 sec, P = 0.001, respectively), but there was more antiplatelet use in the control group (68/91 and 51/91, P = 0.01). Intraoperatively, the sheath sizes, protamine use, closure device use, ultrasound guidance, brachial access, and procedure types were not statistically different. Sheath sizes ranged from 4 to 22F in the study group and 4 to 20F in the control group. Paradoxically, heparin was administered more frequently in the study group (64/91 and 50/91, P = 0.046). Bleeding complications occurred more commonly in the study group (3/91 and 1/91, P = 0.62), but this failed to reach significance and the overall complication rate in both groups was low.
Endovascular procedures may be performed safely with a low risk of bleeding complications in patients with an elevated INR. Ultrasound guidance and closure device use may allow these cases to be performed safely, but a larger series may be needed to confirm this.
接受抗凝治疗的患者经常需要进行紧急血管手术，传统观念认为凝血酶原时间/国际标准化比值（INR）升高会增加拔除鞘管后穿刺部位出血并发症的发生风险。我们旨在确定在现代超声引导穿刺和使用闭合装置的时代，INR升高的患者进行经皮动脉手术的安全性。
回顾性分析2010年10月至2012年11月在单一机构接受动脉血管腔内手术的患者（n = 1333例）。我们对所有INR>1.5的患者进行了回顾性分析。排除静脉手术、溶栓检查以及24小时内未记录INR的病例。共确定了65例患者，进行了91次穿刺。然后从最后91例INR<1.6的介入患者中生成一个对照组。比较了两组患者的人口统计学资料、术中数据和术后并发症。
两组患者的人口统计学资料相似。研究组使用华法林的比例更高，INR也更高（分别为71/91和0/91，P = 0.001；2.3和1.1秒，P = 0.001），但对照组使用抗血小板药物的比例更高（分别为68/91和51/91，P = 0.01）。术中，两组患者的鞘管尺寸、鱼精蛋白使用情况、闭合装置使用情况、超声引导情况、肱动脉穿刺情况及手术类型差异均无统计学意义。研究组鞘管尺寸范围为4至22F，对照组为4至20F。矛盾的是，研究组更频繁地使用肝素（分别为64/91和50/91，P = 0.046）。研究组出血并发症的发生率更高（分别为3/91和1/91，P = 0.62），但未达到显著差异，且两组的总体并发症发生率均较低。
INR升高的患者进行血管腔内手术可能是安全的，出血并发症风险较低。超声引导和闭合装置的使用可能使这些手术能够安全进行，但可能需要更大规模的系列研究来证实这一点。
