Division of Hospital Medicine, University of California, San Francisco; Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
Division of Hospital Medicine, University of California, San Francisco.
Am J Med. 2019 Jun;132(6):722-732.e7. doi: 10.1016/j.amjmed.2019.01.004. Epub 2019 Jan 16.
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.
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.
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.
Periprocedural bridging increases the risk of bleeding compared with VKA interruption without bridging, without a significant difference in periprocedural venous thromboembolism rates.
维生素 K 拮抗剂（VKA）是最广泛使用的抗凝剂，在 VKA 中断期间通常进行桥接治疗。鉴于先前患有静脉血栓栓塞症的患者在围手术期桥接的益处和风险尚不清楚，我们旨在评估该人群中有无桥接治疗时的复发性静脉血栓栓塞和出血结局。
我们进行了系统评价，从开始到 2017 年 12 月 7 日，在 PubMed 和 Embase 数据库中搜索了需要中断 VKA 以进行择期手术的先前患有静脉血栓栓塞症的成人的随机和非随机研究，并报告了静脉血栓栓塞或出血结局。证据质量通过共识进行分级。
我们纳入了 28 项队列研究（其中 20 项为单臂队列），总共分析了 6915 例手术。在 27 项报告围手术期静脉血栓栓塞结局的研究中，桥接时复发性静脉血栓栓塞的发生率为 0.7%（95%CI，0.4%-1.2%），无桥接时为 0.5%（95%CI，0.3%-0.8%）。18 项研究报告了主要或非主要出血结局。任何出血的发生率为 3.9%（95%CI，2.0%-7.4%）时有桥接，无桥接时为 0.4%（95%CI，0.1%-1.7%）。在高血栓栓塞风险的桥接患者中，静脉血栓栓塞的发生率为 0.8%（95%CI，0.3%-2.5%），任何出血的发生率为 7.5%（95%CI，3.1%-17.4%）。可用证据的质量非常低，主要是由于纳入研究的偏倚风险较高。
与无桥接的 VKA 中断相比，围手术期桥接增加了出血风险，而围手术期静脉血栓栓塞发生率没有显著差异。
