Section of Vascular Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Mich.
Section of Vascular Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Neb.
J Vasc Surg. 2020 Dec;72(6):1996-2005.e4. doi: 10.1016/j.jvs.2020.02.021. Epub 2020 Apr 8.
Widespread adoption of direct oral anticoagulants (DOACs) for atrial fibrillation and venous thromboembolism treatment has resulted in peripheral bypass patients receiving therapeutic anticoagulation with DOACs postoperatively. This study was undertaken to evaluate patient outcomes after open peripheral bypass based on anticoagulation treatment.
Postoperative treatment and outcomes of patients undergoing peripheral bypass operations between January 2012 and December 2017 from a statewide multicenter quality improvement registry were examined. Surgeons participating in the registry were surveyed on practice patterns regarding DOACs in bypass patients. Multivariate logistic regression was performed for 30-day transfusion outcomes, and multiple linear regression was performed for length of stay.
Among 9682 patients, 7685 patients received no anticoagulation, whereas 1379 received a vitamin K antagonist (VKA) and 618 received a DOAC postoperatively. Patients receiving anticoagulation compared with no anticoagulation had a higher body mass index and were more likely to have preoperative anemia, congestive heart failure, and atrial fibrillation (all P < .001). Compared with patients receiving VKAs, patients receiving DOACs were less likely to have chronic kidney disease (P = .002) and more likely to have atrial fibrillation (P < .001). The shortest length of stay was among patients receiving no anticoagulation (median, 5 days; interquartile range, 3-9 days; P < .001), followed by DOACs (median, 6 days; interquartile range 3-11 days; P < .001) and VKAs (median, 8 days; interquartile range, 5-13 days; P < .001). Compared with patients receiving VKAs postoperatively, there was no difference in readmission for anticoagulation complications, bypass thrombectomy or thrombolysis, major amputation, or graft patency at 1 year among patients receiving DOACs. On multivariate logistic regression, patients receiving a DOAC (odds ratio, 0.743; confidence interval, 0.59-0.94; P = .011) or no anticoagulation (odds ratio, 0.792; confidence interval, 0.69-0.91; P = .001) were less likely to require transfusion within 30 days than patients taking VKAs. Approximately 70% of the surveyed surgeons reported that they "sometimes" or "always" use DOACs instead of VKAs for protection of a high-risk bypass.
Among patients undergoing lower extremity surgical bypass, those receiving a DOAC postoperatively had a shorter length of stay and were less likely to receive a transfusion in 30 days without compromising graft patency and readmission for anticoagulation complications, thrombectomy, or thrombolysis or affecting amputation rate compared with those receiving a VKA. A majority of surgeons within the quality collaborative have adopted the use of DOACs after peripheral bypass, suggesting the need for a prospective trial evaluating DOAC safety and efficacy in patients requiring anticoagulation for high-risk bypass grafts.
广泛采用直接口服抗凝剂（DOACs）治疗心房颤动和静脉血栓栓塞症，导致外周旁路患者术后接受 DOACs 治疗性抗凝。本研究旨在评估基于抗凝治疗的开放性外周旁路手术后患者的结局。
对 2012 年 1 月至 2017 年 12 月期间来自全州多中心质量改进登记处的外周旁路手术患者的术后治疗和结局进行了检查。参与登记处的外科医生就旁路患者中 DOAC 的应用实践模式进行了调查。对 30 天输血结局进行多变量逻辑回归，对住院时间进行多元线性回归。
在 9682 例患者中，7685 例患者未接受抗凝治疗，1379 例患者接受维生素 K 拮抗剂（VKA）治疗，618 例患者接受 DOAC 治疗。与未接受抗凝治疗的患者相比，接受抗凝治疗的患者体重指数更高，更有可能患有术前贫血、充血性心力衰竭和心房颤动（均 P <.001）。与接受 VKA 的患者相比，接受 DOAC 的患者更不可能患有慢性肾脏病（P =.002），且更有可能患有心房颤动（P <.001）。未接受抗凝治疗的患者住院时间最短（中位数为 5 天；四分位间距为 3-9 天；P <.001），其次是 DOAC（中位数为 6 天；四分位间距为 3-11 天；P <.001）和 VKA（中位数为 8 天；四分位间距为 5-13 天；P <.001）。与术后接受 VKA 的患者相比，在接受 DOAC 治疗的患者中，在接受抗凝并发症、旁路血栓切除术或溶栓、大截肢或移植物通畅性方面，在术后 1 年因抗凝并发症再次入院、旁路血栓切除术或溶栓、大截肢或移植物通畅性方面，无差异。多变量逻辑回归显示，与接受 VKA 的患者相比，接受 DOAC（比值比，0.743；95%置信区间，0.59-0.94；P =.011）或不接受抗凝（比值比，0.792；95%置信区间，0.69-0.91；P =.001）的患者在 30 天内需要输血的可能性更小。大约 70%的调查外科医生报告说，他们“有时”或“总是”使用 DOAC 而不是 VKA 来保护高危旁路。
在接受下肢手术旁路的患者中，与接受 VKA 的患者相比，接受 DOAC 治疗的患者术后住院时间更短，在 30 天内输血的可能性更小，而不会影响移植物通畅率和因抗凝并发症、血栓切除术或溶栓、大截肢或旁路血栓形成导致的再次入院率，或影响截肢率。质量协作组中的大多数外科医生已经采用了 DOAC 治疗外周旁路术后的抗凝治疗，这表明需要进行前瞻性试验来评估 DOAC 在需要抗凝治疗高危旁路移植物的患者中的安全性和疗效。
