Standards of practice
Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image-guided Interventions

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Preamble

The membership of the Society of Interventional Radiology (SIR) Standards of Practice Committee represents experts in a broad spectrum of interventional procedures from both the private and academic sectors of medicine. Generally, Standards of Practice Committee members dedicate the vast majority of their professional time to performing interventional procedures; as such, they represent a valid broad expert constituency of the subject matter under consideration for standards production.

Methodology

SIR produces its Standards of Practice documents by using the following process. Standards documents of relevance and timeliness are conceptualized by the Standards of Practice Committee members. A recognized expert is identified to serve as the principal author for the standard. Additional authors may be assigned depending on the magnitude of the project.

An in-depth literature search is performed by using electronic medical literature databases. Then, a critical review of peer-reviewed

Introduction and Background

Hematologic management in the patient undergoing percutaneous image-guided intervention is complex because of the wide range of procedures and equally wide range of patient demographics and comorbidities. Concurrent increases in the use of short- and long-term anticoagulation, as well as the increasing use of antiplatelet agents, further complicates the periprocedural management of these patients. Despite the continuing increase in the volume of percutaneous image-guided procedures, there is a

Prothrombin time

The prothrombin time (PT) test measures the clotting time upon activation of the extrinsic and common coagulation pathway. It is used for monitoring oral anticoagulant therapy and is now widely reported as an international normalized ratio (INR). The degree of prolongation of the clotting time correlates to the degree of deficiency or inhibition of extrinsic or common pathway clotting factors I (fibrinogen), II (prothrombin), V, VII, and X, which are synthesized by the liver. When any of these

Warfarin

Warfarin (Coumadin) antagonizes the production of the vitamin K–dependent extrinsic pathway clotting factors (II, VII, IX, X) and protein C and S in the liver. The clinical effect is measured by the INR, which reflects antagonism of factor VII, which has the shortest half-life of approximately 6 h. Therapeutic INR values may vary by indication for anticoagulation, but most often range from 2.2 to 2.8. Patient comorbidities, concomitant medication use, as well as diet may significantly alter the

Fresh Frozen Plasma

FFP contains plasma proteins, including coagulation factors, than can be administered to correct coagulopathies secondary to clotting factor deficiency; however, the effect of FFP is variable because the variable concentration of vitamin K–dependent clotting factors. On average, at least 10 mL/kg is needed to effectively increase plasma protein levels. Common dose ranges are from 15 to 30 mL/kg. In practice, in the patient with an INR in the 2.5 range, 2 U of FFP may be effective in reversing

Refusal of Blood Products

There are currently no interventional radiology specific guidelines for handling hemorrhage or preventing bleeding complications in patients who refuse administration of blood products for religious or other reasons. As such, we currently recommend to consult and coordinate care for these patients closely with the hematology department of the respective hospital. Administration of erythropoietin and desmopressin can be strongly considered before the start of procedures that are likely to cause

Fresh Frozen Plasma

The most common intervention before image-guided procedures is transfusion of FFP. In the United States, more than 3 million units of FFP are transfused each year (44, 45). Dzik and Rao reported in a 3-mo audit of FFP use at the Massachusetts General Hospital that the most common reason for prescribing FFP was to prepare a patient with an elevated INR for an invasive procedure. This indication accounted for one third of all requests for FFP (46). Stanworth et al (47) reported a review of 57

Platelet Transfusions

Severe thrombocytopenia may result in an increased bleeding risk with image-guided interventions and open surgery, although the recommended threshold for platelet transfusion varies among procedures. As with the use of FFP, the literature data for platelet use are mostly from case series, retrospective case reviews, and consensus data (63, 64, 65, 66, 67). There are many etiologies of thrombocytopenia and significant variation in platelet function associated with patient comorbidities and

Aspirin

Aspirin irreversibly inhibits platelet cyclooxygenase, a key enzyme in production of thromboxane A2, which acts as a mediator of platelet activation and aggregation (79). In patients with normal bone marrow function and reserve, platelet lifespan is approximately 10 d. Taking into account variabilities in drug clearance, withholding antiplatelet agents for 5 d will therefore result in approximately 30%–50% of platelets at the time of the procedure to have normal function.

Thienopyridines

Thienopyridines include

Recommendations for Preprocedure Testing and Management

Assessment and preparation of the patient before image-guided procedures will vary according to the procedure to be performed in conjunction with a comprehensive assessment of the patient's comorbidities. Although image guidance is likely to make minimally invasive procedures more accurate, for example, in their ability to target lesions or to put effector devices such as needles or catheters in optimal position, by their very nature, these procedures preclude the operator from direct

Summary

In this document, we attempt to summarize some of the available literature regarding periprocedural surveillance and management of hemostatic defects in patients undergoing percutaneous image-guided procedures. Because of the lack of randomized controlled studies or other high-level evidence on this topic, a Delphi panel of experts constructed a set of consensus guidelines to hopefully serve as a reference for the practicing interventionalist in constructing their individual practice

Acknowledgments

Indravadan J. Patel, MD, authored the first draft of this document and served as topic leader during the subsequent revisions of the draft. Wael A. Saad, MD, is chair of the SIR Standards of Practice Committee. Boris Nikolic, MD, is chair of the Revisions Subcommittee. Sanjoy Kundu, MD, FRCPC, served as SIR Standards Division Councilor during the development of this document and contributed to its content. All other authors are listed alphabetically. Other members of the Standards of Practice

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    This article first appeared in J Vasc Interv Radiol 2009; 20(suppl):S240–S249.

    None of the authors have identified a conflict of interest.

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