Current practice of periprocedural haematological management for patients undergoing image-guided procedures

Objective:

To evaluate current UK practice of periprocedural haematological management for image-guided procedures in relation to Cardiovascular and Interventional Radiological Society guidelines, which provide recommendations according to bleeding risk of procedures from Category 1 (lowest) to 3 (highest).

Methods:

Survey of practice in UK radiology departments conducted over a 1-year period

Results:

48 radiology departments responded. The percentage of departments that stop antithrombotics pre-procedurally are as follows (for Category 1, 2 and 3, respectively): aspirin (31.3%, 43.8%, 54.2%); clopidogrel (54.2%, 68.8%, 72.9%); therapeutic low-molecular-weight heparin (56.3%, 77.1%, 75.0%). The percentage of departments that perform pre-procedural laboratory testing are as follows (for Category 1, 2 and 3, respectively): international normalized ratio (INR; 81.3%, 95.8%, 93.8%); activated partial thrombin time ratio (APTTR; 60.4%, 75.0%, 93.8%); platelet (77.1%, 91.7%, 95.7%); haemoglobin (70.8%, 85.4%, 87.5%). Mean threshold (standard deviation) of laboratory results for conducting procedures (Level 1, 2 and 3, respectively) are as follows: INR 1.53 (0.197), 1.47 (0.186), 1.47 (0.188)]; APTTR 1.50 (0.392), 1.50 (0.339), 1.48 (0.344)]; platelet count (x10³ cells per microlitre) 74.4 (28.7), 79.9 (29.1), 80.5 (29.3)]; haemoglobin (grams per decilitre) 9.05 (1.40), 9.00 (1.33), 8.92 (1.21)]. No department practices conformed to current recommendations for (1) pre-procedural cessation of antithrombotics and (2) pre-procedural laboratory testing. Two (4.2%) department practices conformed to recommendations for thresholds of haematological parameters.

Conclusion:

Current peri-procedural haematological management is variable and often does not conform to existing recommendations. Further research into the impact of this variation in practice on patient outcome is required

Advances in Knowledge:

This study demonstrates wide variation in practice in haematological management for image-guided procedures.Periprocedural haematological management, such as correction of coagulopathy, cessation of antithrombotics and pre-procedural laboratory testing (e.g. for haemoglobin levels and platelet count), is an important consideration for patients undergoing image-guided procedures.¹ The challenges of periprocedural haematological management are multifactorial in aetiology. In addition to the increasing range of complex image-guided procedures being performed, the patient population undergoing such procedures may also be complicated.² Many of these patients have comorbidities requiring antithrombotic therapy, or may have liver and marrow dysfunction, which can affect bleeding risk. Decisions on the optimal periprocedural haematological management are also confounded by the lack of high-level evidence, and existing guidelines within the literature can be variable even for equivalent procedures. For example, in two separate internationally accepted guidelines, the recommended international normalized ratio (INR) for chest drain insertion is <1.5 and <2.0.^3,4 There is also limited scope to transfer existing evidence on haematological management from other domains such as open surgery to image-guided interventions. Unlike conventional open surgical procedures where bleeding may be visualized immediately and controlled by direct pressure or vessel ligation, bleeding from image-guided procedures may be difficult to control owing to issues with access and identification.⁵The lack of high-level evidence is unsurprising, given the potential ethical issues in conducting the necessary studies; it would be difficult to justify the randomization of patients to receiving or not receiving coagulopathy correction prior to undergoing various image-guided procedures for the purpose of research.⁶ As a result, current evidence is often based on retrospective studies. To address this complex issue, the Society of Interventional Radiology in conjunction with the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) has previously produced guidelines based on existing evidence and expert consensus on periprocedural haematological management for image-guided procedures which are stratified into three categories according to the bleeding risk (4 However, despite the existence of such guidelines, from our experience, significant variation in practice exists between clinicians, even within our own institution.

Table 1.

Society of Interventional Radiology/Cardiovascular and Interventional Radiological Society of Europe consensus guidelines on periprocedural haematological management for image-guided procedures according to category of bleeding risk

Guideline item	Guidance according to category of bleeding risk
	Category 1 (low risk)	Category 2 (intermediate risk)	Category 3 (high risk)
Examples of procedures
Vascular	Venography, IVC filter, PICC line	Arterial intervention (access size up to 7 French), chemoembolization, uterine fibroid embolization	TIPS
Non-vascular	Thoracentesis, paracentesis, superficial aspiration and biopsy	Intra-abdominal abscess drainage, lung biopsy, percutaneous cholecystostomy	Renal biopsy, biliary interventions (new tract), nephrostomy
Antiplatelet/anticoagulation cessation
Aspirin	Do not withhold	Do not withhold	Withhold 5-day pre-procedure
Clopidogrel	Do not withhold	Withhold 5-day pre-procedure	Withhold 5-day pre-procedure
Therapeutic LMWH	Withhold one-dose pre-procedure	Withhold one-dose pre-procedure	Withhold for 24 h/up to two doses
Pre-procedural testing
INR	On warfarin/with liver disease	All patients	All patients
APTTR	On unfractionated heparin	On unfractionated heparin	On unfractionated heparin
Platelet count	Not routinely recommended	Not routinely recommended	All patients
Haemoglobin	Not routinely recommended	Not routinely recommended	All patients
Threshold for correcting parameter/withholding procedure
INR	INR >2.0	>1.5 (89% consensus)	>1.5 (95% consensus)
APTTR	No consensus	No consensus	>1.5 times control
Platelet count	Transfusion if <50 × 103 μl−1	Transfusion if <50 × 103 μl−1	Transfusion if <50 × 103 μl−1
Haemoglobin	No recommended threshold	No recommended threshold	No recommended threshold

Open in a separate windowAPTTR, activated partial thrombin time ratio; INR, international normalized ratio; IVC, inferior vena cava; LMWH, low-molecular-weight heparin; PICC, peripherally inserted central catheters; TIPS, transjugular intrahepatic portosystemic shunt.Adapted from Patel et al.⁴The aim of this study was to evaluate current practices of haematological management in patients undergoing image-guided procedures in the UK.