CVC: Anticoagulation and Coagulopathy

In 2017, the ACC published, with the aid of other professional societies consensus bleeding risk associated with various procedures [1].

Both the ACCP and ACP rated CVC placement as low bleeding risk, and the ASN rated CVC for temporary hemodialysis as low to intermediate risk, while a RHC is low risk per ACC.

While the ACC recommendation were geared toward elective / planned procedures in patients with atrial fibrillation, the thought process behind an individuals treatment plan peri-procedurally is the same.

1. Assess the patient’s inherit bleeding risk (i.e. HAS-BLED)
2. Consider the procedural bleeding risk
3. Put this information in context of the urgency of the procedure.

It should also be noted, per a 2017 AHA scientific statement on periprocedural management of NOACs, these need not be held nor is bridging required for low risk procedures (Figure 3) [2].

In this context, we believe most cases of temporary CVC placement will be a emergent and / or sufficiently low risk that reversing or holding anticoagulation (AC) or correcting coagulopathy is not automatically warranted.

This is not a guideline or blanket recommendation, such decisions are patient specific and risks and benefits should be considered as should potentially delaying a procedure, if possible.

But, as we will see, there is little evidence that correcting coagulopathy makes a procedures safer, nor is bleeding risk much higher in low risk procedures while on AC. Therefore, correcting lab values or holding AC should not be reflexive.

On Coagulopathy, Thrombocytopenia

There is not much evidence relating to coagulopathy and CVC placement. One meta-analysis, which included only 1 RCT with 21 observational studies is discussed here [3].

A total of 13,256 CVC insertions were pooled

• 4213 pts with severe coagulopathy (platelet <50; INR >1.5; PTT >45s)
• 3150 CVC placements – coagulopathy was not corrected.

Bleeding incidence ranged 0 to 32% (included oozing) and the severity of coagulopathy did not predict bleeding risk.

Author’s Conclusion: No study demonstrated a beneficial effect of prophylactic FFP. Results suggest when platelets > 20 K or INR < 3, correction is not required. But this has not been assessed prospectively.

Therapeutic Anticoagulation

If, based on clinical judgement, the decision to hold a AC is made (possibly if the procedure is elective or non-urgent) then following could be extrapolated from [1]:

Hold time for Apixaban, Edoxaban, or Rivaroxaban based on GFR

GFR (mL/min)	≥30	13-29	<15
Hold time (hr)	≥24	≥36	? ≥48

Hold time for Dabigatran based on GFR

GFR (mL/min)	>80	50-79	30-49	15-29	<15
Hold time (hr)	≥24	≥36	≥48	≥72	N/A

Hold time for VKAs

Low bleed risk*	Do NOT hold
Increased bleed risk*	“use of best clinical judgement” , ?based on INR

*Bleed risk = HAS-BLED ≥3, prior bleed w/in 3 mo, quantitative/qualitative platelet abnormality, supratherapeutic INR, bleed from prior bridging, bleed from similar procedure

1. Doherty JU, et al. 2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation: A Report of the American College of Cardiology Clinical Expert Consensus Document Task Force. J Am Coll Cardiol. 2017 Feb 21;69(7):871-898.
2. Raval AN, et al. Management of Patients on Non-Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association. Circulation. 2017 Mar 7;135(10):e604-e633.
3. van de Weerdt, EK, et al. Central venous catheter placement in coagulopathic patients: risk factors and incidence of bleeding complications. Transfusion. 2017 Oct;57(10):2512-2525.
4. Baron RM. Point: should coagulopathy be repaired prior to central venous line insertion? Yes: why take chances? Chest. 2012 May;141(5):1139-1142.
5. Goldhaber SZ. Counterpoint: should coagulopathy be repaired prior to central venous line insertion? No. Chest. 2012 May;141(5):1142-1144.

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