Abstract
Objectives
Chronic anticoagulation for atrial fibrillation, a history of venous thromboembolism, and after heart valve replacement is often stopped or bridged for surgery. Our institutional practice is to continue anticoagulation through ambulatory phlebectomy (AP) procedures. As such, we aimed to compare postprocedure bleeding and major adverse events in patients on anticoagulation who received AP compared with patients not on anticoagulation.
Methods
We included all patients who required AP from January 2016 to February 2023. Given the low frequency of chronic anticoagulation during the study period, as defined as patients on anticoagulation ≥30 days before index procedure and not held through the procedure, a propensity score match of 16 demographic parameters was performed to better match patients. After propensity matching, we compared the frequency and quality of postprocedural bleeding (none, incisional, large volume), extent of postprocedural ecchymosis (none, minimal, moderate, significant), and pain (minimal, moderate, severe) on follow-up examination with a provider. Thirty-day emergency department (ED) visits and major adverse cardiac events were also recorded for each patient. Continuous variables were compared using independent t tests or Mann-Whitney U tests, and categorical variables were compared using a χ2 or Fisher's exact test.
Results
In total, 1853 patients received AP from four outpatient offices during the study period, 101 (5.5%) of whom were on chronic anticoagulation. Seventy patients for each group were propensity score matched in key demographics including age, gender, body mass index, Clinical-Etiology-Anatomy-Pathophysiology classification, prior vein procedures, concomitant laser procedures, number of phlebectomies performed, and comorbidities like history of deep vein thrombosis, pulmonary embolism, and peripheral arterial disease. There were no intraoperative major bleeding events. Patients on chronic anticoagulation were not more likely to have increased postprocedural bleeding (2.9% vs 0%; P > .05), significant ecchymosis (4.5% vs 1.5%; P = .671), severe pain on follow-up (1.4% vs 0%; P > .05), or increased likelihood of postprocedural cellulitis (1.4% vs 0%; P > .05). There were no instances of 30-day ED visits or major adverse cardiac events. Within patients on anticoagulation, use of rivaroxaban (8%) had higher incidence of bleeding than those on apixaban or warfarin (0%); however, these findings were not significant.
Conclusions
AP while continuing chronic anticoagulation did not result in an increased rate of bleeding, ED visits, or major adverse events. It is likely safe to continue anticoagulation throughout these outpatient procedures.
Keywords: Ambulatory phlebectomy, Anticoagulation, Bleeding
Article Highlights.
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Type of Research: Single-institution retrospective cohort study
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Key Findings: Continuation of chronic anticoagulation through ambulatory phlebectomy for symptomatic venous insufficiency was not associated with an additional burden of postprocedure complications, including frank bleeding, ecchymoses, or pain.
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Take Home Message: Maintaining patients on chronic anticoagulation does not increase the risk of adverse bleeding events after ambulatory phlebectomy.
Patients require the use of chronic anticoagulation such as warfarin, rivaroxaban, dabigatran, enoxaparin, and apixaban for a variety of reasons, including risk reduction of stroke from atrial fibrillation, venous thromboembolism, and prior mechanical valve replacement.1,2 Ambulatory phlebectomy (AP) is a mainstay procedure for the treatment of chronic, symptomatic superficial vein disease, including reflux that results in varicose veins, and frequently require the use of stab incisions for successive extraction of superficial veins.3 Before any intervention, including phlebectomy, it is essential to determine the risk of thromboembolic or procedural bleeding events for patients on chronic anticoagulation; this typically requires the use of clinical calculators like CHA2DS2VASc and HAS-BLED, along with individualized clinical judgment.2,4,5 There are few reports in the literature regarding anticoagulation with phlebectomy, including two surveys of physicians with mixed reports of discontinuing vs remaining on anticoagulation through phlebectomy procedures.6,7 Additionally, patients on chronic warfarin therapy were shown in a retrospective outcomes study to report similar rates of deep vein thrombosis after radiofrequency and laser vein ablation.8 Nonetheless, there is no societal guideline regarding use of anticoagulation in phlebectomy procedures.9
Currently, our institutional practice for patients who undergo elective APs for symptomatic varicose veins has been to continue chronic anticoagulation through their procedure, with seemingly comparable results. Therefore, we sought to identify if there was any difference in postintervention adverse events for patients on and off anticoagulation who undergo elective APs within our institution.
Methods
This was a retrospective study across a single vascular practice within an integrated health care system of patients who underwent APs with and without chronic anticoagulation from January 2016 to February 2023. This study was approved by the Hartford HealthCare Institutional Review Board (#2024-0011). Given the retrospective nature of this study and minimal risk, the need for informed consent was waved.
Clinical practice pattern
The consistent practice pattern for treatment of AP both with and without concomitant laser ablation first includes the use of oral anxiolytic therapy with 1 mg of oral lorazepam taken 1 hour before the procedure. Tumescent anesthesia with 500 mL normal saline, 50 mL of 1% lidocaine with 1% epinephrine, and 12 mL of sodium bicarbonate is injected throughout the treatment area before phlebectomy. At case completion, phlebectomy sites are closed with 5-0 interrupted nylon suture, followed by 4 × 4 gauze pads and a gentle ACE compression across the area of phlebectomy. Last, the patient dons their own compression stockings over these, with assistance by health care staff. We advocate for waist-high 20- to 30-mm Hg compression to prevent rolling down of the stocking after application. Patients are encouraged to keep their stockings on overnight through the day of the procedure, with instructions to remove all postoperative dressing on postoperative day 1. At that time, patients are cleared to shower and are recommended to reapply their stockings alone, during the daytime, for 7 days.
Patient selection
Adult patients who received APs in the study period at four outpatient locations within our institution were queried using Current Procedural Terminology codes 37765, 37766, and 37799. All patients required prior insurance authorization or have set up self-pay before scheduling APs at any outpatient location. Additional demographic metrics including type of anticoagulation such as apixaban, enoxaparin, dabigatran, rivaroxaban, and warfarin were also queried within the institution's electronic medical record (EMR) and matched to individual procedure encounters, which corroborated patient anticoagulant use for ≥30 days before the time of vascular surgery consultation and phlebectomy procedure.
Patients not anticoagulated, on anticoagulation for <30 days, or who had anticoagulation stopped before their procedure were classified as being in the no anticoagulation group. This distinction was determined by a combination of home medication start and end dates, nursing notes, and/or preprocedural or procedural notes within our institutional EMR. Five patients were identified to have stopped their anticoagulation periprocedurally and were included in the no anticoagulation group. We confirmed that each patient included in the anticoagulation group was prescribed a therapeutic dose of anticoagulation as assessed by the vascular surgeon and care team at the time of consultation; patients were instructed to continue their anticoagulation through the procedure, as documented with each preprocedural nurse reminder phone call. There were no patients actively being bridged with enoxaparin on warfarin, and international normalized ratios were noted to be in therapeutic ranges per the supervising specialist. We also ensured that patients had at least one follow-up encounter within our hospital system; one patient did not have any follow-up and was excluded from further analysis. Using this method, we identified 101 patients on chronic anticoagulation throughout the study period.
Given that this was a minority of patients in the total cohort, we decided to propensity score match using a 1:1 case-control ratio. The propensity score was developed as the probability of continuous use of anticoagulants using a multivariate logistic regression with 16 independent variables: age, gender, race, ethnicity, body mass index , hypertension, congestive heart failure, peripheral vascular disease, diabetes mellitus, hypercholesterolemia, history of deep vein thrombosis, history of pulmonary embolism, prior phlebectomy procedures, Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification, number of microphlebectomies, and current antiplatelet use. CEAP classification was determined by the 2020 updated classification system from the CEAP Task Force by the American Venous Forum.10 Body mass index was included if values were collected ±6 months from the index procedure. These parameters were examined to confirm the comparability of the two subpopulations before extracting outcome variables.
After propensity score matching, we conducted patient-level chart review for procedural and postprocedural complications and healing metrics, including any incidence of postprocedure phone calls to nursing staff regarding pain, bleeding, ecchymosis, and complaints at follow-up examination, including postprocedural bleeding, ecchymosis, reported pain, or postoperative infections. Postprocedural bleeding was defined as any surgical site bleeding that required additional health care provider contact, including a phone call to nursing, or indication at physician follow-up visits, as well as any bleeding needing additional intervention in the form of longer ACE compression wrapping or additional gauze. Postprocedural ecchymosis was defined as ecchymosis on the affected leg noted after the index surgical procedure, the area of which ecchymosis coverage was defined qualitatively as none, minimal, moderate, or significant in physician documentation. Postprocedural infections were defined as any clinical suspicion of surgical site or soft tissue infection related to the index procedure that required medical intervention, namely oral antibiotics. The institutional EMR was also queried for emergency department (ED) visits, hospitalizations, and major adverse cardiac events including myocardial infarction, stroke, and/or death from cardiovascular causes. All complications and healing metrics were followed for 30 days after the index procedure.
Statistical analyses
All outcomes of interest were compared using either Pearson's χ2 or Fisher's exact test. A two-sided alpha level of 0.05 was considered significant; all analyses were performed using SPSS version 29 (IBM, 2022, Armonk, NY). In our propensity score-matched patient population, a power of 0.94 was achieved to detect an effect size of 0.30 with an alpha level of 0.05 for our primary outcome.
Results
A total of 1853 patients received APs from four outpatient offices within our institutional network during the 7-year study period, with 101 patients (5.5%) on chronic anticoagulation. Demographics, clinical characteristics, and procedural details of all patients before propensity score matching is provided in Supplementary Table I (online only). Within this cohort on chronic anticoagulation, there were three patients (3%) who reported postprocedural bleeding before their follow-up appointment, either by calling the outpatient office or EMR messaging. There were also two patients (2%) who were prescribed oral antibiotics for postprocedural cellulitis. Ecchymosis was also minimal, including five patients (5%) indicating significant ecchymosis at a 1-week follow-up visit. No patient in the total anticoagulation cohort required an emergency room visit or an additional procedure before their planned, scheduled, postoperative visit.
Nonetheless, given the significant differences between these two populations, including comorbid conditions and clinical presentation, we elected to propensity score match patients to like-controls, yielding a total of 140 patients, 70 in each group. Of note, propensity score matching eliminated patients on anticoagulation who tended to be older (>76 years old), have a history of congestive heart failure, and have a history of previous deep vein thrombosis. This patient cohort was compared for demographic differences, procedural complications, and follow-up sequelae (Fig 1). Of the 70 patients who were on chronic anticoagulation, 25 (35.7%) were taking rivaroxaban, 23 (32.9%) were taking apixaban, 17 (24.3%) were taking warfarin, and the other 5 patients were taking either dabigatran (4.3%) or enoxaparin (2.9%). Reasons for chronic anticoagulation were most often related to atrial fibrillation (56.4%) (Fig 2).
Fig 1.
Flow diagram of patients receiving ambulatory phlebectomy (AP). BMI, body mass index; CEAP, Clinical-Etiology-Anatomy-Pathophysiology; CHF, congestive heart failure; DM, diabetes mellitus; DVT, deep vein thrombosis; HTN, hypertension; PE, pulmonary embolism; PVD, peripheral vascular disease.
Fig 2.
Anticoagulation type and indication for patients on chronic anticoagulation before ambulatory phlebectomy (AP). (A) Pie chart indicating distribution of types of anticoagulation patients are administered for chronic anticoagulation. (B) Indications for anticoagulation for all patients in the anticoagulated cohort.
The demographics for both groups are listed in Table I. As expected, all parameters used in the propensity score matching are equivalent between groups. This includes equal rates of prior vein procedures (28.6% vs 31.4%; P = .712) and concomitant ablation (80.0% vs 75.7%; P = .541). Of note, there was equal use of all four outpatient offices for phlebectomies in our cohort (P = .192). Compared with our entire cohort on anticoagulation, the propensity score matched patient population on anticoagulation tended to represent younger patients (aged ≥76 years, 18.1% vs 22.8%; P = .041) without a history of deep vein thrombosis (5.7% vs 10.9%; P = .003) and less severe venous disease (CEAP 4/5/6, 31.0% vs 53.4%; P = .001). Preprocedural and procedural information are listed in Table II. As expected, CEAP classification was equally distributed amongst both groups (P = .773), with the highest representation of CEAP classes 2 (35.7%), 3 (22.9%), and 4a (16.4%). The majority of patients received 10 to 20 microphlebectomies during the procedure, with no difference between groups (64.3% vs 67.1%; P = .935). No patients had any reported procedural complications, including hematoma or bleeding not controlled with pressure.
Table I.
Demographics of propensity score matched patients undergoing ambulatory phlebectomy (AP)
| Total (n = 140) | Non-anticoagulated (n = 70) | Anticoagulated (n = 70) | P value | |
|---|---|---|---|---|
| Age, years | 67 [60-72] | 67 [61-74] | 67 [60-72] | .682a |
| Female sex | 78 (55.7) | 41 (58.6) | 37 (52.9) | .496 |
| Caucasian | 131 (93.6) | 65 (92.9) | 66 (94.3) | .999 |
| Hispanic or Latino | 2 (1.4) | 1 (1.4) | 1 (1.4) | .999 |
| BMI | 29.3 [25.2-35.2] | 29.0 [25.0-33.8] | 29.9 [25.2-35.9] | .589a |
| Insurance payor | ||||
| Private | 56 (40.0) | 28 (40.0) | 28 (40.0) | .571 |
| Medicare | 75 (53.6) | 39 (55.7) | 36 (51.4) | |
| Medicaid | 9 (6.4) | 3 (4.3) | 6 (8.6) | |
| Former smoker | 133 (95.0) | 65 (92.9) | 68 (97.1) | .441 |
| Diabetes mellitus | 18 (12.9) | 12 (17.1) | 6 (8.6) | .130 |
| Hypercholesterolemia | 14 (10.0) | 6 (8.6) | 8 (11.4) | .573 |
| Hypertension | 52 (37.1) | 26 (37.1) | 26 (37.1) | .999 |
| Congestive heart failure | 7 (5.0) | 5 (7.1) | 2 (2.9) | .441 |
| Peripheral vascular disease | 10 (7.1) | 5 (7.1) | 5 (7.1) | .999 |
| Current antiplatelet use | 37 (26.4) | 17 (24.3) | 20 (28.6) | .565 |
| History of myocardial infarction | 1 (0.7) | 0 (0.0) | 1 (1.4) | .999 |
| History of deep vein thrombosis | 6 (4.3) | 2 (2.9) | 4 (5.7) | .681 |
| History of pulmonary embolism | 5 (3.6) | 3 (4.3) | 2 (2.9) | .999 |
| History of cerebrovascular attack | 4 (2.9) | 0 (0.0) | 4 (5.7) | .120 |
| Prior vein procedures | 42 (30.0) | 20 (28.6) | 22 (31.4) | .712 |
| Concomitant laser procedure | 109 (77.9) | 56 (80.0) | 53 (75.7) | .541 |
Values are median [interquartile range] or number (%).
Independent samples Kruskal-Wallis test.
Table II.
Technical details of propensity score matched patients undergoing ambulatory phlebectomy (AP)
| Total (n = 140) | Non-anticoagulated (n = 70) | Anticoagulated (n = 70) | P value | |
|---|---|---|---|---|
| CEAP classification | ||||
| 2 | 50 (35.7) | 27 (38.6) | 23 (32.9) | .773 |
| 3 | 32 (22.9) | 16 (22.9) | 16 (22.9) | |
| 4 | 6 (4.3) | 3 (4.3) | 3 (4.3) | |
| 4a | 23 (16.4) | 10 (14.3) | 13 (18.6) | |
| 4b | 12 (8.6) | 4 (5.7) | 8 (11.4) | |
| 4c | 1 (0.7) | 1 (1.4) | 0 (0.0) | |
| 5 | 5 (3.6) | 2 (2.9) | 3 (4.3) | |
| 6 | 11 (7.9) | 7 (10.0) | 4 (5.7) | |
| Microphlebectomy number | ||||
| <10 | 44 (31.4) | 23 (32.9) | 21 (30.0) | .935 |
| 10-20 | 92 (65.7) | 45 (64.3) | 47 (67.1) | |
| >20 | 4 (2.9) | 2 (2.9) | 2 (2.9) | |
| Unilateral | 138 (98.6) | 69 (98.6) | 69 (98.6) | .999 |
CEAP, Clinical-Etiology-Anatomy-Pathophysiology.
Values are number (%).
Postprocedural follow-up and clinical sequelae are listed in Table III. There were equal rates of reported postprocedural bleeding between groups (2.9% vs 0%; P = .496), with the quality as minimal incisional as determined by the following physician. There were also equal rates of reported moderate or significant ecchymosis between groups (28.8% vs 22.7%; P = .426) and reported moderate or severe pain (12.9% vs 11.4%; P = .796), albeit still within a minority of patients. The rates of reported postprocedural bleeding did not change based on the use of concomitant laser ablation vs stab phlebectomy alone in either group. There was one case of postprocedural cellulitis in a patient on chronic anticoagulation that was managed with oral outpatient antibiotics without further issue. There were no instances of ED visits, major adverse cardiac events, major adverse limb events, or death within 30 days of the index procedure. Additionally, no patients on anticoagulation required additional ablation of the treated vein during the study period.
Table III.
Follow-up metrics of propensity score matched patients undergoing ambulatory phlebectomy (AP)
| Total (n = 140) | Nonanticoagulated (n = 70) | Anticoagulated (n = 70) | P value | |
|---|---|---|---|---|
| Length of time to follow-up | 7 [7-7] | 7 [7-8] | 7 [7-7] | .504 |
| Any postprocedural complication | 54 (38.6) | 23 (32.8) | 32 (45.7) | .119 |
| Reported postprocedural bleeding | 2 (1.4) | 0 (0.0) | 2 (2.9) | .496 |
| Quality of postprocedural bleeding | ||||
| None | 137 (97.9) | 70 (100.0) | 67 (95.7) | .245 |
| Minimal incisional | 3 (2.1) | 0 (0.0) | 3 (4.3) | |
| Ecchymosis | ||||
| None/minimal | 98 (74.2) | 51 (77.3) | 47 (74.2) | .426 |
| Moderate/significant | 34 (25.8) | 15 (22.7) | 19 (28.8) | |
| Reported pain on follow-up | ||||
| Minimal | 123 (87.9) | 62 (88.6) | 61 (87.1) | .796 |
| Moderate/severe | 17 (12.1) | 8 (11.4) | 9 (12.9) | |
| Postprocedural cellulitis | 1 (0.7) | 0 (0.0) | 1 (1.4) | .999 |
Values are median [interquartile range] or number (%).
Given that there was variability in the type of anticoagulation patients were taking, we conducted a subgroup analysis of postprocedural complaints to elucidate any correlation between type of anticoagulation and reported complaint (Supplementary Table II, online only). Of the three most used anticoagulants, patients on rivaroxaban had higher reported rates of bleeding (8.0%). However, it should be noted that these results did not reach statistical significance, owing to small sample sizes and low power.
Discussion
This 7-year single-institution retrospective study aimed to address a gap in knowledge in regard to outcomes following AP in patients with continued oral anticoagulation. After propensity score matching to identify like-control patients, we found no difference in the rates of postprocedural bleeding, quality of pain, ED visits, or major adverse events in patients who maintained anticoagulation compared with those not on anticoagulation before AP, positing that patients already on chronic anticoagulation for reasons other than postprocedural thromboprophylaxis should continue their regimen without interruption.
To date, the Society for Vascular Surgery has not endorsed any practice guidelines on the continuation of oral anticoagulation through AP procedures.9 Long-standing use of antithrombic agents for protection of hypercoagulable states including atrial fibrillation and mechanical valve replacements has been shown in the literature to be protective against major sequelae like stroke if anticoagulation is discontinued. Landmark clinical trials, including RE-LY, ROCKET AF, ARISTOTLE, and ENGAGE AF-TIMI, have identified that patients taking direct oral anticoagulation have a residual risk of stroke or systemic embolism between 1.11% and 2.40%, with additional studies reporting up to 2.78% risk.11 Rivaroxaban and warfarin have also been shown to decrease stroke and other thrombotic events in patients with mechanical valve replacements to about a 1.2% incidence per year.12,13 Although these studies detail a protective benefit of anticoagulation for chronic conditions, surgical intervention alone carries a significant risk of injury and life-threatening bleeding. There are several advocates that detail a more tailored assessment of the type of procedure, risk of discontinuing anticoagulation to the patient, and clinical judgment before discontinuing anticoagulation.14 This includes work recommending the continuation of anticoagulation for minimal bleeding risk procedures, including any minor surgical procedures for which bleeding is easily controllable, like stab phlebectomy. In our study, we identified no increased bleeding risk during these procedures for patients on chronic anticoagulation, including any increased postprocedural complications or use of health care services when compared with patients not on anticoagulation. Given the low incidence of bleeding and other postprocedural complications in our study, AP likely reflects a minimal risk procedure and should be considered as such in clinical practice patterns.
Many surgeons empirically discontinue anticoagulation shortly before invasive interventions to avoid perioperative and postoperative major bleeding events. There are some societal recommendations for minor surgical procedures regarding chronic anticoagulation, including a North American Consensus Statement for patients with atrial fibrillation undergoing percutaneous coronary intervention and a Society for Vascular Surgery practice recommendation for patients with chronic anticoagulation undergoing venous thrombolysis, both of which endorse holding anticoagulation for 48 to 72 hours before their procedure.15,16 However, the Society for Interventional Radiology has proposed updated practice guidelines for patients on chronic anticoagulation, which remark that anticoagulation can be continued after proper safety assessments, including type of invasive procedure and coagulation laboratory values.17 Other literature suggests that the risk of bleeding for all vascular procedures is not the same, which is particularly the case for patients undergoing phlebectomies. A single-institution retrospective study identified that patients receiving warfarin for atrial fibrillation, remote deep vein thrombosis, and mechanical heart valves had equal durability, safety, and efficacy of vein ablation for symptomatic venous reflux.8 However, this study focused more so on outcomes at 30 days rather than immediate bleeding risk and patient use of health care systems for bleeding. The present study details equivalent periprocedural and postprocedural bleeding and ecchymoses for patients who continued anticoagulation, including warfarin and a variety of direct oral anticoagulants (DOACs) through APs over a 7-year period. Importantly, we also detail no differences between major bleeding events and sequelae including major adverse cardiac events.
Given that there are patients who continue anticoagulation through minor procedures, the specific anticoagulation used does affect postoperative outcomes and bleeding risk in the literature. Warfarin has been used most frequently for anticoagulation in patients with atrial fibrillation undergoing catheter ablation and pacemaker procedures. The COMPARE randomized controlled trial found that the continuation of warfarin through catheter ablation for atrial fibrillation was beneficial for protection against periprocedural stroke and minor bleeding complications compared with periprocedural bridging with low-molecular-weight heparin.18 The VENTURE-AF and RE-CIRCUIT studies identified equivalency between dabigatran, warfarin, and rivaroxaban in terms of stroke risks and number of complications.19,20 In addition, the BRUISE CONTROL 2 study compared uninterrupted vs interrupted DOACs, including apixaban, rivaroxaban, and dabigatran; uninterrupted DOACs did not have any difference in outcomes including stroke, any hematoma, or any adverse event. However, the trial was terminated early owing to futility.21 In our subanalysis of anticoagulation type, we found that patients who took rivaroxaban had the highest rate of minor bleeding (8.0%) and severe pain (4.0%) on follow-up examination, whereas patients taking warfarin had more significant ecchymoses (6.7%). Although these results were not significant, these data do suggest that additional studies should be performed on specific anticoagulants and their suitability for continued use through minor procedures while still maintaining efficacious anticoagulation.
Although the presented study did not find an increase in postprocedural bleeding with patients on chronic anticoagulation, these findings are limited by the largely homogenous nature of our patient population. Given that most of the patients represented are non-Hispanic White, there could still be systemic barriers for patients of other racial and/or ethnic backgrounds from being included in our study. However, recently published studies have shown that socioeconomic factors, ethnicity, and high rates of comorbidities did not influence wound healing after superficial venous intervention or for treatment of venous ulcers.22,23 Although our practice aims to provide care for all demographics of patients with vein disease, other factors including access to vascular surgeons, perceived ability to pay for procedures, and other social determinants of health could have skewed our patient population and thus our postprocedural outcomes, which ultimately limits the generalizability of the results presented. Future studies with larger sample sizes are needed to further assess granular differences between these unique patient populations.
Immediate compression after thermal ablation or stripping of saphenous veins is considered a grade 2C recommendation based on the most recently clinical practice guidelines from multiple societies, including the American Venous Forum and the Society for Vascular Surgery.24 The current compression strategy used in the patients presented in this study include use of ACE compression immediately after the end of the procedure with ≥20- to 30-mm Hg compression stockings over top of the compression wrap for the first 24 hours, followed by guidance to continue wearing compression stockings daily. Nonetheless, this study is limited by data regarding patient compliance with this prescribed postprocedural protocol after leaving the outpatient center. Even further, our institutional practice has changed slightly over the 7-year study period to close stab incisions with 5-0 nylon simple interrupted sutures, along with patient education of continued compression and elevation postprocedurally. This factor alone may have contributed to lower bleeding rates in our entire patient cohort, regardless of anticoagulation status.
Although our study aimed to investigate the effects of discontinuing anticoagulation for phlebectomy procedures, there are several important limitations that warrant additional discussion. The presented study is a retrospective cohort study, which inherently comes with a limitation in missing data that are collected on consultation, like varicosity size, as well as subjective reporting at the time of procedure or at follow-up appointments. This factor is particularly important for the postoperative follow-up appointments, wherein patient symptoms were more likely to be described qualitatively rather than quantitatively and could differ drastically between surgeons. Further, any postprocedural events could have been missing from our institutional EMR, because patients could receive care from other hospital systems, and not be captured in this study. Even though our study was well-powered, we believe that generalizations in our data may have skewed our results. For example, CEAP classification alone has 12 categories, for which C2, C3, and C4a were most heavily represented. Because there can be stark differences in presentation between categories, we cannot say all patients were represented equally in this cohort. Having said that, our specific institutional practice has been to limit elective phlebectomies in patients who have indurated or woody skin or active venous ulcers (C5 and C6 disease). Additionally, blinding to anticoagulation status was attempted during retrospective chart review, but unblinding was unavoidable owing to physician postprocedural and clinical notes. Given these limitations owing to the retrospective nature of this study, we advocate for future prospective studies comparing patients on chronic anticoagulation undergoing outpatient venous procedures for postprocedural bleeding and other sequelae.
Conclusions
We present a 7-year single-institution retrospective cohort study on our practice of continuing longstanding anticoagulation through AP procedures. After propensity score matching like-patients, we did not find increase incidence of adverse bleeding events, even minor, or additional health care use for patients on anticoagulation including ED visits or earlier times to a follow-up appointment. Our findings support the growing body of evidence that suggests that the benefits of continuing anticoagulation for other thrombotic conditions outweigh any risk of bleeding events for outpatient minor procedures such as AP.
Author contributions
Conception and design: JGJ, JGIII, MA, KD, AB, PS, EA, YL, KW, EG
Analysis and interpretation: CC, YL
Data collection: CC, EO
Writing the article: CC, EO, EG
Critical revision of the article: CC, EO, JGJ, JGIII, MA, KD, AB, PS, EA, YL, KW, EG
Final approval of the article: CC, EO, JGJ, JGIII, MA, KD, AB, PS, EA, YL, KW, EG
Statistical analysis: CC, YL, EG
Obtained funding: Not applicable
Overall responsibility: EG
Funding
None.
Disclosures
E.G. is a consultant for Philips Inc, Inroad Medical, and Cagent Vascular; and is a consultant for and has stock ownership in Mavericks Endo, Inc.
From the Eastern Vascular Society
Footnotes
The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
Appendix
Additional material for this article may be found online at www.jvsvenous.org.
Appendix (online only)
References
- 1.Altiok E., Marx N. Oral anticoagulation. Dtsch Arztebl Int. 2018;115:776–783. doi: 10.3238/arztebl.2018.0776. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Polania Gutierrez J.J., Rocuts K.R. StatPearls [Internet] StatPearls Publishing; 2023. Perioperative anticoagulation Management; pp. 1–21. [PubMed] [Google Scholar]
- 3.Andrews R.H., Dixon R.G. Ambulatory phlebectomy and sclerotherapy as tools for the treatment of varicose veins and telangiectasias. Semin Intervent Radiol. 2021;38:160–166. doi: 10.1055/s-0041-1727151. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.January C.T., Wann L.S., Calkins H., et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines and the heart Rhythm society. J Am Coll Cardiol. 2019;74:104–132. doi: 10.1016/j.jacc.2019.01.011. [DOI] [PubMed] [Google Scholar]
- 5.Omran H., Bauersachs R., Rübenacker S., Goss F., Hammerstingl C. The HAS-BLED score predicts bleedings during bridging of chronic oral anticoagulation. Results from the national multicentre BNK Online bRiDging REgistRy (BORDER) Thromb Haemost. 2012;108:65–73. doi: 10.1160/TH11-12-0827. [DOI] [PubMed] [Google Scholar]
- 6.Boyle E., Reid J., O'Donnell M., Harkin D., Badger S. Thromboprophylaxis for varicose vein procedures - a national survey. Phlebology. 2019;34:598–603. doi: 10.1177/0268355519828931. [DOI] [PubMed] [Google Scholar]
- 7.Keo H.H., Knoechel J., Spinedi L., et al. Thromboprophylaxis practice after outpatient endovenous thermal ablation. J Vasc Surg Venous Lymphat Disord. 2021;9:916–924. doi: 10.1016/j.jvsv.2020.10.007. [DOI] [PubMed] [Google Scholar]
- 8.Westin G.G., Cayne N.S., Lee V., et al. Radiofrequency and laser vein ablation for patients receiving warfarin anticoagulation is safe, effective, and durable. J Vasc Surg Venous Lymphat Disord. 2020;8:610–616. doi: 10.1016/j.jvsv.2019.11.013. [DOI] [PubMed] [Google Scholar]
- 9.Gloviczki P., Lawrence P.F., Wasan S.M., et al. The 2022 society for vascular surgery, American venous forum, and American vein and lymphatic society clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. Duplex scanning and treatment of superficial Truncal reflux: endorsed by the society for vascular medicine and the international union of phlebology. J Vasc Surg Venous Lymphat Disord. 2023;11:231–261.e6. doi: 10.1016/j.jvsv.2022.09.004. [DOI] [PubMed] [Google Scholar]
- 10.Lurie F., Passman M., Meisner M., et al. The 2020 update of the CEAP classification system and reporting standards. J Vasc Surg Venous Lymphat Disord. 2020;8:342–352. doi: 10.1016/j.jvsv.2019.12.075. published correction appears in J Vasc Surg Venous Lymphat Disord. 2021 Jan;9(1):288. [DOI] [PubMed] [Google Scholar]
- 11.Ding W.Y. Residual stroke risk in atrial fibrillation. Arrhythm Electrophysiol Rev. 2021;10:147–153. doi: 10.15420/aer.2021.34. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Iung B., Rodés-Cabau J. The optimal management of anti-thrombotic therapy after valve replacement: certainties and uncertainties. Eur Heart J. 2014;35:2942–2949. doi: 10.1093/eurheartj/ehu365. [DOI] [PubMed] [Google Scholar]
- 13.Koertke H., Zittermann A., Tenderich G., et al. Low-dose oral anticoagulation in patients with mechanical heart valve prostheses: final report from the early self-management anticoagulation trial II. Eur Heart J. 2007;28:2479–2484. doi: 10.1093/eurheartj/ehm391. [DOI] [PubMed] [Google Scholar]
- 14.Wagner J., Lock J.F., Kastner C., et al. Perioperative management of anticoagulant therapy. Innov Surg Sci. 2019;4:144–151. doi: 10.1515/iss-2019-0004. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Angiolillo D.J., Bhatt D.L., Cannon C.P., et al. Antithrombotic therapy in patients with atrial fibrillation treated with oral anticoagulation undergoing percutaneous coronary intervention: a North American Perspective: 2021 update. Circulation. 2021;143:583–596. doi: 10.1161/CIRCULATIONAHA.120.050438. [DOI] [PubMed] [Google Scholar]
- 16.Gloviczki P., Comerota A.J., Dalsing M.C., et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011;53(5 Suppl):2S–48S. doi: 10.1016/j.jvs.2011.01.079. [DOI] [PubMed] [Google Scholar]
- 17.Patel I.J., Rahim S., Davidson J.C., et al. Society of interventional radiology consensus guidelines for the periprocedural management of thrombotic and bleeding risk in patients undergoing percutaneous Image-Guided interventions-Part II: recommendations: endorsed by the Canadian association for interventional radiology and the cardiovascular and interventional radiological society of Europe. J Vasc Interv Radiol. 2019;30:1168–1184.e1. doi: 10.1016/j.jvir.2019.04.017. [DOI] [PubMed] [Google Scholar]
- 18.Di Biase L., Burkhardt J.D., Santangeli P., et al. Periprocedural stroke and bleeding complications in patients undergoing catheter ablation of atrial fibrillation with different anticoagulation management: results from the Role of Coumadin in Preventing Thromboembolism in Atrial Fibrillation (AF) Patients Undergoing Catheter Ablation (COMPARE) randomized trial. Circulation. 2014;129:2638–2644. doi: 10.1161/CIRCULATIONAHA.113.006426. [DOI] [PubMed] [Google Scholar]
- 19.Cappato R., Marchlinski F.E., Hohnloser S.H., et al. Uninterrupted rivaroxaban vs. uninterrupted vitamin K antagonists for catheter ablation in non-valvular atrial fibrillation. Eur Heart J. 2015;36:1805–1811. doi: 10.1093/eurheartj/ehv177. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Calkins H., Willems S., Gerstenfeld E.P., et al. Uninterrupted dabigatran versus warfarin for ablation in atrial fibrillation. N Engl J Med. 2017;376:1627–1636. doi: 10.1056/NEJMoa1701005. [DOI] [PubMed] [Google Scholar]
- 21.Birnie D.H., Healey J.S., Wells G.A., et al. Continued vs. interrupted direct oral anticoagulants at the time of device surgery, in patients with moderate to high risk of arterial thrombo-embolic events (BRUISE CONTROL-2) Eur Heart J. 2018;39:3973–3979. doi: 10.1093/eurheartj/ehy413. [DOI] [PubMed] [Google Scholar]
- 22.Blomgren L., Jansson L. The influence of socioeconomic factors on intervention and postoperative healing of venous ulcers: a prospective study. J Wound Care. 2024;33:474–479. doi: 10.12968/jowc.2022.0143. [DOI] [PubMed] [Google Scholar]
- 23.Wahab N., Tettelbach W.H., Driver V., et al. The impact of dual-enrollee (Medicare/Medicaid) status on venous leg ulcer outcomes: a retrospective study. J Wound Care. 2024;33:886–892. doi: 10.12968/jowc.2024.0174. [DOI] [PubMed] [Google Scholar]
- 24.Lurie F., Lal B.K., Antignani P.L., et al. Compression therapy after invasive treatment of superficial veins of the lower extremities: clinical practice guidelines of the American venous forum, society for vascular surgery, American College of Phlebology, society for vascular medicine, and International union of Phlebology. J Vasc Surg Venous Lymphat Disord. 2019;7:17–28. doi: 10.1016/j.jvsv.2018.10.002. [DOI] [PubMed] [Google Scholar]
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