High complication rate after total knee and hip replacement due to perioperative bridging of anticoagulant therapy based on the 2012 ACCP guideline.

Perioperative management of long-term oral anticoagulants is a matter of intense debates, especially with the recent development of new direct thrombin and factor Xa inhibitors. A central question in this challenging discussion is whether to bridge or not to bridge oral anticoagulants. The decision is mainly based on a balance between the risk of thromboembolic complications associated with interruption of long-term anticoagulation and the risk of massive perioperative bleeding following bridging with either low-molecular-weight or unfractioned heparin.

In this study, Leijtens et al. retrospectively assessed the incidence of perioperative complications in a small cohort of patients who received bridging from vitamin K antagonists to low-molecular-weight heparin before total knee or hip replacement surgeries. Although this study has the limitations common to all retrospective studies, as well as a limited number of patients, two interesting observations can be drawn from its results.

Firstly, among 972 patients analysed retrospectively, only 13 (1.3%) required bridging therapy before surgery, when the decision was based on 2012 American College of Chest Physicians guidelines. This is in accordance with most of the recent publications in this field indicating that oral anticoagulation may be safely interrupted without bridging during a short preoperative period in most patients.

Secondly, 92% of the patients who received preoperative bridging therapy (12 of 13) experienced abnormal perioperative bleeding associated with complications (haematoma, infection) and requiring blood product transfusion and/or surgical re-exploration. Despite the small number of cases, this can be considered as a signal that bridging therapy might be associated with more harm than benefits.

In conclusion, although the results of this small study should be interpreted with caution, bridging therapy in patient who received long-term oral anticoagulation may be associated with a high incidence of perioperative bleeding. Further studies are needed to better assess, in a large population, the benefit-to-risk balance of long-term oral anticoagulation interruption, with or without bridging.

– David Faraoni

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