http://journals.sagepub.com/doi/abs/10.5301/jva.5000586?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed

I never hold any anticoagulation for catheters or for fistulagram procedures. For me, our procedures are really not much more invasive than regular needle cannulation at dialysis. Sometimes the patients hold their own anti-coagulation on the day of the procedure, but not really a big issue in my experience.

I don't worry at all about any INR less than 2.5 for catheter inserts, exchanges, or fistulograms/angioplasty. If > 3 not a good idea!!!
I don't worry about any INR for declots. (But if > 5 not a good idea)
I don't worry about plavix in most cases except in the immature AVF where the vessel wall is still thin, and it spasms and may tear and bruise. Occasionally, I might tell a patient to hold off plavix for catheter removal, especially with a deep cuff, but most of the time they show up on plavix and we do it if the cuff is not too deep.
I.R. are notorious for worrying about these things; partly due to hospital policy where all procedures are treated equally. When I refer a patient for a central vein procedure, they give us the run around before we get the patient cleared to do it.

Mostly agree with George. We tend not to insert or remove catheters in patients on warfarin. We like for them to be off for a couple of days. For fistulograms, we usually go ahead unless we see danger for rupture.
Pedro Frommer MD

I do not check INR, nor hold any medications for any of my procedures. For immature fistula evaluation I use clinical judgement. I had two patients today on Eliquis, which I do not hold. Given the surge in patients switching to Eliquis, the INR problem may soon be moot.
A nice review article in CJASN on the new kids on the block.

http://cjasn.asnjournals.org/content/early/2018/05/24/CJN.02170218.full?sid=5fd22d4e-7a66-4742-8e10-9920f20d34df
I do no think there is any evidence-based reason to withhold anticoagulation for procedures performed under direct visualization (ultrasound-guided cannulations).
Physician preference/comfort may be the guiding principle here.

I hold NOACs for 3 doses, not antiplatelets
both for arterial or venous approach, or venous or arterial intervention. It is not just the risk of bleeding I am concerned about, but also limiting surgical options if patients are on anticoagulants

There is clearly an increased risk of bleeding in ESRD patients with NOACs than controls, when we perform angioplasty, we induce micro fractures and sometimes macro fractures in the vessel wall. Anticoagulated patients clearly tend to bleed more, sometimes necessitating the need for stents. I am not opposed to stenting for the appropriate indications, however, would not advocate it for expected bleeding and perf.

For patients on Coumadin, I am comfortable with an INR< 2.5. It is still a substantial increased risk for bleeding , but atleast better than not checking an INR.
Also, it’s difficult to justify liability in elective procedures where NOACs could have been held to avoid an adverse outcome.

Great question and great discussion!
I agree with Bala.
We have a similar approach. We adhere to Up-to-date Guidelines vis a vis NOAC.
We do perform POC for INR testing.
For thrombectomy and regular fistulogram we are fine.
Only special considerations for an arterial stick, arterial PCI, CVC placement.

Many hemodialysis patients are being treated with antithrombotic medications, either vitamin K antagonists, antiplatelet drugs are both. The question as to whether these medications should be held, and clotting parameters normalized prior to a procedure such as a dialysis catheter insertion, AV access angioplasty or thrombectomy has frequently been raised and based upon published literature, I think adequately answered. The answer is NO!
The decision to do anything to a patient should be based upon weighing the risks and benefits of the action. Extremes in either direction certainly dictate the appropriate decision. When the risk and benefits or equal, the action could be said to be optional. Stopping these medications and demanding normalization of clotting parameters create several issues that would be acceptable if doing so was necessary. The fact that it is not makes these issues unacceptable. First, the patient is on these medications for a reason. Stopping the medication creates at least some degree of risk to the patient. Second, there are times when these procedures need to be done on an emergent basis. Not doing them in order to wait for normalization of clotting parameters creates an inconvenience and a risk to the patient. Third, even with the best intentions a patient scheduled for a procedure may arrive at the center not having followed the directions given related to stopping their medications. Refusing to do the procedure creates a major inconvenience for the patient and to some degree for the facility. Fourth, there is the cost of lab test in order to confirm that clotting parameters have been normalized. Any unnecessary cost is unacceptable, and in this instance, this is an unnecessary cost.
A study was done (J Vasc Access. 2016; 17:397-400) which collected data on to groups of patients - 458 cases which had a tunneled catheter placed while taking anti-thrombotic medications which were not discontinued prior to the procedure (referred to as the Med group), and a cohort of 941 cases with a failed thrombectomy in which they had been heparinized and then immediately received a tunneled dialysis catheter (referred to as the DF group. The incidence of procedure related bleeding for these two groups was compared to that observed with tunneled catheter placements in 6,555 routine cases which served as the control. The incidence of bleeding in the control group was 0.46%, in the DF group 0.44% and in the Med group 0.36%. No patient in any group had bleeding that required transfusion, hospitalization or catheter removal.
In an earlier study (J Vasc Interv Radiol. 2010; 21:212-217) involving 3,170 tunneled catheters, 626 catheters were placed in patients with either a platelet count less than 50,000 (n=300), an INR of 1.5 or greater (n = 282) or both (n = 44). Forty-three catheter insertions were in patients with a platelet count lower than 25,000 and 43 were in patients with an INR greater than 2. There were three bleeding complications in the total cohort (0.095%) and none of these occurred in any of the patients with a low platelet count or an elevated INR.
While these reports relate to the risk of bleeding in patients either on antithrombotic medications or low platelet counts, it is an established fact that the baseline risk of bleeding from the interventional procedures that we perform is very low.
In a report (Kidney Int 66:1622-1632, 2004) dealing with 14, 067 cases the safety and efficacy of interventional procedures performed by a nephrologist, complications for different types of procedures were tabulated.
AVG angioplasty - 3561 cases - no cases of bleeding
AVF angioplasty - 1561 cases - delayed bleeding in three cases (0.19%)
AVG thrombectomy - 4671 cases - delayed bleeding in nine cases (0.19%)
AVF thrombectomy - 228 cases - no cases of bleeding
Tunneled catheter placement – 1765 cases – 23 cases of delayed bleeding - oozing from insertion site (1.3%)

Requiring the suspension of antithrombotic medications for the performance of these types of interventional procedures is not warranted and is a practice that cannot be supported based upon data published in the literature.

There is very little data on NOACs and ESRD patient with the exception of the RENAL AF trial. Vitamin K antagonists have been shown to have higher risk than benefit in select A Fib trials in ESRD patients , the risk being bleeding. These are native risks without even adding interventions.

It might take a prospective clinical trial on ESRD patients taking NOACs and having procedure intensity controlled using POBA vs ultrahigh pressure angioplasty comparing NOAC holding vs non-holding strategy. The outcomes in most of these anticoagulation trials include need for transfusion and hospitalization. We would need access specific outcomes as well, including need for salvage stents and access patency post procedure and in 30 days.

Almost all the NOAC trials have excluded ESRD patients, we don’t have adequate data to appropriately assess bleeding risk in ESRD patients undergoing procedures taking NOACs, likewise we don’t have enough data to demonstrate holding NOACs can mitigate this bleeding risk. That’s where interventionalists do a risk benefit analysis, get a good history on prior bleeding episodes etc.. after a procedure. Kindly do not underestimate the impact of our procedures, if one ruptured an artery or an arterial anastomoses with a patient on a NOAC, and if one can not salvage that with an appropriate stent, it might be a major challenge getting your surgeon to work on the arm.

I’ve had pretty good outcomes on patients when they have been asked to hold NOACs. Our cardiologists are highly supportive and infact have strongly recommended us to hold NOACs before our procedures.

Thanks for initiating this discussion
SB

Colleagues,

I appreciate Dr. Beathard’s exaustive explanation. I think this settles it for our society; however, convincing our interventional colleagues from other specialties, particularly radiology, in my practice setting has been a challenge.

I have a question. What is the correct thing to do regarding women of childbearing age and pregnancy tests prior to exposure to radiation for thrombectomies, angiogram procedures and catheter placements.

I would not get pregnancy tests
Always inquire about pregnancy
If the young lady is pregnant or thinks that she might be or if there is any question, place a lead apron beneath her pelvic area all the way up to the thorax - between her and the table be fore any radiation exposure.

an apron with a 0.5 mm lead equivalent which is required in most states will block 99% of the radiation at a kVp of 75 which is higher that you will probably ever use routinely

Dr High,
The best practice as it pertains to ionizing radiation dose in general is adhering to " as low as reasonable achievable (ALARA)". In other words, collimate, cone, minimize the frames per second and distance between body & image intensifier etc.
In women of child bearing age, the additional recommendation is to institute a gonadal shield. This is what we do.

Thanks
Naveen

Naveen Atray MD
Sacramento, CA

Been a while, as I lost my password and have been so busy ....
But now that I am in prison again, I had the time to go through things and catch up on my e-mail - greetings!
When Dr. Beathard answers a question, you might as well put the society logo on it and make it a white paper - nothing else to say!
But I will add a surgeons perspective and a story.
Years ago, I was a more important person and had two PAs who did all the catheter work. They were so risk adverse that they would take an hour for informed consent, and frequently talked old ladies out of getting a dialysis catheter.
One day I found them with a patient who had been sent down with an infected catheter for removal. The INR was over 2, and these guys wanted to send the patient back to the floor to get FFP before catheter removal. Knowing that early infection of the catheter cuff may prevent incorporation, I cut the stitches still holding the catheter in and pulled it out in one motion while placing pressure on the tract to prevent more than momentary backbleeding. I handed one of them the explanted catheter and said, "I think you guys are overintellectualizing the process". Having said that, I do remember a patient bleeding all over the room from a 14 French hole in his neck, and am a firm believer in having a 4-0 prolene mounted and ready for any case.
Without the wealth of data that Dr. Beathard has mustered, I can only say that I agree completely with his position, and offer only my humble opinion about stopping anticoagulation and antiplatelet therapy for surgery.
As Dr. Beathard notes, patients are on these agents for a reason, and suspending therapy may have deleterious effects. Given a choice between bleeding and clotting, I'd rather bleed than clot up to a point. I NEVER ask patients to stop antiplatelet therapy for any procedure, and will perform percutaneous procedures with an INR of less than 4 in noncontroversial patients. I NEVER request normalization of the INR prior to open surgery, and prefer a level between 2 and 2.5, sometimes up to 3. I tell patients they may need to stay overnight, and I drain liberally for the first 12 hours. Many clotted or ischemic patients on a heparin drip stay on the drip through surgery. I end up evacuating a dozen hematomas a year as part of the price. If I were a better surgeon, I might not have all these problems.

Been a while, as I lost my password and have been so busy ....
But now that I am in prison again, I had the time to go through things and catch up on my e-mail - greetings!
When Dr. Beathard answers a question, you might as well put the society logo on it and make it a white paper - nothing else to say!
But I will add a surgeons perspective and a story.
Years ago, I was a more important person and had two PAs who did all the catheter work. They were so risk adverse that they would take an hour for informed consent, and frequently talked old ladies out of getting a dialysis catheter.
One day I found them with a patient who had been sent down with an infected catheter for removal. The INR was over 2, and these guys wanted to send the patient back to the floor to get FFP before catheter removal. Knowing that early infection of the catheter cuff may prevent incorporation, I cut the stitches still holding the catheter in and pulled it out in one motion while placing pressure on the tract to prevent more than momentary backbleeding. I handed one of them the explanted catheter and said, "I think you guys are overintellectualizing the process". Having said that, I do remember a patient bleeding all over the room from a 14 French hole in his neck, and am a firm believer in having a 4-0 prolene mounted and ready for any case.
Without the wealth of data that Dr. Beathard has mustered, I can only say that I agree completely with his position, and offer only my humble opinion about stopping anticoagulation and antiplatelet therapy for surgery.
As Dr. Beathard notes, patients are on these agents for a reason, and suspending therapy may have deleterious effects. Given a choice between bleeding and clotting, I'd rather bleed than clot up to a point. I NEVER ask patients to stop antiplatelet therapy for any procedure, and will perform percutaneous procedures with an INR of less than 4 in noncontroversial patients. I NEVER request normalization of the INR prior to open surgery, and prefer a level between 2 and 2.5, sometimes up to 3. I tell patients they may need to stay overnight, and I drain liberally for the first 12 hours. Many clotted or ischemic patients on a heparin drip stay on the drip through surgery. I end up evacuating a dozen hematomas a year as part of the price. If I were a better surgeon, I might not have all these problems.