Temporary Discontinuation Of Warfarin For Endovascular Procedures And Risk Of Ischemic Stroke

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http://www.neurology.org/content/84/14_Supplement/P4.301.short

1. Ahmed Malik₇,
2. Mushtaq Qureshi₂,
3. Hashim Zeb₆,
4. Archie Defillo₁,
5. Michelle Thompson₄,
6. Muhammad Suri₃ and
7. Adnan Qureshi₅

+Show Affiliations

1. Neurology April 6, 2015 vol. 84 no. 14 Supplement P4.301

• Abstract

Abstract

Background: Temporary discontinuation of warfarin for endovascular procedures is necessary to avoid risk of bleeding complications. The risks and benefits associated with such discontinuation are not well described. 

Methods: We reviewed the medical records of patients who underwent discontinuation of warfarin prior to endovascular procedures. The primary end point was ischemic stroke during warfarin discontinuation, occurrence of death, cerebral infarction, and unplanned or urgent endovascular or surgical intervention. The primary safety end point was bleeding, for which complications were classified according to the Thrombolysis in Myocardial Infarction scheme as major (hemoglobin decrease of more than 5 g/dl), minor (hemoglobin decrease of 3-5 g/dl), or insignificant.  

Results: Seventy three patients (mean age, 68.4 ± 70.4 yr; 43 men) underwent discontinuation of warfarin prior to endovascular procedure. Low molecular weight heparin was instituted after discontinuation of warfarin in 27 of 73 patients. Mean (±SD) international normalized ratio was 1.1 ± 0.2 prior to procedure. Warfarin was restarted within 1 day (n=9), 2-4 days (n=17) or greater than 4 days (n=1) after procedure. Among the 27 patients who underwent discontinuation, no intracerebral hemorrhages and 2 and 5 ischemic strokes occurred during the period of warfarin discontinuation in bridging and without bridging therapy or during 1-month follow-up period, respectively. Stroke events occurred within 1 day (n=0), 2-4 days (n=0) or greater than 4 days (n=2) after procedure. There was one episode of major bleeding from the femoral insertion site. The risk of ischemic stroke was similar in patients who did or did not receive interim low molecular weight heparin (2 of 27 versus 5 of 46, p=0.7). The duration of warfarin discontinuation was correlated with risk of ischemic stroke.  

Conclusions: The risk of ischemic stroke during discontinuation of warfarin is higher than expected and requires a careful evaluation of risk and benefits.