Pre-Operative Warfarin and Novel Anticoagulant use in Infra-inguinal Bypass Patients Associated with Increased MALE and Bleeding Requiring Return to Operating Room
Rishi A. Roy, MD, Min-Woong Sohn, PhD, Carlin Williams, MD, George J. Stukenborg, PhD, William Robinson, III, MD.
University of Virginia, Charlottesville, VA, USA.
OBJECTIVES: Patients with PAD often take some form of anticoagulation. In 2010, the first novel anticoagulant (NOAC) was FDA approved. The utilization trends in patients undergoing infrainguinal bypass (IIB) and the impact of these anticoagulants is unknown. This study seeks to identify anticoagulant utilization trends in patients undergoing IIB and determine how preoperative anticoagulant use impacts short term outcomes including major adverse limb events (MALE), major adverse cardiac events (MACE), and bleeding requiring reoperation.METHODS: Between 2014 and 2017 11,565 patients underwent IIB at hospitals participating in Vascular Quality Initiative. Trends in utilization of preoperative NOACs and warfarin were compared. Patients were separated into groups based upon preoperative anticoagulants: NOACs +/-aspirin, warfarin +/-aspirin, and aspirin alone as control. Outcomes of MACE, MALE, and bleeding that required reoperation were generated in these groups with unadjusted and adjusted analyses using t-test and the X2 test. Statistical significance was accepted at p<0.05.
RESULTS: The largest age group of patients were 60 to 69 (34.2%). 40.82% of patients were current smokers, 85.65% patients were positive for hypertension 45.41% have a history of CHF, 25.42% have a history of coronary artery, and 45.41% had a history of diabetes. Indications for intervention were claudication (22.58%), rest pain (36.27%), tissue loss (13.03%), and acute ischemia (32.16%). Increased NOAC use was observed, Figure 1. Using univariate analysis, warfarin was associated with increased MALE(OR 1.327; p-value 0.01), MACE(OR 1.414; p-value 0.023), return to OR for revision(OR 1.404; p-value 0.037) or thrombosis(OR 1.366; p-value 0.024), in hospital death(OR 1.669; p-value 0.016), and transfusion(OR 1.391; p-value <0.001). NOACs were associated with increased bleeding(OR 2.229; p-value 0.017). Using multivariate analysis, warfarin was associated with increased MALE(OR 1.284; p-value 0.033) and return to OR for revision(OR 1.453; p-value 0.03). NOACs were associated with increased reoperation due to bleeding(OR 1.998; p-value 0.045).CONCLUSIONS: This study demonstrated that preoperative use of NOACs is increasing in patients undergoing IIB. Preoperative NOACs were associated with increased short-term bleeding complications requiring reoperation. Warfarin utilization was associated with inferior limb-related outcomes. Further study is warranted to better define long term impact of warfarin and NOAC on IIB patients. 
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