Comparing the Effectiveness of Different Hemostatic Methods in Minimally Invasive Intervention

Purpose To determine and compare effectiveness of various methods of local hemostasis in patients with elevated international normalized ratio (INR) undergoing imaging-guided interventions, such as solid organ biopsy.

Materials and Methods Retrospective chart review was performed of 182 patients with elevated INR (average INR of 2.3) undergoing ultrasound or computed tomography (CT)-guided solid organ biopsy or cholangiogram. Patients underwent either injection of a small amount of fresh frozen plasma (FFP), Gelfoam, or embolization coils through the tract sites to provide hemostasis after the procedure. This was compared with an equal number of patients undergoing systemic fresh frozen plasma infusion through peripheral intravenous (IV) for elevated INR prior to ultrasound and CT-guided solid organ biopsies or cholangiograms. Size of tracts and amounts of injections were all obtained and controlled during data analysis. Rates of clinically significant and insignificant bleeding and additional complications were calculated and compared. A threshold of 30cc of blood loss after the procedure was used as a marker of significant bleeding. Clinically significant bleeding was defined as blood loss causing symptoms and/or requiring intervention, such as additional invasive procedure or blood product transfusion.

Results In patients receiving local injection of FFP, all type bleeding rate and clinically significant bleeding rate was 0%. In patients receiving Gelfoam tract plugging, the bleeding rate was 12.5% with a clinically significant bleeding rate of 0%. In patients for whom embolization coils were used to manage bleeding, there was a 37.5% rate of all types of bleeding and a 12.5% rate of clinically significant bleeding requiring intervention or blood products. In patients receiving systemic FFP only, the all type bleeding rate was 17.1%, and clinically significant bleeding rate was 2.8%. Fifteen percent of patients experienced a transfusion-related complication including three deaths directly attributable to infusion-related volume overload or transfusion allergic reaction.

Conclusion Local injection of FFP provides a low-risk alternative for hemostasis in patients with coagulopathy undergoing minimally invasive procedures. This technique is comparable, if not superior, to more commonly used methods of reducing operative bleeding risk including synthetic fibrin injection and systemic FFP infusion. Local injection also allows interventionalists to avoid significant complications associated with systemic infusion of blood products including volume overload and allergic reactions while still reducing risk of bleeding.