Safety Assessment of Continuous Versus Discontinuous Warfarin Therapy in Cardiovascular Endovascular Procedures: Observations from a Meta-analysis

Background: Endovascular procedures are commonly performed in patients with a history of anticoagulation treatment. Proper balance between reduction of thromboembolic events and the risk of bleeding is necessary to improve perioperative patient outcomes. Anticoagulation achieved with oral medication is not easily reversible, thus many patients are advised to discontinue warfarin and are given heparin before endovascular procedure. An alternative strategy, to perform endovascular procedures in patients without interruption of anticoagulation therapy, has been adopted. In our study we conducted a meta-analysis of complication rates and outcomes in patients undergoing endovascular procedures who receive continuous versus discontinuous warfarin therapy. Methods: Literature published between 2000 and 2015 was searched for reports of comparative studies of vascular procedures. Information on periprocedural complications and patient deaths less than 30 days after the procedure was extracted. A random effects model was used and odds ratios (ORs) were reported. An OR of less than 1 was considered to indicate lower risk of the outcome with discontinuous warfarin therapy. Meta-analysis was conducted by using meta-analysis software. Results: A total of 32 studies of 15,326 patients were included. For arterial procedures, there were no significant differences between the continuous versus discontinuous warfarin therapy groups in access site hematoma (OR, 0.59; 95% confidence interval [CI]: 0.33, 1.03; P =0.06), any bleeding complications (OR, 0.56; 95% CI: 0.30, 1.06; P =0.07), mortality (OR, 1.40; 95% CI: 0.37, 5.25; P =.62), intracranial hemorrhage (OR, 0.55; 95% CI: 0.03, 8.91; P =.68), ischemic stroke (OR, 0.85; 95% CI: 0.12, 5.84; P =.87), and major bleeding (OR, 0.56; 95% CI: 0.21, 1.51; P =.25). For venous procedures, uninterrupted warfarin was associated with lower odds of access site hematoma (OR, 0.70; 95% CI: 0.50, 0.99; P =.04), any bleeding complications (OR, 0.61; 95% CI: 0.48, 0.77; P <.01), ischemic stroke (OR, 0.21; 95% CI: 0.10, 0.45; P <.01), and major bleeding (OR, 0.64; 95% CI: 0.51, 0.80; P <.01). For arterial and venous procedures combined, uninterrupted warfarin was associated with lower odds of access site hematoma (OR, 0.68; 95% CI: 0.51, 0.91; P =.01), bleeding complications (OR, 0.59; 95% CI: 0.48, 0.74; P <.01), ischemic stroke (OR, 0.25; 95% CI: 0.12, 0.50; P <.01), and major bleeding (OR, 0.61; 95% CI: 0.49, 0.77; P <.01). Heterogeneity in most analyses was low, and confidence in the estimates was moderate. Conclusions: Continuous perioperative warfarin therapy is safe for patients undergoing arterial procedures, but discontinuous warfarin may be preferred for those undergoing venous procedures; no differences in outcome rates were found in the randomized controlled trials. Future studies are required to confirm these results.

Publication History

Article published online:
26 April 2021