Continuation of Anticoagulation through Ambulatory Phlebectomy Does Not Impact Post-Operative Bleeding Risk.

Abstract

Objectives: Chronic anticoagulation for atrial fibrillation, history of venous thromboembolism, and following heart valve replacement is often stopped or bridged for surgery. Our institutional practice is to continue anticoagulation through ambulatory phlebectomy (AP) procedures. As such, we aimed to compare post-procedure bleeding and major adverse events in patients on anticoagulation who received ambulatory phlebectomy compared to patients not on anticoagulation.

Methods: We included all patients who required AP from January 2016 to February 2023. Given the low frequency of chronic anticoagulation during the study period, as defined as patients on anticoagulation ≥30 days before index procedure and not held through the procedure, a propensity score match of 16 demographic parameters was performed to better match patients. Following propensity matching, we compared the frequency and quality of post-procedural bleeding (none, incisional, large volume), extent of post-procedural ecchymosis (none, minimal, moderate, significant), and pain (minimal, moderate, severe) on follow up examination with a provider. Thirty-day ED visits and major adverse cardiac events (MACE) were also recorded for each patient. Continuous variables were compared using independent t-tests or Mann-Whitney U tests while categorical variables were compared using a Chi-square or Fisher's Exact test.

Results: In total, 1,853 patients received AP from four outpatient offices during the study period, 101 (5.5%) of which were on chronic anticoagulation. Seventy patients for each group were propensity score matched in key demographics including age, gender, BMI, Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification, prior vein procedures, concomitant laser procedures, number of phlebectomies performed, and co-morbidities like history of deep vein thrombosis, pulmonary embolism, and peripheral arterial disease. There were no intra-operative major bleeding events. Patients on chronic anticoagulation were not more likely to have increased post-procedural bleeding (2.9% vs 0%, p=0.496), significant ecchymosis (4.5% vs 1.5%, p=0.671), severe pain on follow up (1.4% vs 0%, p=0.604), or increased likelihood of post-procedural cellulitis (1.4% vs 0%, p=1.000). There were no instances of 30-day ED visits, or MACE. Within patients on anticoagulation, use of rivaroxaban (8%) had higher incidence of bleeding than those on apixaban or warfarin (0%), however, these findings were not significant.

Conclusions: Ambulatory phlebectomy while continuing chronic anticoagulation did not result in an increased rate of bleeding, ED visits, or major adverse events. It is likely safe to continue anticoagulation throughout these outpatient procedures.