SAN DIEGO – Oral anticoagulation with warfarin is routinely discontinued before venous surgery to avoid potential bleeding complications, but results from a single-center study suggest that endovenous laser therapy can be safely performed in patients taking warfarin.
"Cessation of warfarin therapy may necessitate an alternative form of bridging anticoagulation before and after the intervention in order to minimize the risk of perioperative thromboembolic complications from preexisting medical conditions," Dr. Paul J. Riesenman said at the annual meeting of the American Venous Forum. "This practice adds cost and complexity to the operative planning. But in many patients, minimizing the perioperative time period off the anticoagulation may be required to safely perform the procedure."
Dr. Paul J. Riesenman
According to Dr. Riesenman, a vascular surgery fellow at Emory University in Atlanta, endovenous laser therapy is minimally invasive and "bleeding complications are uncommonly reported." Noninterruption of warfarin therapy in these patients could simplify preoperative planning and minimize the risk of perioperative complications.
"One of the unknowns of this practice is how the presence of therapeutic anticoagulation may affect the success of the ablative procedure," he noted.
Between September 2004 and July 2010, 518 patients underwent 770 lower-extremity EVLT (endovenous laser therapy) procedures. Of these, five patients ranging in age from 31 to 69 years underwent 12 separate EVLT procedures without interruption of warfarin therapy. The great saphenous vein was targeted in eight procedures, and the small saphenous vein in the remaining four. Concomitant procedures included phlebectomies during five interventions and ultrasound-guided sclerotherapy during an additional five procedures.
At Emory, EVLT is routinely done in an office setting using a 55- or 80-cm inducer sheath placed in the target vessel. "We use an 810-nm wavelength system run on continuous operating mode at 14 W," Dr. Riesenman said. "Once successful ablation of the target vessel is confirmed by ultrasound and any additional venous interventions are performed, a two-layer compression bandage is applied and the patient receives a 20- to 30–mm Hg compression stocking. Follow-up with ultrasound is performed at 1 and 8 weeks."
No intraprocedural bleeding complications were observed in the five patients, and no excessive ecchymosis was documented at 1-week follow-up. Successful ablation of the target vessels was confirmed by ultrasound at 1 and 8 weeks in all patients.
"Most patients reported significant resolution of their symptoms, although one patient did report severe lower extremity pain during her 8-week follow-up," Dr. Riesenman said. "At that follow-up, there were no concerning ultrasound or physical exam findings. Interestingly, she did inquire about having her contralateral extremity treated at that time."
Although he acknowledged that the study is a "small, limited case series," Dr. Riesenman concluded that EVLT "can be safely and effectively performed on patients undergoing oral anticoagulation therapy with warfarin. We recommend that warfarin not routinely be interrupted when patients undergo this procedure."
Dr. Riesenman said that he had no relevant financial disclosures to make.