warfarin and Endoleak

To evaluate whether postoperative long-term oral anticoagulation affects the durability of endovascular aneurysm repair (EVAR) and whether it is associated with an increased incidence of endoleak and subsequent need for reintervention.. A literature search was performed to identify studies of abdominal aortic aneurysm patients undergoing EVAR including an arm receiving warfarin postoperatively and reporting the frequency of any endoleaks and/or persistent type II endoleaks and reinterventions. The search identified 81 articles, of which 5 observational cohort studies ultimately met the inclusion criteria.. Postoperative anticoagulation was required in 219 (14.6%) of the 1499 patients in the selected studies. The pooled effects analysis found that EVAR patients receiving long-term warfarin postoperatively had significantly more endoleaks of any type (OR 1.77, 95% CI 1.26 to 2.48, p=0.001) as well as persistent type II endoleaks (OR 1.58, 95% CI 1.05 to 2.37, p=0.03) compared with patients not on anticoagulation; however, there was no statistically significant difference in the reintervention rate between the groups.. Long-term anticoagulation in EVAR patients was associated with a statistically significant increase in any endoleak and persisting type II endoleaks, although it was not linked to an increased risk of reintervention. Close monitoring for EVAR patients who require long-term oral anticoagulation is advised.

Topics: Administration, Oral; Anticoagulants; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis Implantation; Chi-Square Distribution; Endoleak; Endovascular Procedures; Humans; Odds Ratio; Retreatment; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; Warfarin

Within the context of endovascular aneurysm repair (EVAR), the role of anticoagulation therapy on endoleak development and subsequent reintervention is unclear with conflicting data in the literature. The hypothesis of this study is that long-term anticoagulation is associated with persistent type II endoleaks and failure of sac regression in patients undergoing endoluminal repair of intact infrarenal aortic aneurysm.. Retrospective cohort abstracted from the Vascular Quality Initiative index hospitalization and long-term follow-up datasets for EVAR (2003-2017) were included in the analysis. Patients not taking aspirin preoperatively and postoperatively were excluded. Patients taking anticoagulation and aspirin concomitantly (treatment) after the index procedure were compared against patients taking aspirin alone (control). Anticoagulation included warfarin and novel oral anticoagulants, including factor Xa inhibitors and direct thrombin inhibitors. One-to-one greedy matching using propensity scores was implemented to match patients. The primary end points were failure of aneurysm sac regression, sac expansion, risk of endoleak, and reintervention rate for endoleak at follow-up. Sac regression was defined as a decrease of at least 5 mm and sac expansion was defined as an increase of at least 5 mm.. There were 9004 patients who received ASA alone and 332 patients who received ASA and anticoagulation. Propensity scores were used to create 301 matching pairs to account for differences in baseline characteristics and comorbidities, including but not limited to age, sex, smoking, coronary artery disease, heart failure, and chronic kidney disease between the treatment and control groups. After adjusting for covariables anticoagulation use was independently associated with a significantly decreased abdominal aortic aneurysm sac regression (41.59% vs 58.41%; P = .001), but no statistically significant difference in sac expansion with long-term anticoagulation use (9.7% vs 4.9%; P = .056). There was increased risk of type II endoleaks (11.96% vs 6.31%; P = .023; relative risk, 1.89; 95% confidence interval, 1.11-3.23; P = .016), but no significant differences in type I, III, or indeterminate endoleaks. There was no statistical difference in 2-year reintervention rates (4.32% vs 2.66%; hazard ratio, 1.43; 95% confidence interval, 0.55-3.77; P = .461). There were no differences in any primary outcome between warfarin and novel oral anticoagulants.. These data demonstrate that long-term aspirin plus anticoagulation use is associated with a lack of aortic sac reduction and persistent type II endoleak, but not an increased risk for subsequent reintervention. Because prior studies have demonstrated that sac regression is a correlate of survival, these findings associating regression failure suggest a potential therapeutic failure for patients undergoing EVAR who also require long-term anticoagulation therapy. Although not a contraindication, long-term anticoagulation should be considered when counseling patients with a surgical indication aortic aneurysm.

Topics: Anticoagulants; Aortic Aneurysm; Aortic Aneurysm, Abdominal; Aspirin; Blood Vessel Prosthesis Implantation; Endoleak; Endovascular Procedures; Humans; Retrospective Studies; Risk Factors; Treatment Outcome; Warfarin

The impact of anticoagulation on late endoleaks after endovascular aneurysm repair (EVAR) is unclear despite multiple investigators studying the relationship. The purpose of this study was to determine if long-term anticoagulation impacted the development of late endoleaks and if specific anticoagulants were more likely to exacerbate the development of endoleaks.. Using the Society for Vascular Surgery Vascular Quality Initiative database, patients undergoing EVAR between 2003 and 2019 for abdominal aortic aneurysms were evaluated. Patients were divided into two groups: those without a late endoleak and those with a late endoleak. Bivariate analysis was performed to assess preoperative, intraoperative, postoperative, and long-term follow-up variables. A multivariable analysis was done to determine associations of independent variables with late endoleaks. Patients were further subcategorized based on anticoagulation status before and after EVAR, specific type of anticoagulation, and the presence of an index endoleaks (diagnosed at the time of EVAR) to determine the subsequent frequency of late endoleaks.. A total of 29,783 patients were analyzed with 2169 (7.3%) having a late endoleak identified. Several risk factors were related to late endoleaks, including anticoagulation before and after EVAR (odds ratio [OR], 4.23; 95% confidence interval [CI], 2.57-6.96; P < .001), anticoagulation after EVAR (OR, 1.88; 95% CI, 1.43-2.49; P < .001), and index endoleak (OR, 1.45; 95% CI, 1.26-1.66; P < .001). The frequency of late endoleaks in patients anticoagulated before and after EVAR and after EVAR as compared with those never anticoagulated was 16.89% and 14.40% vs 6.95%, respectively (both P > .001). No difference in late endoleaks were noted for patients treated with warfarin and novel oral anticoagulants. The most common type of index and late endoleak identified was type II, but patients with type I, type II, and type IV index endoleaks were more commonly found to have type I, type II, and type IV late endoleaks, respectively. The frequency of late endoleaks in patients with both an index endoleak and anticoagulation after EVAR was 20.42% as compared with patients with only anticoagulation after EVAR (14.63%; P = .0015) and with patients with index endoleaks not anticoagulated (10.06%; P < .00001).. Late endoleaks were more common in patients treated with anticoagulation after EVAR. No difference in late endoleak frequency was detected between anticoagulation with warfarin and novel oral anticoagulants. Patients on anticoagulation and those with an index endoleak were at a higher risk of having a late endoleak.

Topics: Administration, Oral; Anticoagulants; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis Implantation; Canada; Databases, Factual; Endoleak; Endovascular Procedures; Factor Xa Inhibitors; Female; Humans; Incidence; Male; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; United States; Warfarin

This study aims to determine whether warfarin therapy influences the occurrence of endoleaks or aneurysm sac enlargement after endovascular aortic repair (EVAR).. A total of 367 patients who underwent EVAR for abdominal aortic aneurysm between 2007 and 2013 were recruited for this study. Satisfactory follow-up data including completed computed tomography scan follow-up for more than 2 years were available for 209 patients, and the mean follow-up time was 37 ± 12 months. Twenty-nine (16%) patients were on warfarin therapy (warfarin group), whereas 180 (84%) patients were not on warfarin therapy (control group).. Two- and four-year freedom rates for persistent type II endoleaks were significantly lower in patients of the warfarin group compared with the control group (85 and 49% vs 93 and 91%, respectively; P = 0.0001). Similarly, 2- and 4-year freedom rates for sac enlargement (>5 mm) were significantly lower in patients of the warfarin group compared with the control group (83 and 61% vs 92 and 82%, respectively; P = 0.0036). Using Cox regression analysis, the warfarin therapy was identified to be an independent positive predictor of sac enlargement after EVAR [hazard ratio (HR): 2.4; 95% confidence interval (CI): 1.08-5.40; P = 0.032], together with persistent type II endoleak. Warfarin therapy was also an independent predictor for persistent type II endoleak (HR: 3.7; 95% CI: 1.81-7.41; P < 0.0001) together with the number of patent lumbar arteries.. Results suggested that warfarin therapy was significantly associated with an increased risk for persistent II endoleak and sac enlargement after EVAR.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis Implantation; Endoleak; Endovascular Procedures; Female; Humans; Male; Middle Aged; Postoperative Complications; Proportional Hazards Models; Retrospective Studies; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

Current data supporting the effect of anticoagulation drug use on aneurysm sealing and the durability of endovascular abdominal aneurysm repair (EVAR) are conflicting. This study assessed the safety of chronic anticoagulation therapy after EVAR.. Records of 1409 consecutive patients having elective EVAR during 1997-2011 who were prospectively followed were reviewed. Survival, reintervention, conversion, and endoleak rates were analyzed in patients with and without chronic anticoagulants. Cox proportional hazards models were used to estimate the effect of anticoagulation therapy on outcomes.. One-hundred and three (7.3%) patients were on chronic anticoagulation drugs (80 on vitamin K antagonists) at the time of EVAR. An additional 46 patients started on anticoagulants after repair were identified. Patients on chronic anticoagulation therapy at repair (mean age 73.6 years; 91 males) had more frequent cardiac disease (74.8% vs. 44.2%; p < 00001), but no other differences in demographic and major baseline comorbidities with respect to the others. At baseline, mean abdominal aortic aneurysm (AAA) diameter was 56.43 mm vs. 54.65 mm (p = .076) and aortic neck length 26.54 mm vs. 25.21 mm (p = .26) in patients with and without anticoagulants, respectively. At 5 years, freedom from endoleak rates were 55.5% vs. 69.9% (p < .0001), and freedom from reintervention/conversion rates were 69.4% vs. 82.4% (p < .0001) in patients with (including those with delayed drug use) and without chronic anticoagulants, respectively. Controlling for covariates with the Cox regression method, at a mean follow-up of 64.3 ± 45.2 months after EVAR, use of anticoagulation drugs was independently associated with an increased risk of endoleak (odds ratio, OR 1.6; 95% confidence interval, CI: 1.23-2.07; p < .0001) and reintervention or late conversion rates (OR 1.8; 95% CI: 1.31-2.48; p < .0001).. The safety of anticoagulation therapy after EVAR is debatable. Chronic anticoagulation drug use risks exposure to a poor long-term outcome. A critical and balanced decision-making approach should be applied to patients with AAA and cardiac disease who may require prolonged anticoagulation treatment.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aortic Aneurysm, Abdominal; Endoleak; Endovascular Procedures; Female; Humans; Kaplan-Meier Estimate; Male; Postoperative Complications; Postoperative Period; Proportional Hazards Models; Retrospective Studies; Warfarin

Endoleak after endovascular aortic aneurysm repair (EVAR) can affect the durability of the repair and lead to continued sac expansion, rupture, and the need for further endovascular or open surgical interventions. The purpose of this study was to determine whether chronic anticoagulation therapy with warfarin is associated with an increased incidence of endoleak and thus increased need for reintervention after EVAR.. We reviewed the records of 401 consecutive patients who underwent EVAR at a single institution from 2003 until 2011. Patients on warfarin were compared with a control group not on warfarin. Primary endpoints included reintervention, defined as rupture, explant, or angiography; death from any cause; and a composite outcome of reintervention or death. The presence of an endoleak at last follow-up, identified by computed tomography or ultrasound scan, and increase of more than 5 mm in aneurysm sac size were secondary endpoints. Cox proportional hazards models were used to estimate the effect of warfarin use on the primary and secondary outcomes, controlling for age, gender, obesity, specific comorbidities, antiplatelet drugs, statin use, and urgency of EVAR.. Three hundred sixty-three patients with a median follow-up period of 29 months had sufficient data for analysis. Warfarin use was not associated with an increased risk of any of the primary endpoints. Controlling for covariates and length of observation via proportional hazards models, the effect of warfarin remained insignificant. It was found, however, on regression analysis, that adverse outcomes were more prevalent after emergency EVAR and in patients deemed unfit for open surgical repair.. Chronic oral anticoagulation does not appear to affect the incidence of endoleak after EVAR, nor does it impact the need for reintervention or degree of sac regression. We feel that warfarin may be safely used in post-EVAR patients. It appears that adverse long-term outcomes are more likely after emergency EVAR and in patients deemed unfit for open surgery.

Topics: Aged; Anticoagulants; Aortic Aneurysm; Aortic Rupture; Aortography; Blood Vessel Prosthesis Implantation; Drug Administration Schedule; Elective Surgical Procedures; Emergencies; Endoleak; Endovascular Procedures; Female; Humans; Incidence; Kaplan-Meier Estimate; Maine; Male; Multivariate Analysis; Predictive Value of Tests; Proportional Hazards Models; Reoperation; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; Ultrasonography, Doppler, Duplex; Warfarin