title: Outcomes after arterial endovascular procedures performed in patients with an elevated international normalized ratio.
abstract: BACKGROUND
  Patients treated with anticoagulants frequently require urgent vascular procedures and elevated prothrombin time/international normalized ratio (INR) is traditionally thought to increase access site bleeding complications after sheath removal. We aimed to determine the safety of percutaneous arterial procedures on patients with a high INR in the era of modern ultrasound-guided access and closure device use.
  
  
  METHODS
  Patients undergoing arterial endovascular procedures at a single institution between October 2010 and November 2012 were reviewed (n = 1,333). We retrospectively analyzed all patients with an INR > 1.5. Venous procedures, lysis checks, and cases with no documented INR within 24 hr were excluded. Sixty-five patients with 91 punctures were identified. A comparison group was then generated from the last 91 patients intervened on with INR < 1.6. Demographics, intraoperative data, and postoperative complications were compared.
  
  
  RESULTS
  The demographics were similar. More Coumadin use and higher INR were found in the study group (71/91 and 0/91, P = 0.001; 2.3 and 1.1 sec, P = 0.001, respectively), but there was more antiplatelet use in the control group (68/91 and 51/91, P = 0.01). Intraoperatively, the sheath sizes, protamine use, closure device use, ultrasound guidance, brachial access, and procedure types were not statistically different. Sheath sizes ranged from 4 to 22F in the study group and 4 to 20F in the control group. Paradoxically, heparin was administered more frequently in the study group (64/91 and 50/91, P = 0.046). Bleeding complications occurred more commonly in the study group (3/91 and 1/91, P = 0.62), but this failed to reach significance and the overall complication rate in both groups was low.
  
  
  CONCLUSIONS
  Endovascular procedures may be performed safely with a low risk of bleeding complications in patients with an elevated INR. Ultrasound guidance and closure device use may allow these cases to be performed safely, but a larger series may be needed to confirm this.
authors.affiliation: Department of Vascular and Endovascular Surgery, University of Arkansas for Medical Sciences, Little Rock, AR.
authors.forename: Joshua A
authors.initials: JA
authors.lastname: Wilensky
authors.affiliation: Department of Vascular and Endovascular Surgery, University of Arkansas for Medical Sciences, Little Rock, AR.
authors.forename: Ahsan T
authors.initials: AT
authors.lastname: Ali
authors.affiliation: Department of Vascular and Endovascular Surgery, University of Arkansas for Medical Sciences, Little Rock, AR.
authors.forename: Mohammed M
authors.initials: MM
authors.lastname: Moursi
authors.affiliation: Department of Vascular and Endovascular Surgery, University of Arkansas for Medical Sciences, Little Rock, AR.
authors.forename: Guillermo A
authors.initials: GA
authors.lastname: Escobar
authors.affiliation: Department of Vascular and Endovascular Surgery, University of Arkansas for Medical Sciences, Little Rock, AR. Electronic address: mrsmeds@uams.edu.
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Smeds
mesh_terms: D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use*; D001131:Arkansas; D001158:Arteries / Q000000981:diagnostic imaging; D001777:Blood Coagulation / Q000187:drug effects*; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods; D004867:Equipment Design; D005260:Female; D006470:Hemorrhage / Q000209:etiology / Q000517:prevention & control; D006489:Hemostatic Techniques / Q000295:instrumentation; D006801:Humans; D019934:International Normalized Ratio; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011237:Predictive Value of Tests; D011677:Punctures; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional; D062666:Vascular Access Devices
chemical_list: D000925:Anticoagulants