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DURNER L.,BOURDOUMIS A., MASOOD J., BUCHHOLZ N. ROYAL LONDON HOSPITAL, BARTSHEALTH NHS TRUST ROYAL DEVON AND EXETER NHS TRUST HOMERTON UNIVERSITIY HOSPITAL NHS TRUST Handling thromboprophylaxis minimally invasive stone procedures

DURNER L.,BOURDOUMIS A., MASOOD J., BUCHHOLZ N. ROYAL LONDON HOSPITAL, BARTSHEALTH NHS TRUST ROYAL DEVON AND EXETER NHS TRUST HOMERTON UNIVERSITIY HOSPITAL

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Page 1: DURNER L.,BOURDOUMIS A., MASOOD J., BUCHHOLZ N. ROYAL LONDON HOSPITAL, BARTSHEALTH NHS TRUST ROYAL DEVON AND EXETER NHS TRUST HOMERTON UNIVERSITIY HOSPITAL

DURNER L.,BOURDOUMIS A., MASOOD J., BUCHHOLZ N.

ROYAL LONDON HOSPITAL, BARTSHEALTH NHS TRUSTROYAL DEVON AND EXETER NHS TRUSTHOMERTON UNIVERSITIY HOSPITAL NHS TRUST

Handling thromboprophylaxis minimally invasive stone

procedures

Page 2: DURNER L.,BOURDOUMIS A., MASOOD J., BUCHHOLZ N. ROYAL LONDON HOSPITAL, BARTSHEALTH NHS TRUST ROYAL DEVON AND EXETER NHS TRUST HOMERTON UNIVERSITIY HOSPITAL

Introduction

multiple co-morbiditiescardiology procedures get more complexAntiplatelets Anticoagulationcronic bleeding disorder

• peri- and post- operative thromboprophylaxis

• low / intermediate / high risk

Page 3: DURNER L.,BOURDOUMIS A., MASOOD J., BUCHHOLZ N. ROYAL LONDON HOSPITAL, BARTSHEALTH NHS TRUST ROYAL DEVON AND EXETER NHS TRUST HOMERTON UNIVERSITIY HOSPITAL

Purpose

current evidence practical guide for thromboprophylaxisdosing and duration modifications anticoagulation regimens dependent on

planned procedure

Page 4: DURNER L.,BOURDOUMIS A., MASOOD J., BUCHHOLZ N. ROYAL LONDON HOSPITAL, BARTSHEALTH NHS TRUST ROYAL DEVON AND EXETER NHS TRUST HOMERTON UNIVERSITIY HOSPITAL

Materials and Methods

systematic review and evidence-based research of the literature.

Key words: anticoagulation treatment, antiplatelet agents, stone surgery, lithotripsy, perioperative thromboprophylaxis, perioperative bridging therapy and coagulopathy, alone or in combination.

Evidence synthesis and creation of a management protocol.

Page 5: DURNER L.,BOURDOUMIS A., MASOOD J., BUCHHOLZ N. ROYAL LONDON HOSPITAL, BARTSHEALTH NHS TRUST ROYAL DEVON AND EXETER NHS TRUST HOMERTON UNIVERSITIY HOSPITAL

The rationale.....

Appropriate indication for stone treatment modality

Appropriate patient selection (don’t be a hero...)

Risk of thrombosis

Risk of bleeding

Page 6: DURNER L.,BOURDOUMIS A., MASOOD J., BUCHHOLZ N. ROYAL LONDON HOSPITAL, BARTSHEALTH NHS TRUST ROYAL DEVON AND EXETER NHS TRUST HOMERTON UNIVERSITIY HOSPITAL

Arterial thromboembolismArterial thromboembolism

Venous thromboembolismVenous thromboembolism

Mechanical heart valves (risk of arterial thrombosis (CVAs, INR < 2)

High risk group (> 10%/year) Patients with mechanical heart valves,

especially mitral valve or one of the older generation aortic valves (caged-ball, tilting-disk), and also patients suffering from ischemic stroke or transient ischemic attack within the last 6 months.

Intermediate risk group (4-10%/year) Patients with a bileaflet aortic valve and

one or more of the following: atrial fibrillation, history of ischemic stroke or transient ischemic attack, hypertension, diabetes, age >75 years and congestive heart failure.

Low risk group (<4%/year) Patients with a bileaflet aortic valve with

no additional co morbidities.

High risk group (> 10%/year)Recent episode of DVT/PE (< 3 months), hereditary thrombophilia (Protein S or C deficiency, antithrombin deficiency, homozygotes for Factor V Leiden and G20210A prothrombin gene mutation), antiphospholipid syndrome and active cancer .

Intermediate risk group

(5-10%/year) Patients with history of DVT/PE between 3-12 months, heterozygotes for Factor V Leiden and prothrombin gene mutation and patients with previous malignancy.

Low risk group (<5%/year)All other patients are considered in the low risk level group (<5%/year).

Allocating into risk groups

Page 7: DURNER L.,BOURDOUMIS A., MASOOD J., BUCHHOLZ N. ROYAL LONDON HOSPITAL, BARTSHEALTH NHS TRUST ROYAL DEVON AND EXETER NHS TRUST HOMERTON UNIVERSITIY HOSPITAL
Page 8: DURNER L.,BOURDOUMIS A., MASOOD J., BUCHHOLZ N. ROYAL LONDON HOSPITAL, BARTSHEALTH NHS TRUST ROYAL DEVON AND EXETER NHS TRUST HOMERTON UNIVERSITIY HOSPITAL
Page 9: DURNER L.,BOURDOUMIS A., MASOOD J., BUCHHOLZ N. ROYAL LONDON HOSPITAL, BARTSHEALTH NHS TRUST ROYAL DEVON AND EXETER NHS TRUST HOMERTON UNIVERSITIY HOSPITAL

Conclusions

The regulation of anticoagulation treatment and the relative risk of thromboembolic events ultimately rest with the operating surgeon in collaboration with the anesthesiology / cardiology / hematology specialists when required.

Ureteroscopy is favored in anticoagulated patients, always with respect to stone size and location.

Shock wave lithotripsy and PCNL is a form of stone treatment, with strict adherence to bridging protocols and patient risk factors required in most cases.

Patients with cardiovascular stents constitute a unique risk group and specialist input should always be sought.

Page 10: DURNER L.,BOURDOUMIS A., MASOOD J., BUCHHOLZ N. ROYAL LONDON HOSPITAL, BARTSHEALTH NHS TRUST ROYAL DEVON AND EXETER NHS TRUST HOMERTON UNIVERSITIY HOSPITAL

Questions-Discussion

Thank you for your attention

Douketis JD, Spyropoulos AC, Spencer FA, et al. American College of Chest Physicians. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 141 (2 Suppl):e326S-50S (2012).

Thromboprophylaxis and bleeding diathesis in minimally invasive stone surgery. Bourdoumis A, Stasinou T, Kachrilas S, Papatsoris AG, Buchholz N, Masood J.

Nat Rev Urol. 2014 Jan;11(1):51-8.

Page 11: DURNER L.,BOURDOUMIS A., MASOOD J., BUCHHOLZ N. ROYAL LONDON HOSPITAL, BARTSHEALTH NHS TRUST ROYAL DEVON AND EXETER NHS TRUST HOMERTON UNIVERSITIY HOSPITAL

Introduction

The urologist frequently encounters patients with multiple and complex co-morbidities, who are on regular antiplatelet or anticoagulation medication or suffering from a chronic bleeding disorder.

Decisions regarding peri- and post- operative thromboprophylaxis in urological surgery patients and stone surgery patients in particular are frequently met with confusion.

Page 12: DURNER L.,BOURDOUMIS A., MASOOD J., BUCHHOLZ N. ROYAL LONDON HOSPITAL, BARTSHEALTH NHS TRUST ROYAL DEVON AND EXETER NHS TRUST HOMERTON UNIVERSITIY HOSPITAL

The evidence.... - for stones -

increased bleeding risk during perioperative antithrombotic drug administration, probably due to urokinase release

All lithotripsy options except ureteroscopy are contraindicated in the face of uncorrected bleeding tendency

SWL and ureteroscopy performed as day case appear to have very low risk of thromboembolism

PCNL and complicated ureteroscopy (prolonged operating time, impacted stone, large stone burden) carry an intermediate risk for thromboembolic events

Page 13: DURNER L.,BOURDOUMIS A., MASOOD J., BUCHHOLZ N. ROYAL LONDON HOSPITAL, BARTSHEALTH NHS TRUST ROYAL DEVON AND EXETER NHS TRUST HOMERTON UNIVERSITIY HOSPITAL

The evidence....- for anticoagulants -

day case procedures do not usually require pharmacological thromboprophylaxis.

Patients with inherent or acquired risk factors anticoagulation for 10d

In low risk for thromboembolism, no bridging of anticoagulation during

interruption of warfarin (LE: 2c) Aspirin may be continued up to the time of surgery

instead of stopping 7 to 10 days before (LE: 2c)