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Real-time ultrasound guidance reduces total and major vascular complications in patients undergoing pulmonary vein antral isolation on therapeutic warfarin

  • Christine C. Tanaka-Esposito
  • Mina K. Chung
  • JoEllyn M. Abraham
  • Daniel J. Cantillon
  • Bernard Abi-Saleh
  • Patrick J. TchouEmail author
Article

Abstract

Background

Vascular complications are a known risk of catheter-based pulmonary vein antral isolation (PVAI). Procedure-related thromboembolic events necessitate full-dose anticoagulation, which worsens outcomes in the event of vascular access injury.

Objective

Real-time ultrasound allows direct visualization of vascular structures. We hypothesized that ultrasound use with venipuncture reduces vascular complications associated with PVAI.

Methods

Retrospective analysis of all adverse events occurring with PVAI was performed during two periods: 2005–2006 when ultrasound was not used and 2008–2010 when ultrasound was routinely employed. All patients received full-dose IV heparin during PVAI. In the no ultrasound cohort, only 14 % underwent PVAI without stopping warfarin, while 91 % of patients in the ultrasound cohort were on continued warfarin. Only patients deemed at high risk for thromboembolism with a periprocedural international normalized ratio (INR) less than 2 were bridged with subcutaneous low-molecular-weight heparin.

Results

Ultrasound reduced total vascular complications (1.7 vs. 0.5 %, p < 0.01) and decreased the incidence of major vascular complications by sevenfold. Warfarin with INR ≥ 1.2 on the day of PVAI was associated with more vascular complications (4.3 vs. 1.2 %, p < 0.01). Ultrasound guidance overcame the risk associated with warfarin therapy. Vascular complications in anticoagulated patients with INR ≥ 1.2 using ultrasound guidance were two- and ninefold lower than those in patients not using ultrasound with an INR < 1.2 (0.5 vs. 1.2 %, p < 0.05) and INR ≥ 1.2 (0.5 vs. 4.3 %, p < 0.01), respectively.

Conclusion

Ultrasound-guided venipuncture improves the safety profile of PVAI, reducing vascular complications in patients on warfarin to levels below those with no ultrasound and off warfarin.

Keywords

Vascular complications Ultrasound guidance Pulmonary vein antral isolation Periprocedural anticoagulation Procedure-related thromboembolic events 

Abbreviations

PVAI

Pulmonary vein antral isolation

AF

Atrial fibrillation

AV

Arteriovenous

F

French

mg/kg

Milligram per kilogram

mg

Milligram

s

Seconds

mm

Millimeter

INR

International normalized ratio

CT

Computed tomography

OR

Odds ratio

mg/dl

Milligram per deciliter

US

Ultrasound

Notes

Conflict of interest

Dr. Christine C. Tanaka-Esposito, Dr. Patrick J. Tchou, and Dr. Daniel J. Cantillon have received modest honorarium from Medtronic, Inc.

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Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Christine C. Tanaka-Esposito
    • 1
  • Mina K. Chung
    • 1
  • JoEllyn M. Abraham
    • 1
  • Daniel J. Cantillon
    • 1
  • Bernard Abi-Saleh
    • 1
  • Patrick J. Tchou
    • 1
    Email author
  1. 1.Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular MedicineHeart and Vascular InstituteClevelandUSA

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