The Use of Bivalirudin as Procedural Thromboprophylaxis in the Cardiac Catheterization Laboratory for Infants at Risk for Arterial Thrombosis
Taylor Paige Demkin, B.S.N., Children's Hospital of Philadelphia, Philadelphia, PA
Taylor Paige Demkin, B.S.N., Children's Hospital of Philadelphia, Philadelphia, PA
Keywords: Cath Lab Safety, Critical Limb Ischemia (CLI), Interventional Pharmacology and Managing Complications
Background
Arterial thrombosis (AT) is a common complication following cardiac catheterization with femoral arterial cannulation (FAC) in neonates and infants. Heparin (UFH) is the standard procedural anticoagulant, but its efficacy may be limited in these patients at high risk for AT. As a quality improvement initiative, we sought to reduce the rate of AT in patients <1 year of age by using bivalirudin (BVN) as an alternative procedural anticoagulant.
Methods
A practice change was designed and implemented utilizing BVN as an alternative to UFH in patients <1 year of age undergoing catheterization with FAC. The primary outcome was the incidence of AT. Secondary outcomes included charges related to anticoagulation and duration of treatment for those who developed AT. Balancing metrics included prep and hemostasis times, and bleeding complications. The practice change began 5/15/2017. We compared patients treated with BVN to patients treated with UFH (both historical patients back to 1/1/2015 and contemporary patients who did not receive BVN at an operator’s discretion).
Results
Since initiation, 199 of 302 (66%) eligible patients received BVN. Common reasons BVN was not used included: prematurity, ECMO, and anticipated short case duration. Of the 199 treated with BVN, 24 (12.1%) had AT, less than the rate of contemporary heparin-treated patients (15%) and historical patients (20%). With AT, average duration of treatment until thrombus resolution was shorter for those who received BVN (15.2 v. 30.2 days). With BVN, anticoagulation-related procedural charges were 1120% higher, but AT treatment-related chargers were 43% less, a net average per-patient increase in total anticoagulation-related charges of 29%. Average hemostasis time increased (21.6 v. 17.3 minutes), but there was no change in prep time or rate of bleeding complications.
Conclusions
Use of BVN was associated with a reduced incidence of post-catheterization AT and a shorter duration of treatment needed for those who developed AT with a modest increase in total anticoagulation-related charges. Based on this experience, we have continued to use BVN as the preferred procedural anticoagulant during cardiac catheterization with FAC for patients <1 year of age.