Strategies for Antithrombotic Management During Non-cardiac Arterial Procedures: Results of the International ACTION Survey

Objective: Peri-procedural antithrombotics are used extensively to prevent thromboembolic complications during non-cardiac arterial procedures (NCAP) worldwide. However, there is a lack of evidence to support recommendations on antithrombotic strategies, possibly leading to substantial variation in local practices. A comprehensive overview of antithrombotic strategies is needed to identify the most widely accepted protocols employed during NCAP, highlight variations in local practices, and identify new research targets to establish evidence based peri-procedural anticoagulation management. Methods: An international, web based survey study was conducted from March to October 2023, targeting vascular clinical specialists who applied antithrombotic strategies during NCAP in daily practice. Results: The survey was completed by 436 vascular clinical specialists from 45 countries (Europeans: 93%, vascular surgeons or vascular surgery residents: 98%). Systemic unfractionated heparin was used by nearly all vascular specialists during all procedures (varying between 98–99%, depending on the procedure type), but could vary depending on specific NCAP. A fixed starting dose (39–52%, most often 5 000 IU [80–89%]) or an actual bodyweight dependent dose (42–52%, most commonly 100 IU/kg [40–67%] or 50 IU/kg [17–40%]) was mainly used. Except during fenestrated or branched endovascular aneurysm repair procedures (51%), activated clotting time (ACT) was employed by a minority (26–31%). A large variety in measurement protocols was observed, yet a target ACT of 200 seconds was most often used for all NCAP types (44–54%). Most vascular specialists considered a heparin follow up dose (61–81%) and heparin reversal using protamine (54–63%), both for a variety of indications. Of the participants, 68% expressed discontent with their current antithrombotic protocol(s). Conclusion: This comprehensive, international survey study revealed large variation among vascular clinical specialists’ heparinisation strategies during NCAP. Together with the considerable discontent expressed regarding protocols, this emphasises the urgent need for comparative, randomised studies on antithrombotic management during NCAP.