Expert opinion on bleeding risk from invasive procedures in cirrhosis
Alix Riescher-Tuczkiewicz,
Stephen H. Caldwell,
Patrick S. Kamath,
Erica Villa,
Pierre-Emmanuel Rautou,
Afdhal Nezam H,
Ageno Walter,
Bianchini Marcello,
Blasi Annabel,
Caldwell Stephen H,
Callaway Mark,
Cardenas Andres,
Darwish Murad Sarwa,
De Gottardi Andrea,
De Pietri Lesley,
De Raucourt Emmanuelle,
Dell'Era Alessandra,
Denys Alban,
Elkrief Laure,
Garcia-Pagan Juan-Carlos,
Garcia-Tsao Guadalupe,
Gatt Alexander,
Giannini Edoardo G,
Golfieri Rita,
Greenberg Charles S,
Hernández-Gea Virginia,
Heydtmann Mathis,
Intagliata Nicolas M,
Kamath Patrick S,
Lester Will,
Magnusson Maria,
Neuberger James,
Northup Patrick G,
O'Leary Jacqueline G,
Patton Heather,
Peck-Radosavljevic Markus,
Pillai Anjana,
Plessier Aurélie,
Rautou Pierre-Emmanuel,
Ripoll Cristina,
Roberts Lara N,
Sarwar Ammar,
Senzolo Marco,
Shukla Akash,
Simioni Paolo,
Simonetto Douglas A,
Singal Ashwani K,
Soto Robin,
Stine Jonathan G,
Tapper Elliot B,
Thabut Dominique,
Thachil Jecko,
Tomescu Dana,
Tripathi Dhiraj,
Tsochatzis Emmanuel A,
Villa Erica,
Valla Dominique
Affiliations
Alix Riescher-Tuczkiewicz
Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
Stephen H. Caldwell
Division of Gastroenterology & Hepatology, University of Virginia Health System, Charlottesville, VA 22908, USA
Patrick S. Kamath
Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
Erica Villa
Gastroenterology Unit, Chimomo Department, University of Modena and Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
Pierre-Emmanuel Rautou
Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France; Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France; Corresponding author. Address: Service d’hépatologie, Hôpital Beaujon, 100 boulevard du Général Leclerc, 92110 Clichy, France; Tel.: +33.1.40.87.52.83, fax: +33.1.40.87.55.30.
Background & Aims: Despite several recent international guidelines, no consensus exists on the bleeding risk nor haemostatic parameter thresholds that define the safety of invasive procedures in patients with cirrhosis. The aim of this study was to establish a position paper on the bleeding risk associated with invasive procedures in patients with cirrhosis among the experts involved in various guidelines. Methods: All experts involved in recent guidelines on the management of invasive procedures in patients with cirrhosis were invited to classify 80 procedures as ''high risk'' or ''low risk'' with respect to bleeding. Procedures were considered high risk when the estimated risk of major bleeding was 1.5% or more, or when even minor bleeding might lead to significant morbidity or death. The experts were also asked to choose safety thresholds for laboratory test values at which elective invasive procedures could be safely performed. The predetermined threshold considered as “consensus” was ≥75% agreement. Results: Fifty-two experts participated in the study. Out of 80 procedures, a consensus opinion was reached for 52 procedures (65%): 17 procedures were classified as “high risk”, primarily interventional endoscopic procedures, percutaneous organ biopsies, or procedures involving the central nervous system; and 35 as “low risk”, primarily “diagnostic” procedures. The lowest platelet counts at which performance of a low-risk procedure or a high-risk procedure/surgery were deemed acceptable were 30 × 109/L and 50 × 109/L, respectively. Experts did not believe that international normalised ratio should be considered before performing low-risk procedures; 71% also indicated that it should not be considered before performing high-risk procedures. Conclusions: This experience-based classification may be helpful to refine future study designs and to guide clinical decision making regarding invasive procedures in patients with cirrhosis. Impact and implications: Several risk classifications and management guidelines for invasive procedures in patients with cirrhosis have been proposed, but with conflicting recommendations. By providing a position paper, based on the opinion of a broad panel of experts, on the bleeding risk associated with 52 invasive procedures in patients with cirrhosis, this survey will help to provide a framework for future study design. The consensus on platelet count, international normalised ratio, fibrinogen and activated partial thromboplastin time identified in this survey will inform physicians regarding the laboratory test values considered acceptable by the experts prior to the performance of an elective invasive procedure in patients with cirrhosis.
