Do you need to stop taking aspirin (acetylsalicylic acid) prior to tunneled dialysis catheter placement?

Management of Aspirin Prior to Tunneled Dialysis Catheter Placement

Aspirin does not need to be discontinued prior to tunneled dialysis catheter placement as the procedure is classified as having a very low risk of bleeding.

Evidence for Continuing Aspirin

The most recent and highest quality evidence directly addressing this question comes from a 2016 study that specifically evaluated bleeding risk with tunneled dialysis catheter (TDC) placement in patients on antithrombotic medications 1. This study found:

• The incidence of bleeding in patients taking aspirin without discontinuation was only 0.36%, compared to 0.46% in control patients not on antithrombotic therapy
• No patients required transfusion, hospitalization, or catheter removal due to bleeding complications
• The authors concluded that TDC placement should be classified as a very low-risk bleeding procedure

Risk Stratification Framework

When considering aspirin management for procedures, guidelines classify procedures based on bleeding risk:

1. Very Low/Low Bleeding Risk Procedures:

   • Tunneled dialysis catheter placement falls into this category 1
   • For such procedures, aspirin can be safely continued

2. High Bleeding Risk Procedures:

   • Neurosurgery, spinal surgery, and intracranial procedures
   • These require aspirin discontinuation 5-7 days before surgery 2

Guideline Recommendations

Multiple guidelines support continuing aspirin for low bleeding risk procedures:

• The American College of Chest Physicians recommends continuing aspirin around the time of surgery in patients at moderate to high risk for cardiovascular events 2
• The French Working Group on Perioperative Haemostasis notes that a three-day washout of aspirin is often sufficient for most procedures, but this is unnecessary for low bleeding risk procedures 2

Special Considerations

1. Patients with coronary stents:

   • If the patient has a drug-eluting stent placed within the past 12 months, aspirin should absolutely be continued 2
   • For bare metal stents placed within 6 weeks, aspirin should be continued 2

2. Dual antiplatelet therapy:

   • If the patient is on both aspirin and a P2Y12 inhibitor (clopidogrel, ticagrelor, prasugrel):
     • Continue aspirin
     • Consider holding the P2Y12 inhibitor (clopidogrel for 5 days, ticagrelor for 3-5 days, prasugrel for 7 days) if bleeding risk is a significant concern 2

3. Timing of aspirin effects:

   • Aspirin irreversibly inhibits platelet function
   • Complete recovery of platelet function occurs 5-6 days after discontinuation 3
   • However, this level of recovery is unnecessary for low bleeding risk procedures

Practical Approach

For tunneled dialysis catheter placement:

1. Continue aspirin (81-325 mg) without interruption
2. Ensure proper technique during catheter placement to minimize bleeding risk
3. Monitor for bleeding during and after the procedure
4. Apply adequate pressure at the insertion site after the procedure

Benefits of Continuing Aspirin

Continuing aspirin during TDC placement offers several advantages:

• Maintains protection against thrombotic events
• May actually improve catheter patency (studies show aspirin can prolong catheter patency) 4
• Avoids the risks associated with temporary aspirin discontinuation in high-risk cardiovascular patients

In conclusion, the evidence strongly supports continuing aspirin therapy for patients undergoing tunneled dialysis catheter placement, as the procedure carries a very low bleeding risk and the thrombotic risk of discontinuation likely outweighs any minimal bleeding risk.