What is the management for bleeding at a thrombectomy site post procedure?

Management of Bleeding at a Thrombectomy Site Post Procedure

For post-thrombectomy site bleeding, immediate management should include direct pressure to the site, temporary discontinuation of anticoagulation, and consideration of hemostatic agents, followed by close monitoring for both bleeding and thrombotic complications. 1

Initial Assessment and Management

• Maintain arterial access for 12-24 hours in high-risk patients to allow prompt intervention if needed 1
• Apply direct manual pressure to the bleeding site as the first-line intervention 1
• Monitor vital signs and neurological status closely in a neurointensive care unit environment 1
• Temporarily pause anticoagulation therapy when bleeding occurs, although there are no specific guidelines on the safe duration of this pause 1

Specific Interventions for Bleeding Control

• For persistent bleeding despite direct pressure:
  • Apply hemostatic dressings or topical hemostatic agents to the puncture site 1
  • Consider vascular closure devices if the bleeding is from the arterial access site 1
  • For severe bleeding, surgical exploration and repair may be necessary 1

Blood Product Support

• For significant bleeding with hemodynamic instability or substantial hemoglobin drop:
  • Administer packed red blood cells transfusions as needed 1
  • Consider platelet transfusions, especially if the patient was on antiplatelet therapy prior to the procedure 2
  • Fresh frozen plasma may be required in cases of coagulopathy 1

Anticoagulation Management

• The decision to restart anticoagulation must balance the risk of thrombotic complications against ongoing bleeding risk 1
• In patients with high thrombotic risk:
  • Consider using heparin-coated devices if anticoagulation must be withheld 1
  • When restarting anticoagulation, begin with lower doses and monitor closely 1
• Monitor coagulation parameters (aPTT, ACT) regularly when restarting anticoagulation 1

Monitoring and Prevention of Complications

• Monitor for signs of thrombotic complications, which occur in approximately 22.9% of patients when anticoagulation is withheld 1
• Watch for neurological deterioration, which may indicate thrombotic complications or intracranial hemorrhage 3
• Continue close hemodynamic monitoring, as severe bleeding complications occur in 11.5-32% of patients depending on anticoagulation status 1

Special Considerations

• Patients on pre-procedure antiplatelet therapy have a higher risk of bleeding complications, particularly subarachnoid hemorrhage (SAH) 2
• Bleeding from the thrombectomy site occurs in 21-42% of patients, with higher rates in those receiving therapeutic anticoagulation 1
• Isolated subarachnoid hemorrhage post-thrombectomy is associated with worse neurological outcomes and higher in-hospital mortality (41.7% vs. 23.8% in non-ICH patients) 3

Pitfalls and Caveats

• Avoid hypothermia, which can worsen coagulopathy and increase bleeding risk 1
• Do not use ice packs directly on the puncture site as this may promote vasoconstriction followed by rebound vasodilation and increased bleeding 1
• Be cautious with vasoconstricting agents as they might lead to poor vascular perfusion and acidosis in peripheral tissue 1
• Remember that the risk of bleeding complications must be balanced against the risk of thrombotic events, which can occur in up to 22.9% of patients when anticoagulation is withheld 1