From the Guidelines
Anticoagulants can be resumed in a patient with pulmonary embolism and a splenic hematoma after angioembolization, with stable Hemoglobin (Hb) levels and a Functional Vascular Catheter Insertion (FVCI) in place, once the bleeding is controlled and the patient is clinically stable, which is typically after 1 to 2 weeks, as suggested by the 2020 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants 1.
Considerations for Resuming Anticoagulation
The decision to resume anticoagulation should be based on the balance between the risk of thrombosis (recurrence of pulmonary embolism) and the risk of bleeding (rebleeding of the splenic hematoma) 1.
- The patient's clinical stability and control of bleeding are crucial factors in determining the optimal timing for reinitiation of anticoagulation.
- A multidisciplinary care team should be involved in making this decision, taking into account the patient's individual risk factors and clinical characteristics.
- The use of prophylactic doses of parenteral anticoagulants, such as subcutaneous unfractionated or low-molecular-weight heparin, may be considered to reduce the risk of further bleeding while balancing thrombotic risk.
Recommendations for Anticoagulation Resumption
The resumption of anticoagulation can start with a prophylactic dose of heparin, such as enoxaparin 40 mg subcutaneously daily, for 2-3 days, followed by a transition to a therapeutic dose if no bleeding is observed 1.
- Close monitoring of the patient's hemoglobin levels and imaging studies is essential during this transition period to promptly detect any signs of rebleeding or thrombosis.
- The FVCI provides temporary protection against pulmonary embolism during this period without anticoagulation, but its use should be judicious and limited to patients with a high risk of thrombosis.
- Nonpharmacological therapies, such as left atrial appendage closure/occlusion devices or retrievable inferior vena cava filters, may be considered in patients with both high bleeding risk and high thrombotic risk, in consultation with the appropriate specialists 1.
From the Research
Resuming Anticoagulants in Patients with Pulmonary Embolism and Splenic Hematoma
- The decision to resume anticoagulants in a patient with pulmonary embolism, splenic hematoma, and angioembolization, with stable Hemoglobin (Hb) levels and a Functional Vascular Catheter Insertion (FVCI) in place, depends on various factors, including the risk of bleeding and the presence of an inferior vena cava (IVC) filter 2, 3.
- In patients with contraindications to anticoagulation, such as a splenic hematoma, an IVC filter may be considered to prevent recurrent pulmonary embolism 3, 4.
- However, the use of an IVC filter does not eliminate the need for anticoagulation, as it can increase the risk of filter thrombosis and recurrent deep vein thrombosis (DVT) 2, 5.
- The timing of resuming anticoagulants in these patients is not well established, but it is generally recommended to wait until the risk of bleeding has decreased and the patient's condition has stabilized 6, 5.
- A study published in 2015 found that the use of a retrievable IVC filter plus anticoagulation did not reduce the risk of recurrent pulmonary embolism compared to anticoagulation alone in patients with severe acute pulmonary embolism 5.
- Another study published in 2024 suggested that a computed tomography (CT) venogram and inferior vena cavagram should be considered the standard of care in patients with recurrent DVT and IVC filter to evaluate for thrombus in or around the filter 4.
Considerations for Resuming Anticoagulants
- The patient's risk of bleeding and thrombosis should be carefully assessed before resuming anticoagulants 2, 3.
- The presence of an IVC filter and the patient's response to anticoagulation therapy should be closely monitored 6, 5.
- The decision to resume anticoagulants should be made on a case-by-case basis, taking into account the individual patient's condition and medical history 3, 4.