Long-term antithrombotic therapy practices in adult patients with short bowel syndrome following acute mesenteric ischemia: An international case-based survey

Abstract

Background & aims: Long-term antithrombotic therapy is recommended for short bowel syndrome (SBS) after acute mesenteric ischemia (AMI). However, targeted recommendations on drug selection, dosing, duration and monitoring, are lacking. Current recommendations rely on data from other arterial diseases, often overlooking SBS-related drug absorption issues. To understand current practices, this survey aimed to assess the long-term antithrombotic therapy practices in AMI.

Methods: An e-survey was disseminated to HAN-CIF (Home Artificial Nutrition - Chronic Intestinal Failure) database centers of ESPEN (European Society on Clinical nutrition and Metabolism) and coagulation specialists. It included ten cases with varying postsurgical intestinal anatomy, revascularisation and aetiology. Questions focused on drug class choice, administration route, dosing, duration and monitoring of antithrombotic therapy.

Results: For patients with AMI of unknown aetiology, but with hypercholesterolaemia and smoking status, intestinal failure (IF) teams preferred anticoagulants (55.8-65.1 %) over antiplatelet therapy (27.9-37.2 %), while coagulation specialists favoured antiplatelet therapy (57.1 %). IF teams selected antiplatelet therapy more often in patients with type 3 anatomy (largest absorptive capacity). They favoured parenteral agents for patients with end-jejunostomy or duodenocolic anastomosis (51.2 % and 55.8 % respectively; lowest absorptive capacity), oral agents for those without IF (69.8 %; highest absorptive capacity), and both for patients with a jejunocolic anastomosis (48.8 % oral, 44.2 % parenteral; moderate absorptive capacity). Coagulation specialists consistently preferred oral therapy. Lifelong antiplatelet therapy was preferred by IF teams (71.4-100.0 %), while anticoagulants were prescribed either temporarily (16.7-59.1 %) or lifelong (40.9-83.3 %). Standard doses were used for all drug classes, irrespective of anatomy, revascularisation or comorbidities. Monitoring varied: IF teams monitored subcutaneous low molecular weight heparins and non-vitamin K oral anticoagulants (DOACs), whereas coagulation specialists only monitored DOACs. Both specialists commonly performed a 24-h Holter, transthoracic and transoesophageal echocardiograms for arterial mesenteric ischaemia (MI) and requested thrombophilia parameters more for venous MI, with antiphospholipid antibodies checked for both MI subtypes.

Conclusion: We observed significant variation in long-term antithrombotic management in post-AMI SBS patients, with differing approaches between IF and coagulation specialists. A multidisciplinary position statement is necessary to standardise care.

Keywords: Acute mesenteric ischemia; Anticoagulants; Antithrombotic therapy; Platelet aggregation inhibitors; Short bowel syndrome.