Safety of Percutaneous Dilatational Tracheostomy Under Uninterrupted Therapeutic Anticoagulation

Background: Percutaneous dilatational tracheostomy (PDT) is increasingly performed without interrupting therapeutic anticoagulation in critically ill patients with extracorporeal membrane oxygenation (ECMO) or ventricular assist devices (VADs). However, the safety of PDT performed under ongoing therapeutic anticoagulation, particularly regarding periprocedural bleeding risk, remains uncertain. This study compared periprocedural bleeding complications between patients undergoing PDT under therapeutic and prophylactic anticoagulation. Methods: This observational cohort study in a cardiovascular ICU included all patients who underwent PDT between 2016 and 2024. The cohort comprised critically ill patients receiving uninterrupted therapeutic anticoagulation for ECMO, VAD, MVs (mechanical heart valves), and arrhythmia, as well as patients receiving low-dose anticoagulation for venous thromboprophylaxis. The primary endpoint was any severe procedure-related or late bleeding complication, while secondary endpoints included all minor procedure-related or late bleeding complications. Results: The cohort included 174 patients of whom 84 (48.3%) underwent PDT receiving uninterrupted therapeutic anticoagulation for ECMO, VAD, MVs, or arrhythmia. None experienced severe procedure-related bleeding. The incidence of major and minor bleeding complications did not differ between patients receiving uninterrupted therapeutic anticoagulation and those undergoing PDT under low-dose prophylactic anticoagulation. Other bleeding complications were also rare and comparable between the two groups. Conclusions: In this cohort, the incidence of severe and minor bleeding was low among patients undergoing PDT under uninterrupted therapeutic anticoagulation for ECMO, VAD, MVs, or arrhythmia and did not differ from that in patients receiving low-dose anticoagulation for venous thromboprophylaxis. BMI, but not anticoagulation intensity, was independently associated with post-PDT bleeding.