Anticoagulation for heparin-induced thrombocytopenia before, during, and after peripheral endovascular procedures

Acute heparin-induced thrombocytopenia (HIT) type II requires the immediate discontinuation of heparin and initiation of a non-heparin anticoagulant. Lifelong avoidance of heparin is generally recommended due to the risk of recurrence. Therefore, anticoagulation management in endovascular procedures remains challenging, as heparin is the preferred anticoagulant and evidence on alternative strategies is limited. This narrative review outlines an institutional approach aligned with current guidelines and examines the available data on non-heparin anticoagulants in this setting. Current evidence may support the use of bivalirudin among non-heparin anticoagulants for peripheral endovascular interventions due to indirect evidence of its use during percutaneous coronary intervention in patients with acute HIT. However, bivalirudin is often not available due to drug shortage and not approved for HIT in Europe. This leaves argatroban as the main alternative, particularly in patients with renal impairment. Data on non-heparin anticoagulation for HIT were extrapolated from other types of intervention and from small retrospective studies. In selected cases of patients with remote or subacute HIT B and negative antibodies, intraoperative heparin may be considered if alternative anticoagulants are not practical, particularly in emergency situations, even in this approach is controversial and not discussed in current guidelines regarding peripheral endovascular procedures. In the absence of robust evidence, anticoagulation strategies should be individualized and patients adequately informed. Further studies are necessary to optimize anticoagulant management among patients with HIT undergoing peripheral endovascular interventions.