Therapeutic Dilemma in Epidural Catheter Removal During Dual Antiplatelet Therapy and Anticoagulation Following Hepatic Artery Injury: A Case Report.

Epidural catheter removal in the setting of concurrent dual antiplatelet therapy (DAPT) and anticoagulation poses a high risk of neuraxial hematoma. Current guidelines mandate prolonged interruption of antithrombotic therapy, which may be unfeasible in patients with recently implanted arterial stents at high risk of thrombosis. We present the case of a 56-year-old man who underwent combined epidural and general anesthesia for a partial hepatectomy. An inadvertent intraoperative injury to the proper hepatic artery required aborting the surgery and deployment of a rescue drug-eluting stent. Intravenous unfractionated heparin and DAPT (aspirin and clopidogrel) were initiated. On postoperative day 7, inflammatory signs at the epidural catheter site made its removal urgent. However, interrupting clopidogrel for the guideline-recommended five to seven days posed an unacceptable risk of acute thrombosis of the newly deployed hepatic artery stent. To navigate this conflict between preventing neuraxial hematoma and acute hepatic ischemia, a multidisciplinary team reached a consensus to implement an unorthodox 24-hour therapeutic window off antithrombotics. The catheter was removed uneventfully at the end of this period; antiplatelet therapy and enoxaparin were restarted at two and six hours, respectively. No neurological deficits occurred. This case illustrates that, in scenarios of competing high-risk priorities, strict adherence to standardized recommendations may not be feasible. An individualized strategy based on multidisciplinary consensus, careful timing of antithrombotic interruption and reintroduction, and close neurological monitoring was successfully implemented without complications in this patient. However, given the limitations of a single case report, this individualized salvage strategy should not be generalized and requires further clinical evidence.