Table of contents

Periprocedural management of antithrombotic therapy


Key sources

The following summarized guidelines for the evaluation and management of periprocedural management of antithrombotic therapy are prepared by our editorial team based on guidelines from the American College of Chest Physicians (ACCP 2022), the American College of Gastroenterology (ACG/CAG 2022), the European Society of Gastrointestinal Endoscopy (ESGE/BSG 2021), the American Heart Association (AHA/HRS/ACC 2019), the Society of Interventional Radiology (SIR ...
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Diagnostic investigations

Coagulation tests
As per SIR 2019 guidelines:
Do not obtain screening coagulation laboratory testing in patients with minimal risk factors for bleeding undergoing procedures carrying low risk for bleeding. Consider obtaining coagulation testing in patients receiving warfarin or UFH or in patients with an inherently higher risk of bleeding. Correct INR to within the range of ≤ 2.0-3.0 and consider administering platelet transfusion if the platelet count is < 20×10⁹/L. Correct INR to < 1.8 for femoral access and < 2.2 for radial access in patients undergoing low bleeding risk procedures requiring arterial access.
Obtain appropriate preprocedural coagulation testing in patients undergoing procedures with high bleeding risk. Correct INR to within the range of ≤ 1.5-1.8 and consider administering platelet transfusion if the platelet count is < 50×10⁹/L.
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Perioperative care

General principles: as per SIR 2019 guidelines, ensure a multidisciplinary, shared decision-making approach for planning periprocedural management in patients at high risk for thromboembolic or bleeding events. Involve specialists in cardiology, hematology, or vascular or internal medicine in order to provide optimal periprocedural medical management in high-risk patients.

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  • Patients on VKAs (elective surgeries/procedures)

  • Patients on VKAs (minor procedures)

  • Patients on heparins

  • Patients on DOACs

  • Patients on antiplatelets

Specific circumstances

Patients with chronic liver disease
As per SIR 2019 guidelines:
Administer plasma and platelet transfusion in patients with chronic liver disease judiciously because of rebalanced hemostasis and given the potential for increased portal pressure and transfusion-related adverse events.
Consider adjusting the INR and platelet count thresholds in patients with chronic liver disease undergoing invasive procedures to higher and lower, respectively, than in the general population to minimize unnecessary transfusions. Consider measuring the fibrinogen level and administering cryoprecipitate for replacement if the level is low.

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  • Patients with AF (preprocedural interruption)

  • Patients with AF (preprocedural bridging)

  • Patients with AF (postprocedural resumption)

Patient education

General counseling
As per BSG/ESGE 2021 guidelines:
Counsel all patients on antiplatelets or anticoagulants about the increased risk of postprocedural hemorrhage.
Counsel all patients on the thrombotic risks of discontinuing antiplatelets or anticoagulants, as well as the hemorrhagic risks of continuing therapy.