Anticoagulation and Antiplatelet Medications during High-Risk Procedures
E.g.
Ablations of bones, lung, soft tissue, solid organs
Abscess drainage of deep structures like lung, abdomen, pelvis, retroperitoneum
Angiograms needing > 7 F sheath
Angiograms needing interventions like stenting of aorta, CNS, extremity arteries, mesenteric arteries
Biliary interventions
Biopsy of intraabdominal, lung, pelvis, retroperitoneum, solid organs (liver, kidney etc), spine lesions
Catheter-directed thrombolysis
Cholecystostomy
Gastrostomy/Gastrojejunostomy
IVC filter removal – Complex
Portal vein interventions
Spine procedures – cervical facet injection, epidural injections, lumbar punctures, vertebroplasty
Transjugular intrahepatic portosystemic shunt
Urinary tract interventions – Nephrostomy, Ureteral dilatation, stone removal
Venous interventions needing venoplasty, stent placement
INR: Routinely recommended. Correct to ≤ 1.5
Platelets: Routinely recommended. Transfuse Platelets if ≤ 50000/µL
For patients with Chronic liver disease: INR < 2.5, Platelet count > 30, Fibrinogen > 100
For INR > 2.5 give 10 mg slow IV infusion of Vitamin K
For Platelet count < 30 and in patients with large spleen administer a dose of platelets
For Fibrinogen < 100 administer 1 dose (body weight < 80 kg) or 2 doses (body weight > 80 kg) of Cryoprecipitate.
| MEDICATION | INTERVAL B/N LAST DOSE & PROCEDURE | RESUMPTION AFTER PROCEDURE | REVERSAL AGENT |
|---|---|---|---|
| Abciximab (Reopro) | 24 h | 48 h (D/w cardiology) | Platelet transfusion |
| Acetylsalicylic acid (ASA) low dose | None | Immediate | Desmopressin acetate (DDAVP) |
| Acetylsalicylic acid (ASA) high dose | 5 d | 24 h | Desmopressin acetate (DDAVP) |
| Aspirin/Dipyridamole(Aggrenox) | 5 d | 24 h | |
| Apixaban (Eliquis) | 4 doses. 6 doses if CrCl < 50 mL/min. For emergent cases uses reversal agent | 24 h | Andexanet alfa |
| Argatroban(Acova) | 4 h | 4-6 h | None |
| Betrixaban(Bevyxxa) | 3 doses. For emergent cases use reversal agent | 24 h | Andexanet alfa |
| Bivaluridin (Angiomax) | 4 h | 4-6 h | None |
| Cangrelor(Kengreal) | Defer until off medications. For emergent cases – 1 h | D/w Cardiology | |
| Cilostazol (Pletal) | None | NA | Desmopressin |
| Clopidogrel (Plavix) | 5 d | 6 h (24 h if using a loading dose) | None |
| Dabigatran (Pradaxa) | 4 doses (6-8 doses for CrCl < 50 mL/min) For emergent cases use reversal agent | 48 h | Idarucizumab (praxbind) |
| Desirudin (Iprivask) | 4 h | 1 h | None |
| Edoxaban(Savaysa) | 2 doses. For emergent cases use reversal agent | 24 h | Andexanet alfa |
| Eptifibatide (Integrilin) | 8 h | 24 h (D/w Cardiology) | Desmopressin |
| Fondaparinux | 48h (72 h for renal failure patients) | 24 h | None |
| LMW Heparin Enoxaparin (Lovenox) (SQ) | 12 h – 1 dose for prophylactic 24 h – 2 dose for therapeutic | 12 h | None. Protamine partial temporary reversal |
| LMW Heparin Dalteparin (Fragmin) | Hold am of procedure | 4 h | Protamine incomplete antagonist |
| LMW Heparin Tinzaparin (Innohep) | Hold am of procedure | 4 h | Protamine incomplete antagonist |
| Prasugrel (Effient) | 7 d | 24 h | None |
| Rivaroxaban (Xarelto) | 2 doses (3 doses for CrCl < 30 mL/min) For emergent cases use reversal agent | 24 h | Andexanet alfa |
| NSAIDs | None | Immediate | None |
| Ticagrelor (Brilanta) | 5 d | 24 h | None |
| Tirofiban(Aggrastat) | 8 h | D/w Cardiology | |
| Unfractionated heparin (IV) | 4-6 h | 6-8 h | Protamine |
| Unfractionated heparin (SQ) | 4-6 h | 6-8 h | Protamine |
| Warfarin(Coumadin) | 5 d until INR<=1.8. Consider bridging for high thrombosis risk. | 24 h High thrombosis risk cases benefit from bridging if reversal agent used. | Vitamin K, Fresh frozen plasma, Prothrombin complex concentrate |