Hematology and Coagulation | Periprocedural Management with Antithrombotic Therapy - Adult - Inpatient/Ambulatory
Periprocedural Management of Antithrombotic Therapy- Adults-
Inpatient/Ambulatory Consensus Care Guideline Summary
Target Population: Adults with indication(s) for antithrombotic medications who require antithrombotic therapy to be held for a
planned surgical procedure.
Full Guideline: https://uconnect.wisc.edu/clinical/cckm-tools/content/cpg/hematology-and-coagulation/related/name-148493-
en.cckm
Guideline Overview
• Periprocedural interruption or continuation of long-term antithrombotic therapy requires a patient-specific assessment of
thromboembolic and bleeding risks
o Step 1. Identify the bleeding risk of the procedure
o Step 2. Identify the usual recommendation for stopping the antithrombotic prior to the procedure
o Step 3. Identify the usual recommendation for restarting the antithrombotic after the procedure
o Step 4. Determine if bridging therapy is usually recommended
o Step 5. Individualize recommendations
o Step 6. Communicate and document plan
o Step 7. Revisit the plan after the procedure and revise as necessary
Table 1. Surgical Procedure Bleeding Risk Categories
For procedures with
minimal bleed risk, may
continue antithrombotic
therapy uninterrupted;
See Step #2
for more details
Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions
Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: CCKM@uwhealth.org Last Revised: 08/2023
Table 2. Stopping Antithrombotics Prior to Surgical Procedures
1 day = all doses on the calendar day prior to the procedure
24 hours = any dose within 24 hours from the time of the procedure
Oral Anticoagulant Patient-Specific
Criteria
Low/ Moderate Bleed Risk
Procedure
High Bleed Risk Procedure Neuraxial Anesthesia6
Warfarin4 INR 2.0-3.5
Stop 5 days prior
Stop 5 or more days prior;
check INR 1-2 days prior; if INR
> 1.5, consider 1 to 2 mg oral
vitamin K INR > 3.5
Stop 6 or more days prior
Apixaban (Eliquis)4 Stop 1 day prior Stop 2 days prior Stop 72 hours prior
Dabigatran (Pradaxa)4 CrCl ≥ 80 ml/min
Stop 1 day prior Stop 2 days prior
Stop 72 hours prior*
CrCl 50-79 ml/min Stop 96 hours prior*
CrCl < 50 ml/min Stop 2 days prior Stop 4 days prior Stop 120 hours prior
Edoxaban (Savaysa)4 Stop 1 day prior Stop 2 days prior Stop 72 hours prior
Rivaroxaban (Xarelto)4 Stop 1 day prior Stop 2 days prior Stop 72 hours prior
Parenteral Anticoagulant Patient-Specific
Criteria
Low/Moderate Bleed Risk
Procedure
High Bleed Risk Procedure Neuraxial Anesthesia6
Argatroban¥ Normal liver function Stop 3 hours prior Stop 5 hours prior Neuraxial anesthesia is not
recommended
Child-Pugh > 6 Stop 9 hours prior Stop 15 hours prior
Bivalirudin¥ CrCl ≥ 30 ml/min Stop 1.5 hours prior Stop 2.5 hours prior
CrCl < 30 ml/min Stop 3 hours prior Stop 5 hours prior
Enoxaparin (Lovenox)4 Prophylactic Dose Stop 12 hours prior¥ Stop ≥ 12 hours prior
Therapeutic Dose Stop 24 hours prior Stop ≥ 24 hours prior
Fondaparinux (Arixtra)¥ CrCl ≥ 50 ml/min Stop 3 days prior Stop 4 days prior See ASRA Guidelines for details
CrCl < 50 ml/min Stop 5 days prior Stop 6 days prior
Unfractionated heparin
(UFH)4
5000 units BID/TID Stop at least 4 hours prior¥ Stop 4 to 6 hours prior
UFH infusion Stop at least 4 hours prior Stop 4 to 6 hours prior
Antiplatelet Agent Patient-Specific
Criteria
Low/Moderate Bleed Risk
Procedure
High Bleed Risk Procedure Neuraxial Anesthesia6
Aspirin (ASA)4 Continue ASA uninterrupted
(If ASA interruption is required, stop ASA 7 days prior**)
ASA may be continued
Cangrelor¥ Stop 1 to 3 hours prior Stop 3 hours prior
Cilostazol (Pletal)¥ Stop 1 to 2 days prior Stop 2 days prior
Clopidogrel (Plavix)4 Stop 5 days prior** Stop 5 to 7 days prior
Prasugrel4 Stop 7 days prior** Stop 7 to 10 days prior
Ticagrelor4 Stop 3 to 5 days prior** Stop 5 to 7 days prior
* For patients with additional risk factors for bleeding (e.g., age > 65 years, hypertension, concurrent antiplatelet medication), consider holding dabigatran 120 hours
prior to procedure
**For patients taking dual antiplatelet therapy (DAPT) with stents in place, ANY interruption in antiplatelets should be coordinated with surgeon, anesthesiologist, the
prescribing provider (e.g., cardiologist, neurosurgeon, vascular surgeon); elective noncardiac surgery should be delayed at least 30 days after bare metal stent and at
least 6 months after drug-eluting stent
¥ UW Health-specific recommendation based on institutional standards and/or opinion of guideline workgroup members
Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions
Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: CCKM@uwhealth.org Last Revised: 08/2023
Table 3. Restarting Antithrombotics After Surgical Procedures
Oral Anticoagulant Patient-Specific
Criteria
Low or Moderate Bleed Risk
Procedure
High Bleed Risk Procedure Neuraxial Anesthesia6
Warfarin4 Restart within 24 hours post-op Remove neuraxial catheter
when INR < 1.5
Apixaban (Eliquis)4
Restart at least 24 hours post-
op
Restart 48 to 72 hours post-op
Restart at least 6 hours after
catheter removal
Dabigatran (Pradaxa)4
Edoxaban (Savaysa)4
Rivaroxaban (Xarelto)4
Parenteral Anticoagulant Patient-Specific
Criteria
Low or Moderate Bleed Risk
Procedure
High Bleed Risk Procedure Neuraxial Anesthesia6
Argatroban¥ Restart at least 24 hours post-
op
Restart 48 to 72 hours post-op Neuraxial anesthesia not
recommended
Bivalirudin¥ Restart at least 24 hours post-
op
Restart 48 to 72 hours post-op
Enoxaparin (Lovenox)4 Prophylactic Dose
(once daily)
Restart at least 12 hours post-
op¥
Restart at least 24 hours post-
op¥
Restart once-daily
prophylactic LMWH at least
12 hours after neuraxial
catheter placement and at
least 4 hours after catheter
removal¥
Prophylactic Dose
(twice daily)
Restart at least 12 hours post-
op¥
Restart at least 24 hours post-
op¥
Restart twice-daily
prophylactic LMWH no sooner
than the day after the
procedure, at least 4 hours
after catheter was removed
Therapeutic Dose Restart at least 24 hours post-
op
Restart 48 to 72 hours post-op Restart at least 4 hours after
neuraxial catheter was
removed, and at least 24
hours after catheter was
placed
Fondaparinux (Arixtra)¥ Restart at least 24 hours post-
op
Restart 48 to 72 hours post-op Restart at least 6 hours after
catheter removal
Unfractionated heparin
(UFH)4
5000 units BID/TID Restart at least 12 hours post-
op¥
Restart at least 24 hours post-
op¥
OK to use with indwelling
neuraxial catheter; remove
indwelling neuraxial catheters
4 to 6 hours after last heparin
dose; restart at least 1 hour
after catheter removal
UFH infusion Restart at least 24 hours post-op; when therapeutic dose UFH is
used for bridging therapy, omit bolus dose and start with a
lower intensity infusion4
Delay restarting UFH at least 1
hour after needle placement;
remove indwelling neuraxial
catheters 4 to 6 hours after
last UFH dose; restart at least
1 hour after catheter removal
Antiplatelet Medication Patient-Specific
Criteria
Low or Moderate Bleed Risk
Procedure
High Bleed Risk Procedure Neuraxial Anesthesia6
Aspirin4 Restart within 24 hours post-op Restart 24 hours post-op;
neuraxial catheter may be
maintained and removed
without regard to ASA
Cangrelor4 Restart within 4 to 6 hours post-op, continue for a minimum of
48 hours and maximum of 7 days total
Restart at least 8 hours after
catheter removal
Cilostazol (Pletal)¥ Restart within 24 hours post-op Restart at least 6 hours after
catheter removal
Clopidogrel (Plavix)4 Restart within 24 hours post-op Restart 24 hours post-op,
neuraxial catheter may be
maintained for 1 to 2 days
provided no loading dose is
given; if loading dose is
planned, wait at least 6 hours
after catheter removal
Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions
Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: CCKM@uwhealth.org Last Revised: 08/2023
Prasugrel4 Restart within 24 hours post-op Restart 24 hours post-op,
after neuraxial catheter has
been removed (if a loading
dose is planned, wait at least
6 hours after catheter
removal)
Ticagrelor4 Restart within 24 hours post-op Restart 24 hours post-op,
after neuraxial catheter has
been removed (if a loading
dose is planned, wait at least
6 hours after catheter
removal)
¥ UW Health-specific recommendation, based on institutional standards and/or expert opinion of guideline workgroup members
Figure 1. Is Bridging Therapy Usually Recommended?
Warfarin DOAC
• Apixaban
• Dabigatran
• Edoxaban
• Rivaroxaban
Parenteral Anticoagulant
• Argatroban
• Bivalirudin
• Enoxaparin
• Fondaparinux
• Unfractionated heparin
Antiplatelet Medication
• Aspirin
• Clopidogrel
• Dipyridamole
• Prasugrel
• Ticagrelor
Bridging is NOT
recommended
What is the TE
risk of the patient s
indication?
Which type of
antithrombotic is the
patient taking?
Bridging is NOT recommended,
but may be considered on a case-by-case
basis for select high-risk individuals with
coronary stents in a critical location,
placed within the past 3 months when
surgical procedure cannot be delayed
See Appendix B
Bridging is NOT
recommended for low and
moderate TE risk indications
Bridging therapy is
recommended for high TE
risk indications
See Appendix A
Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions
Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: CCKM@uwhealth.org Last Revised: 08/2023
References:
Effective 8/17/2023. Contact CCKM@uwhealth.org for previous versions
Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: CCKM@uwhealth.org Last Revised: 08/2023