Anticoagulation for IR Procedures
Based on 2019 SIR Consensus Guidelines. JVIR 2019; 1168-1184. The length of time anticoagulation is held may differ from these guidelines in certain clinical circumstances at the discretion of the proceduralist.
Generally, may resume anticoagulation 24 hours after the procedure. More details about re-initiation of anticoagulation can be found in the SIR guidelines.
Low risk procedures
- Screening coagulation laboratory tests: PT/INR, platelet count, Hgb not routinely needed
- Suggested laboratory thresholds for most pts
- INR: correct to <3.0
- Platelets: transfuse if <20,000
- Suggested laboratory thresholds in pts with chronic liver disease
- INR: n/a
- Platelets: transfuse if <20,000
- Fibrinogen: cryoprecipitate if <100
- List of low risk procedures
- Vascular
- Central venous catheter non-tunneled/tunneled line placement, removal and exchanges (e.g. port)
- Dialysis assess interventions (e.g. shuntograms)
- Gonadal vein embolization
- IVC filter placement and retrieval
- Laser ablation and phlebectomy
- Lymphangiogram
- Sclerotherapy for venous malformation
- Transjugular liver biopsy
- Venography and select venous interventions (e.g. adrenal vein sampling)
- Nonvascular
- Superficial abscess drainage
- Catheter exchanges (e.g. biliary, nephrostomy, abscess)
- FNA/superficial biopsy
- Gastrostomy and GJ exchanges
- Appendicular skeleton bone biopsy, joint injections, peripheral nerve blocks
- Thoracentesis
- Paracentesis
- Tunneled drainage catheter placement
- Vascular
Medication |
Action |
|---|---|
| Anticoagulants | |
| Warfarin (Coumadin) | Target INR <3.0. Withhold 5 days for MSK procedures only. Bridging per PCP/cardiology |
| Heparin (unfractionated) | Do not withhold |
| LMWH (therapeutic) | Do not withhold |
| LMWH (prophylactic) | Do not withhold |
| Rivaroxaban (Xarelto) | Do not withhold |
| Edoxaban (Savaysa) | Do not withhold |
| Fundaparinux (Arixtra) | Do not withhold |
| Apixaban (Eliquis) | Do not withhold |
| Argatroban | Do not withhold |
| Bivalirudin (Angiomax) | Do not withhold |
| Antiplatelets | |
| Aspirin (81 or 325 mg) | Do not withhold |
| Clopidogrel (Plavix) | Do not withhold |
| Prasugrel (Effient) | Do not withhold |
| Ticagrelor (Brilinta) | Do not withhold |
| Cangrelor (Kengreal) | Do not withhold |
| NSAIDs | |
Short-acting - Ibuprofen - Diclofenac - Ketoprofen - Indomethacin |
Do not withhold |
Intermediate-acting - Ibuprofen - Diclofenac - Ketoprofen - Indomethacin |
Do not withhold |
Long-acting - Meloxicam |
Do not withhold |
| Glycoprotein IIb/IIIa Inhibitors | |
Long-acting - Abciximab (ReoPro) |
Withhold 24 hours |
Short-acting - Eptifibatide (Integrilin) - Tirofiban (Aggrastat) |
Withhold 24 hours |
High risk procedures
- Screening coagulation laboratory tests: PT/INR, platelet count, Hgb
- Suggested laboratory thresholds for most pts
- INR: correct to <1.8 (<1.5 if neuro procedure)
- Platelets: transfuse if <50,000
- Suggested laboratory thresholds in pts with chronic liver disease
- INR: <2.5. (<1.5 if neuro procedure)
- Platelets: transfuse if <30,000
- Fibrinogen: cryoprecipitate if <100
- List of high risk procedures
- Vascular
- Angiography and arterial interventions (e.g. chemoembolization, renal embolization, uterine embolization)
- BRTO/BATO
- Catheter directed thrombolysis (e.g. DVT, PE, portal vein)
- Complex IVC filter removal
- Lymphangiogram with thoracic duct embolization
- Portal vein interventions
- Pulmonary artery malformation embolization
- Transjugular intrahepatic portosystemic shunt (TIPS)
- Nonvascular
- Ablations (e.g. cryoablation, microwave ablation, radiofrequency ablation)
- Deep abscess drainage
- Biliary interventions (new placement e.g. cholecystostomy)
- Deep non-organ biopsy (e.g. retroperitoneal, pelvic, intra-abdominal)
- New Gastrostomy and GJ tube placement
- Axial skeleton biopsy, bone marrow biopsy
- Neuro: epidural injection, facet block, LP, myelogram, vertebral biopsy
- Solid organ biopsy (e.g. liver, kidney, lung) - Spine procedures
- Urinary tract interventions (nephrostomy tube placement, ureteral dilation)
- Vascular
Medication |
Action |
|---|---|
| Anticoagulants | |
| Warfarin (Coumadin) | Withhold 5 days, goal INR <1.8. Bridging per PCP/cardiology |
| Heparin (unfractionated) | Withhold IV for 4 hours Withhold SQ for 6 hours |
| LMWH (therapeutic) | Withhold for 24 hours |
| LMWH (prophylactic) | Withhold for 12 hours |
| Rivaroxaban (Xarelto) | Withhold: 2 days (CrCl>30) 3 days (CrCl<30) |
| Edoxaban (Savaysa) | Withhold 2 days |
| Fundaparinux (Arixtra) | Withhold: 2 days (CrCl>50) 3 days (CrCl<50) |
| Apixaban (Eliquis) | Withhold: 2 days (CrCl>50) 3 days (CrCl<50) |
| Bivalirudin (Angiomax) | Withhold for 2 hours |
| Dabigatran (Pradaxa) | Withhold: 2 days (CrCl>50) 3 days (CrCl<50) |
| Antiplatelets | |
| Aspirin (81 or 325 mg) | 81mg: Do not withhold 325mg: Withhold 5 days unless angiography or neuro procedure |
| Clopidogrel (Plavix) | Withhold 5 days unless angiography/embolization |
| Prasugrel (Effient) | Withhold 7 days |
| Ticagrelor (Brilinta) | Withhold 5 days |
| Cangrelor (Kengreal) | Avoid; if emergent withhold 1 hour |
| NSAIDs | |
Short-acting - Ibuprofen - Diclofenac - Ketoprofen - Indomethacin |
No recommendation |
Intermediate-acting - Ibuprofen - Diclofenac - Ketoprofen - Indomethacin |
No recommendation |
Long-acting - Meloxicam |
No recommendation |
| Glycoprotein IIb/IIIa Inhibitors | |
Long-acting - Abciximab (ReoPro) |
Withhold 24 hours |
Short-acting - Eptifibatide (Integrilin) - Tirofiban (Aggrastat) |
Withhold 4 hours |