Anticoagulation and invasive procedures

One of the classical dilemmas in patients on anticoagulation is how to manage anticoagulant therapy if the patient requires an invasive procedure or elective surgery. Concerns in these situations revolve around the potential difficulty in achieving haemostasis, the concern of excessive bleeding at the time of the surgery or post-operatively, and the risk of thromboembolism. Regardless of the indication for the anticoagulation, patients taking anticoagulant medicines require careful perioperative observation and planning to avoid such complications.

Perioperative management of warfarin

The perioperative steps that are taken in the case of patients on vitamin K antagonist (VKA) treatment can be complex, demanding and time consuming. The latest guidelines by the American College of Chest Physicians (ACCP 2012 guidelines) summarise recommendations on perioperative management with VKA’s, based on the patient’s risk for thromboembolism, as follows¹ (Figure 1):

• VKA should be stopped 5 days prior to surgery^*
• VKA may be resumed 12 to 24 hours after surgery, when adequate haemostasis has been achieved

• ‘Bridging’ therapy:
  • In patients with mechanical heart valves, atrial fibrillation (AF) or venous thromboembolism (VTE) who are at a high risk for thromboembolism → bridging therapy with intravenous unfractionated heparin (UFH) or subcutaneous low molecular weight heparin (LMWH)
  • If the patient is receiving UFH as bridging therapy, this should be stopped 4-6 hours before surgery

• If the patient is receiving LMWH as bridging therapy, the last dose should be administered approximately 24 hours before surgery
• If the patient is receiving LMWH as bridging therapy and undergoing high-bleeding-risk surgery, LMWH should be resumed 48-72 hours after surgery

• Patients with mechanical heart valves, AF or VTE at moderate risk for thromboembolism should be considered candidates for bridging therapy based on individual risk and the nature of the surgery or intervention

• Patients with mechanical heart valves, AF or VTE at a low risk for thromboembolism need not receive bridging therapy
• Patients on VKA who require a dental procedure should continue VKA in combination with an oral prohaemostatic agent, or VKA should be stopped 2-3 days prior to the dental procedure

Perioperative management of Xarelto^®2

As with all patients on anticoagulation treatment who require surgery, a patient on Xarelto^® (rivaroxaban) requiring a surgical or invasive procedure should be clinically assessed and the importance and urgency of the procedure should be considered. If the procedure cannot be delayed, the risk of bleeding should be weighed against the urgency of the procedure. In the case of elective surgery, Xarelto^® should be discontinued at least 24 hours before the procedure. Xarelto^® should be restarted after the procedure, once

adequate haemostasis has been achieved (Figure 2). In case of uncomplicated surgery with good hemostasis early after the procedure this should normally be feasible within 6-8 hours after surgery. In case of major surgery with incomplete hemostasis, bleeding risk outweighs the risk of thromboembolic events in the early post-operative period and therapy may only be restarted once there is no drainage or other evidence of active bleeding. The management of Xarelto^® perioperatively is quite obviously much simpler than that of VKA.