Perioperative management in

patients with risk for thrombosis

Sabine Eichinger
Dept. of Medicine I
Medical University of Vienna, Austria
 Perioperative Management

Bleeding risk Thrombotic risk

Stop Bridging
antithrombotics
Atrial Fibrillation

Risk of cerebral infarction

CHADS2 Risk/year
Non surgical (%)
0 1.9 (1.2-3.0)

1 2.8 (2.0-3.8)

2 4.0 (3.1-5.1)

3 5.9 (4.6-7.3)

4 8.5 (6.3-11.1)

5 12.5 (8.2-17.5)

6 18.2 (10.5-27.4)

Kaatz, J Thromb Haemost 2010

Atrial Fibrillation

Risk of cerebral infarction

CHADS2 Risk/year 30 days
Non surgical (%) postoperative (%)
0 1.9 (1.2-3.0) 1.01 (0.83-1.21)

1 2.8 (2.0-3.8) 1.62 (1.46-1.79)

2 4.0 (3.1-5.1) 2.05 (1.87-2.24)

3 5.9 (4.6-7.3) 2.63 (2.26-3.04)

4 8.5 (6.3-11.1) 3.62 (2.66-4.80)

5 12.5 (8.2-17.5) 3.65 (1.83-6.45)

6 18.2 (10.5-27.4) 7.35 (2.42-16.3)

Kaatz, J Thromb Haemost 2010

Anticoagulation and perioperative management

Low bleeding risk

• Tooth extraction
• Root canal procedures
• Small skin excisions
• Endoscopic procedures with low bleeding risk
• Cataract surgery
• Minor bleeding: OR 3.3 (95% CI 1.7-6.2); Jamula, Thromb Res 2009
• Perioorbital bleeding and retrobulbar anesthesia: 1/136 (<1%)
Katz, Ophthalmology 2003

Dunn, Arch Intern Med 2003

Anticoagulation and perioperative management

High bleeding risk

• Intracranial or intraspinal surgery

• Coronary artery bypass
• Major vascular surgery
• Major orthopedic surgery
• Major cancer surgery
• Reconstructive plastic surgery
• Urogenital surgery
• Colonpolypectomie (particularly > 1 cm Ø)
• Prostate- or kidney biopsy
 Thromboembolic risk categories

Thromboembolic Atrial Mechanical Heart Venous

Risk Fibrillation Valves Thromboembolism

Mitral valve
Older aortic valve
High CHADS2 5,6 VTE < 3 mo
(caged-ball, tilting disk)
Stroke/TIA < 3 mo

Bileaflet aortic valve

Moderate CHADS2 3,4 VTE > 3-12 mo
+ risk factor

Bileaflet aortic valve

Low CHADS2 0-2 VTE > 12 mo
w/o risk factor

Douketis, Blood 2011

 Thromboembolic risk categories

Thromboembolic
Risk
Bridging

High
YES
Moderate

Low NO

Douketis, Blood 2011

 Bridging

Thromboembolic
Risk
Bridging

High LMWH therapeutic

LMWH therapeutic
Moderate
LMWH low dose

Low none

Douketis, Blood 2011

Anticoagulation and perioperative management

Practical advice

• Do not stop VKA too early

 Discontinuation of VKA
PREOPERATIVE MANAGEMENT

Stop Stop
warfarin THROMBOPROPHYLAXIS
acenocoumarol

NO VKA
Days -6 -5 -4 -3 -2 -1 0P

Check INR
if < 1.5: surgery possible

Check INR
if >2.0: 6-10 mg vit. K p.o.

Check INR
if >2.0 (>2.5): check daily
if <2.0 (<2.5): LMWH (except low thrombotic risk)
Anticoagulation and perioperative management

Practical advice

• Do not stop VKA too early

• Last therapeutic dose of LMWH 24 h before surgery
 Discontinuation of VKA
POSTOPERATIVE MANAGEMENT

THERAPEUTIC LMWH DOSE

PROPHYLACTIC

High/moderate STOP LMWH

THROMBOTIC RISK IF INR >2.0

RESUME VKA

DAYS 0P +1 +2 +3 +4 +5 +6

RESUME VKA

Low
THROMBOTIC RISK

STOP LMWH
USUAL THROMBOPROPHYLAXIS IF INR >2.0
Anticoagulation and perioperative management

Practical advice

• Do not stop VKA too early

• Last therapeutic dose of LMWH 24 h before surgery
• Resume therapeutic LMWH not before 48 h postop.
 Heparin bridging – bleeding risk

All patients Heart valves AFIB

N=224 N=112 N=112

Major bleeding 15 (6.7%) 8 (7.1%) 7 (6.3%)

intraoperative 8 (3.6%) 4 (3.6%) 4 (3.6%)

<7 T postop. 5 (2.2%) 4 (3.6%) 1 (0.9%)
Kovacs, Circulation 2004

Low High All patients

bleeding risk bleeding risk N=650
N=542 N=108

Major bleeding 0.74% 1.85% 0.92%

Douketis, Arch Intern Med 2004

 Bridging – bleeding risk

Group TE Events Major Bleeding Overall Bleeding

% (95% Cl) % (95% Cl) % (95% Cl)

Bridged cohort 0.9% (0.0-3.4) 4.2% (0.0-11.3) 13.1% (0.0-45.2)

LMWH dose
therapeutic 0.4% (0.0-0.9) 3.2% (1.3-5.2) 13.6% (2.9-24.3)
prophylactic/ 0.2% (0.0-0.6) 3.4% (0.0-8.7) 8.5% (2.9-14.2)
intermediate

Nonbridged cohort 0.6% (0.0-1.2) 0.9% (0.2-1.6) 3.4% (1.1-5.8)

Siegal, Circulation 2012

Clinically significant device-pocket hematoma

Birnie, N Engl J Med 2013

Anticoagulation and perioperative management

Practical advice

• Do not stop VKA too early

• Last therapeutic dose of LMWH 24 h before surgery
• Resume therapeutic LMWH not before 48 h postop.
• LMWH bridging preoperatively only in patients at
high thrombotic risk
Anticoagulation and perioperative management

Practical advice

• Do not stop VKA too early

• Last therapeutic dose of LMWH 24 h before surgery
• Resume therapeutic LMWH not before 48 h postop.
• LMWH bridging preoperatively only in patients at
high thrombotic risk
• VKA postoperative: start low - go slow
 Perioperative Management

D i r e c t or a l OP anticoagulants

Stop Start
DOAC and perioperative management

Low bleeding risk

• Do not stop DOAC

• Perform intervention at trough level
• OD dosing: halt morning dose until after intervention
• BID dosing: miss morning dose
 Low bleeding risk
Dabigatran, Apixaban
day - 3 day - 2 day - 1 day 0 day + 1 day + 2 day + 3

Rivaroxaban
day - 3 day - 2 day - 1 day 0 day + 1 day + 2 day + 3

P R E O P E R AT I VE P O S T O P E R AT I VE
Dabigatran – perioperative management

Elective surgery/interventions

Last intake before surgery

Renal function
Half life
(CrCl in ml/min)
High bleeding risk
Standard risk
or major surgery

≥ 80 ~ 13 h >48 h >24 h

≥ 50 to < 80 ~ 15 h >72 h >36 h

≥ 30 to < 50 ~ 18 h >96 h >48 h

EHRA guidelines, Heidbuchel, Eur Heart J 2013

Rivaroxaban, Apixaban – perioperative management

Elective surgery/interventions

Last intake before surgery

Renal function
(CrCl in ml/min)
High bleeding risk or
Standard risk
major surgery

≥ 80 >48 h >24 h

≥ 50 to < 80 >48 h >24 h

≥ 30 to < 50 >48 h >24 h

≥ 15 to < 30 >48 h >36 h

EHRA guidelines, Heidbuchel, Eur Heart J 2013

Rivaroxaban – perioperative management

High bleeding risk

day - 3 day - 2 day - 1 day 0 day + 1 day + 2 day + 3

PREOPERATIVE P O S T O P E R AT I VE
usual thromboprophylaxis
Direct oral anticoagulants

Restart after surgery

• Not licensed for postoperative thromboprophylaxis

except for elective hip/knee replacement.
• Immediate and complete hemostasis  resume DOAC
after 6-8 hours.
• Maximum concentration within 2-3 h.
• Start therapeutic dose not before 48-72 h postop.
• Use LMWH at prophylactic dose until safe to use
therapeutic dose.
RE-ly – dabigatran in atrial fibrillation

Periprocedural bleeding

100
D110
90 20
D150
80 Warfarin
15
70
60 10
% Cases

50
5
40
30 0
minor major reoperation transfusion

20
10
0
minor major reoperation transfusion

Healey, Circulation 2012

RE-ly – dabigatran in atrial fibrillation

Periprocedural thromboembolism

100
D110
90
D150
80 1
Warfarin
70 0,8

60
% Cases

0,6
50
0,4
40
0,2
30
20 0
CV death stroke
10
0
CV death stroke

Healey, Circulation 2012

Direct oral anticoagulants – perioperative management

Practical advice

• Prescribe DOAC exactly as licensed

• Check contraindications
• Dose according to indication an renal function
• check renal function and ensure proper diuresis
• Collect standardized bleeding and thrombotic history
• Lower dose in case of higher bleeding risk
• Use platelet function inhibitors together with DOAC with caution
• Avoid long acting NSARs
• No preoperative heparin bridging