Duke IR guidelines for management of preprocedural labs, anticoagulant, and antiplatelet medications for patients undergoing IR procedures.
Note: These guidelines, based on the 2019 Society of Interventional Radiology consensus guidelines, have been reviewed and approved by all Duke IR attending physicians, but final decision is at the discretion of the attending physician or APP responsible for the case, as patient circumstances and procedural details can result in varying risk. For urgent circumstances, benefit of proceeding may outweigh risks of bleeding – furthermore, reversal agents may be available. For full details, please refer to the source document, available at http://sites.duke.edu/dukeir
Procedural Bleeding Risk Categorization
| Low bleeding risk | High bleeding risk |
| Central lines (including ports) | Organ ablations |
| Venous ablations | Arterial interventions: > 7-F sheath (rare) |
| IVC filter placement and simple removal (i.e. not laser) | PBD/cholecystostomy insertions |
| Catheter exchanges (G/GJ tubes, PBD, PCN, permcath) | PCN (new insertions) |
| Arteriograms (if sheath <6F)(nearly all of our procedures) | Solid organ and deep biopsies (including transcaval) |
| AV fistula/ graft interventions | GJ-tube/GJ tube/J-tube insertion |
| Transjugular liver biopsy | IVC filter removal complex |
| Tunneled ascites drainage catheter | Portal vein interventions |
| Paracentesis | Kyphoplasty/vertebroplasty |
| Superficial biopsy or abscess drainage | TIPS |
| Venous malformations | Arteriovenous malformations |
| Catheter directed thrombolysis | |
| Lymphangiography |
Preprocedural Laboratory values
| Low bleeding risk | High bleeding risk | |
| CBC | Do not obtain routinely. If known platelets under 20, transfuse platelets | Obtain CBC, transfuse if platelets <50 |
| INR | Obtain only if on Coumadin therapy. Do not obtain routinely. If INR >3.0, consider hold for 5 days or transfuse FFP (depending on risk) | Obtain INR, transfuse if > 1.8 |
| Cirrhosis | Same as above | Check CBC, transfuse if platelets < 30; Check INR, transfuse if >2.5; Consider checking fibrinogen, transfuse cryoprecipitate if <100 |
Management of anticoagulation and antiplatelet medications
Low risk procedures: If on warfarin, withhold for 2-5 days if INR >3.0. For all other listed medications below, do not withhold.
High risk procedures: instructions as follows
| Heparin | Withhold 4 hrs prior, reinitiate after 8 hrs |
| Argatroban (Acova) | Withhold 2 hrs. Reinitiate after 4 hrs |
| Bivalirudin (Angiomax) | Withhold 2 hrs. Reinitiate after 4 hrs |
| Enoxaparin (Lovenox) | Proph dosing (usually 40mg or less): withhold 12 hours (1 dose). Therapeutic dosing (usually >50mg): withhold 24hrs. Reinitiate after 12 hrs |
| Warfarin (Coumadin) | Withhold 5d or until INR<= 1.8. Reinitiate day after. |
| Apixiban (Eliquis) | Withhold 4 doses (48 hours) if normal renal function, 6 doses (72 hours) if renal insuff*. Reinitiate after 24 hrs |
| Rivaroxaban (Xarelto) | Withhold 2 doses (usually 48 hours), 3 doses (usually 72 hours) if renal failure. Reinitiate after 24 hrs |
| Clopidogrel (Plavix) | Withhold 5 days. Reinitiate after 6 hrs. |
| Aspirin (full dose)
Baby aspirin (81mg) |
Withhold 3 days. Reinitiate next day
Do not withhold |
| deltaparin (Fragmin) | Withhold 1 dose. Reinitiate after 12 hrs |
| Fondaparinux (Arixtra) | Withhold 3 days, 4d if renal insuff. Reinitiate after 24 hrs |
| Betrixaban (Bevyxxa) | Withhold 3 doses. Reinitiate after 24 hrs |
| Dabigatran (Pradaxa) | Withhold 4 doses, 6 doses if renal insuff. Reinitiate after 24 hrs |
| Edoxaban (Savaysa) | Withhold 2 doses. Reinitiate after 24 hrs. |
| Ticagrelor (Brilinta) | Withhold 5 days. Reinitiate next day |
| Prasugrel (Effient) | Withhold 7 days. Reinitiate next day. |
| Aspirin/dipyridamole (Aggrenox) | Withhold 4 days. Reinitiate next day |
| Cilostazol (Pletal) | Do not withhold |
| NSAIDS: ibuprofen, diclofenac, ketoprofen, indomethacin, ketorolac, naproxen, sulindac, diflunisal, celecoxib, meloxicam, nabumetone, piroxicam: Do not withhold | |
Special cardiology medications – high risk procedures
| Abciximab (ReoPro) | Withholding: Hold 24 hrs. ACT < 170s prior to removing arterial sheath; Reinitiation: Discuss with cardiology |
| Eptifibatide (Intregrilin), tirofiban (Aggrastat) | Withholding: Hold 4 hrs. ACT < 150s prior to removing arterial sheath; Reinitiation: Discuss with cardiology |
| Cangrelor (Kengreal) | Withholding: Try to wait until off this medication or hold at least 1hr if emergency; Reinitiation: Discuss with cardiology |
* Patient has renal insufficiency if mentioned in medical history, or if Cr ≥ 2.0. Renal failure if mentioned in medical history or Cr≥ 4.0.
SOURCE DOCUMENT: SIR thrombotic and bleeding recs part 2 JVIR 2019 Patel
