Periprocedural Bleeding Risk for Thrombocytopenia, Coagulopathy, Antiplatelets and Anticoagulation

by Joseph Esherick, M.D., FAAFP, FHM

This blog summarizes the 2019 Society of Interventional Radiology (SIR) for Periprocedural Management of Image-guided Procedures with regards to thrombocytopenia, coagulopathies, antiplatelets and anticoagulation.  The SIR guidelines are summarized as follows:

  • Anticoagulation for Procedures
  • Anticoagulation with heparin, LMWH, fondaparinux, argatroban, warfarin, DOAC, clopidogrel, ticagrelor and prasugrel should not be withheld prior to low-risk procedures

Figure 1: Anticoagulation Management before Procedures

Dual antiplatelet therapy and procedures

Figure 2: Dual Antiplatelet Therapy before Procedures

  • Thresholds for Low Bleed Risk Procedures
  • INR<3 for arterial interventions and tunneled catheter placement
  • Screening PT/INR and PTT is not routinely recommended for low risk procedures unless patients have risk factors for bleeding or if they are receiving warfarin or heparin
  • Lumbar puncture should be treated as a high risk procedure

Table 1: Platelet and Coagulation Thresholds for Low Risk Procedures

  • Thresholds for High Risk Procedures
  • INR <1.5-1.8 prior to lumbar puncture
  • INR>50K prior to lumbar puncture

Table 2: Platelet and Coagulation Thresholds for High Risk Procedures

  • Thresholds for Procedures in Cirrhotic Patients
  • Invasive procedures should not be performed in cirrhotic patients with DIC and hyperfibrinolysis

Table 3: Platelet and Coagulation Thresholds for Procedures in Cirrhotic Patients

Post-Procedure Anticoagulation Use

Figure 3: Post-Procedure Anticoagulation Use Based on Bleed Risk

  

MEDICATIONS                         WITHHOLD TIME PRIOR TO HIGH RISK PROCEDURES

Heparin                                       4-6 hours

LMWH prophylactic               12 hours

LMWH therapeutic                 24 hours

Fondaparinux                           2-3d (CrCl>50) and 3-5 d (CrCl<50)

Argatroban                                4-6 hours

Warfarin                                     5 days (INR<1.8)

Apixiban                                     48 hours (CrCl>50) or 72 hours (CrCl<50)

Dabigatran                                48 hours (CrCl>50) or 72 hours (CrCl<50)

Edoxaban                                   48 hours

Rivaroxaban                              48 hours (CrCl>30) or 72 hours (CrCl<30)

Clopidogrel and Ticagrelor  5 days

Prasugrel                                    7 days

ASA                                               None

NSAIDS                                        None

SUMMARY OF THESE GUIDELINES

  • Low risk procedures (paracentesis, thoracentesis, central lines, dialysis catheter placement, arterial interventions with catheters <6F, and chest tube placement) can be performed under full anticoagulation or use of all antiplatelets including dual antiplatelet therapy
  • Low risk procedures can be performed for platelet count >20K or if INR<3.0 without blood product administration
  • High risk procedures (lumbar puncture and arterial interventions with catheters >7F) can be performed for platelet count >50K or if INR<1.5-1.8 without blood product administration
  • Anticoagulants and thienopyridines (clopidogrel, ticagrelor and prasugrel) should be held for a period of time prior to performing high risk procedures
  • Fibrinogen levels should be >100 mg/dL prior to initiation of low risk or high risk procedures

Source; Patel, IJ et al. Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions - Part II: Recommendations.  J Vasc Interv Radiol. 2019; 30: 1168-1184.