Definition of Problem

In performing noncardiac surgery on patients on anticoagulation, the major concern is when it is safe to perform surgery without increasing the risk of hemorrhage or increasing the risk of thromboembolism (eg, venous, arterial) after discontinuing treatment. In treating patients on long-term warfarin perioperatively, consider the risks of hemorrhage or thromboembolism versus the benefit from the operation. When considering noncardiac surgery, these factors and the need to weigh the risk of hemorrhage against that of thromboembolism must be analyzed on an individual patient basis. Certain procedures (eg, oncologic procedures, threats to limb or life) are easy analyses. More complex discussions must be had for such cases as hernia repair of other elective nonurgent operations.

The perioperative management for these patients can be one of the following: continue warfarin therapy, withhold warfarin therapy for a period of time before and after the procedure, or temporarily withhold warfarin therapy and also provide a "heparin bridge" during the perioperative period. Which management option to follow is primarily determined by the characteristics of the patient and by the nature of the procedure.

Patients with prosthetic heart valves pose a particular problem. Arterial thromboembolism from the heart often results in death (40% of events) or major disability (20% of events).

Wijeysundera DN, Karkouti K, Rao V, et al. N-acetylcysteine is associated with increased blood loss and blood product utilization during cardiac surgery. Crit Care Med. 2009 Jun. 37(6):1929-34. [QxMD MEDLINE Link].
Di Biase L, Burkhardt JD, Santangeli P, Mohanty P, Sanchez JE, Horton R, et al. Periprocedural stroke and bleeding complications in patients undergoing catheter ablation of atrial fibrillation with different anticoagulation management: results from the Role of Coumadin in Preventing Thromboembolism in Atrial Fibrillation (AF) Patients Undergoing Catheter Ablation (COMPARE) randomized trial. Circulation. 2014 Jun 24. 129(25):2638-44. [QxMD MEDLINE Link].
Douketis JD, Spyropoulos AC, Kaatz S, Becker RC, Caprini JA, Dunn AS, et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med. 2015 Jun 22. [QxMD MEDLINE Link].
Douketis JD, Spyropoulos AC, Duncan J, et al. Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant. JAMA Intern Med. 2019 Nov 1. 179 (11):1469-78. [QxMD MEDLINE Link]. [Full Text].
Douketis JD, Berger PB, Dunn AS, et al. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun. 133(6 suppl):299S-339S. [QxMD MEDLINE Link]. [Full Text].
Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb. 141(2 Suppl):e326S-50S. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest. 2022 Nov. 162 (5):e207-43. [QxMD MEDLINE Link].
Akl EA, Labedi N, Terrenato I, Barba M, Sperati F, Sempos EV, et al. Low molecular weight heparin versus unfractionated heparin for perioperative thromboprophylaxis in patients with cancer. Cochrane Database Syst Rev. 2011 Nov 9. 11:CD009447. [QxMD MEDLINE Link].
Douketis JD. Perioperative management of patients receiving anticoagulant or antiplatelet therapy: a clinician-oriented and practical approach. Hosp Pract (Minneap). 2011 Oct. 39(4):41-54. [QxMD MEDLINE Link].
Turna B, Stein RJ, Smaldone MC, et al. Safety and efficacy of flexible ureterorenoscopy and holmium:YAG lithotripsy for intrarenal stones in anticoagulated cases. J Urol. 2008 Apr. 179(4):1415-9. [QxMD MEDLINE Link].
Law SK, Song BJ, Yu F, et al. Hemorrhagic complications from glaucoma surgery in patients on anticoagulation therapy or antiplatelet therapy. Am J Ophthalmol. 2008 Apr. 145(4):736-746. [QxMD MEDLINE Link].
Garwood CL, Hwang JM, Moser LR. Striking a balance between the risks and benefits of anticoagulation bridge therapy in patients with atrial fibrillation: clinical updates and remaining controversies. Pharmacotherapy. 2011 Dec. 31(12):1208-20. [QxMD MEDLINE Link].
Nuttall MT, Rodgers GM. Perioperative management of antithrombotic therapy in cardiovascular patients. Methodist Debakey Cardiovasc J. 2011 Oct. 7(4):10-4. [QxMD MEDLINE Link].
Kearon C. Perioperative management of long-term anticoagulation. Semin Thromb Hemost. 1998. 24 suppl 1:77-83. [QxMD MEDLINE Link].
Jaffer AK, Brotman DJ, Chukwumerije N. When patients on warfarin need surgery. Cleve Clin J Med. 2003 Nov. 70(11):973-84. [QxMD MEDLINE Link].
Lai A, Davidson N, Galloway SW, Thachil J. Perioperative management of patients on new oral anticoagulants. Br J Surg. 2014 Jun. 101(7):742-9. [QxMD MEDLINE Link].
Pollack CV Jr, Reilly PA, Eikelboom J, Glund S, Verhamme P, Bernstein RA, et al. Idarucizumab for Dabigatran Reversal. N Engl J Med. 2015 Aug 6. 373 (6):511-20. [QxMD MEDLINE Link].
Siegal DM, Curnutte JT, Connolly SJ, Lu G, Conley PB, Wiens BL, et al. Andexanet Alfa for the Reversal of Factor Xa Inhibitor Activity. N Engl J Med. 2015 Dec 17. 373 (25):2413-24. [QxMD MEDLINE Link]. [Full Text].
Connolly SJ, Milling TJ Jr, Eikelboom JW, Gibson CM, Curnutte JT, Gold A, et al. Andexanet Alfa for Acute Major Bleeding Associated with Factor Xa Inhibitors. N Engl J Med. 2016 Sep 22. 375 (12):1131-41. [QxMD MEDLINE Link]. [Full Text].
Madura JA, Rookstool M, Wease G. The management of patients on chronic Coumadin therapy undergoing subsequent surgical procedures. Am Surg. 1994 Jul. 60(7):542-6; discussion 546-7. [QxMD MEDLINE Link].
Kraai EP, Lopes RD, Alexander JH, Garcia D. Perioperative management of anticoagulation: guidelines translated for the clinician. J Thromb Thrombolysis. 2009 Jul. 28(1):16-22. [QxMD MEDLINE Link].
Scharf RE. Management of bleeding in patients using antithrombotic agents. Hamostaseologie. 2009 Sep. 29(4):388-98. [QxMD MEDLINE Link].
Tanaka KA, Key NS, Levy JH. Blood coagulation: hemostasis and thrombin regulation. Anesth Analg. 2009 May. 108(5):1433-46. [QxMD MEDLINE Link].
American College of Chest Physicians. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. 2004. 126(3 suppl):214S -215S.
Wamala H, Scott IA, Caney X. Perioperative management of new oral anticoagulants in patients undergoing elective surgery at a tertiary hospital. Intern Med J. 2017 Dec. 47 (12):1412-1421. [QxMD MEDLINE Link].

Media Gallery

Perioperative anticoagulation management. Low molecular weight heparin, prophylactic doses, and therapeutic doses.
Which patients on warfarin should receive heparin bridging before surgery? Adapted from Cleveland Clinic Journal.
Protocol for low molecular weight heparin as a bridge to surgery in patients on warfarin. Adapted from Cleveland Clinic Journal.

of 3

#author-disclosures{display:block}#author-disclosures.modal-layer{position:relative}#author-disclosures .modal-content{max-height:none}#author-disclosures .close-modal{display:none}

Author

Brian J Daley, MD, MBA, FACS, FCCP, CNSC Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian J Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma, Southern Surgical Association, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, Tennessee Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Trenton W Kinnear, MD Fellow in Vascular Surgery, Department of Surgery, University of Tennessee Graduate School of Medicine

Trenton W Kinnear, MD is a member of the following medical societies: American Medical Association, Southern Association for Vascular Surgery

Disclosure: Nothing to disclose.

Dana Taylor, MD, FACS Assistant Professor of Surgery, University of Tennessee Health Science Center College of Medicine; Consulting Surgeon, University General Surgeons, PC

Dana Taylor, MD, FACS is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, Southeastern Surgical Congress, Eastern Association for the Surgery of Trauma, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Donna Leco Mercado, MD, MD

Donna Leco Mercado, MD, MD is a member of the following medical societies: Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Chief Editor

William A Schwer, MD Professor, Department of Family Medicine, Rush Medical College; Chairman, Department of Family Medicine, Rush-Presbyterian-St Luke's Medical Center

William A Schwer, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Marc D Basson, MD, PhD, MBA, FACS Senior Associate Dean for Medicine and Research, Professor of Surgery, Pathology, and Biomedical Sciences, University of North Dakota School of Medicine and Health Sciences

Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Gastroenterological Association, Phi Beta Kappa, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Jose Fernando Aycinena Goicolea, MD Colorectal Surgeon, The Longstreet Clinic

Jose Fernando Aycinena Goicolea, MD is a member of the following medical societies: American College of Surgeons, Pennsylvania Medical Society

Disclosure: Nothing to disclose.

TOP PICKS FOR YOU

Perioperative Anticoagulation Management

Definition of Problem

References

Tables

Contributor Information and Disclosures

What would you like to print?