FAQ – Radiologic Procedures

The information below is intended only as general guidelines for imaging-guided procedures. On a case-by-case basis, radiology providers can alter the lab and medication suggestions based on individual assessment of patient risk versus benefit.

Procedure-Associated Bleeding Risk Categorization

Screening Coagulation Laboratory Test

Procedures

Low Bleeding Risk

PT/INR: Not routinely recommended*

Platelet count/hemoglobin: not routinely recommended

Thresholds

INR: Correct to within range of ≤ 2.0–3.0

Platelets: transfuse if < 20 × 10⁹/L
• Catheter exchanges (gastrostomy, biliary, nephrostomy, abscess, including gastrostomy/gastrojejunostomy conversions)

• Diagnostic arteriography and arterial interventions: peripheral, sheath < 6 F, embolotherapy

• Diagnostic venography and select venous interventions: pelvis and extremities

• Dialysis access interventions

• Facet joint injections and medial branch nerve blocks (thoracic and lumbar spine)

• IVC filter placement and removal

• Lumbar puncture

• Nontunneled chest tube placement for pleural effusion

• Nontunneled venous access and removal (including PICC placement)

• Paracentesis

• Peripheral nerve blocks, joint, and musculoskeletal injections

• Sacroiliac joint injection and sacral lateral branch blocks

• Superficial abscess drainage or biopsy (palpable lesion, lymph node, soft tissue, breast, thyroid, superficial bone, eg, extremities and bone marrow aspiration)

• Thoracentesis

• Transjugular liver biopsy

• Trigger point injections including piriformis

• Tunneled drainage catheter placement

• Tunneled venous catheter placement/removal (including ports)
High Bleeding Risk

PT/INR: routinely recommended

Platelet count/hemoglobin: routinely recommended

Thresholds

INR: correct to within range of ≤ 1.5–1.8

Platelets: transfuse if < 50 × 10⁹/L
• Ablations: solid organs, bone, soft tissue, lung

• Arterial interventions: > 7-F sheath, aortic, pelvic, mesenteric, CNS, Biliary interventions (including cholecystostomy tube placement)

• Catheter directed thrombolysis (DVT, PE, portal vein)

• Deep abscess drainage (eg, lung parenchyma, abdominal, pelvic, retroperitoneal)

• Deep nonorgan biopsies (eg, spine, soft tissue in intraabdominal, retroperitoneal, pelvic compartments)

• Gastrostomy/gastrojejunostomy placement

• IVC filter removal complex

• Portal vein interventions

• Solid organ biopsies

• Spine procedures with risk of spinal or epidural hematoma (eg, kyphoplasty, vertebroplasty, epidural injections, facet blocks cervical spine)

• Transjugular intrahepatic portosystemic shunt

• Urinary tract interventions (including nephrostomy tube placement, ureteral dilation, stone removal)

• Venous interventions: intrathoracic and CNS interventions

Management Recommendations for Anticoagulant and Antiplatelet Agents

Medication

Low Risk for Bleeding

High Risk for Bleeding*

Anticoagulants
UFH
WithholdingDo not withholdWithhold IV heparin for 4–6 h before procedure; check aPTT or anti-Xa level; for BID or TID dosing of SC heparin, procedure may be performed 6 h after last dose
ReinitiationNA6-8 h
LMWH: enoxaparin (Lovenox), dalteparin (Fragmin)
WithholdingDo not withholdEnoxaparin, withhold 1 dose if prophylactic dose is used; withhold 2 doses or 24 h before procedure if therapeutic dose is used; check anti-Xa level if renal function impaired; dalteparin, withhold 1 dose before procedure
ReinitiationNA12 h
Fondaparinux (Arixtra)
WithholdingDo not withholdWithhold 2/3 d (CrCl ≥ 50 mL/min) or 3–5 d (CrCl ≤ 50 mL/min)
ReinitiationNA24 h
Argatroban (Acova)
WithholdingDo not withholdWithhold 2-4 h before procedure; check aPTT
ReinitiationNA4-6 h
Bivalirudin (Angiomax)
WithholdingDo not withholdWithhold 2-4 h before procedure; check aPTT
ReinitiationNA4-6 h
Warfarin (Coumadin)
WithholdingTarget INR ≤ 3.0; consider bridging for high thrombosis risk casesWithhold 5 d until target INR ≤ 1.8; consider bridging for high thrombosis risk cases; if STAT or emergent, use reversal agent
ReinitiationNA or same-day reinitiation for bridged patientsResume day after procedure; high thrombosis risk cases may benefit from bridging with LMWH and multidisciplinary management especially if reversal agent used along with vitamin K
Apixaban (Eliquis)
WithholdingDo not withholdWithhold 4 doses (CrCl ≥ 50 mL/min) or 6 doses (CrCl < 30–50 mL/min); if procedure is STAT or emergent, use reversal agent (andexanet alfa); consider checking anti-Xa activity or apixaban level especially with impaired renal function
ReinitiationNA24 h
Betrixaban (Bevyxxa)
WithholdingDo not withholdWithhold for 3 doses 113; if procedure is STAT or emergent, use reversal agent (andexanet alfa); consider checking anti-Xa activity especially with impaired renal function
ReinitiationNA24 h
Dabigatran (Pradaxa)
WithholdingDo not withholdWithhold 4 doses (CrCl ≥ 50 mL/min) or 6–8 doses (CrCl < 30–50 mL/min); if procedure is STAT or emergent, use reversal agent (idarucizumab); consider checking thrombin time or dabigatran level with impaired renal function
ReinitiationNA24 h
Edoxaban (Savaysa)
WithholdingDo not withholdWithhold for 2 doses; if procedure is STAT or emergent, use reversal agent (andexanet alfa); consider checking anti-Xa activity especially with impaired renal function
ReinitiationNA24 h
Rivaroxaban (Xarelto)
WithholdingDo not withholdDefer procedure until off medication for 2 doses (CrCl ≥ 50 mL/min), 2 doses (CrCl < 30–50 mL/min), or 3 doses (CrCl < 15–30 mL/min); if procedure is STAT or emergent, use reversal agent (andexanet alfa); consider checking anti-Xa activity or rivaroxaban level especially with impaired renal function
ReinitiationNA24 h
Antiplatelet agents: thienopyridines
Clopidogrel (Plavix)
WithholdingDo not withholdWithhold for 5 d before procedure
ReinitiationNAReinitiation can occur 6 h after procedure if using 75-mg dose but should occur 24 h after procedure if using a loading dose (300–600 mg)
Ticagrelor (Brilinta)
WithholdingDo not withholdWithhold for 5 d before procedure
ReinitiationNAResume the day after procedure
Prasugrel (Effient)
WithholdingDo not withholdWithhold for 7 d before procedure
ReinitiationNAResume the day after procedure
Cangrelor (Kengreal)
WithholdingDefer procedure until off medication; if procedure is emergent, withhold 1 h before procedure; multidisciplinary discussion with cardiology suggest
ReinitiationPatients receiving cangrelor are undergoing PCI or are within immediate periprocedural period from cardiac intervention; multidisciplinary, shared decision making recommended
Antiplatelet agents: NSAIDs
Aspirin
WithholdingDo not withholdWithhold 3-5 d before procedure
ReinitiationNAResume the day after procedure
Aspirin/dipyridamole (Aggrenox)
WithholdingDo not withholdWithhold 3-5 d before procedure
ReinitiationNAResume the day after procedure
Short-acting NSAIDs (half-life 2–6 h): ibuprofen, diclofenac, ketoprofen, indomethacin, ketorolac
WithholdingDo not withholdNo recommendation
ReinitiationNANA
Intermediate-acting NSAID (half-life 7–15 h): naproxen, sulindac, diflunisal, celecoxib
WithholdingDo not withholdNo recommendation
ReinitiationNANA
Long-acting NSAIDs (half-life > 20 h): meloxicam, nabumetone, piroxicam
WithholdingDo not withholdNo recommendation
ReinitiationNANA
Antiplatelet agents: glycoprotein IIb/IIIa inhibitors
Long-acting abciximab (ReoPro)
WithholdingWithhold 24 h before procedure
ReinitiationPatients receiving glycoprotein IIb/IIIa inhibitor are undergoing PCI or within immediate periprocedural period from cardiac intervention; multidisciplinary, shared decision making recommended
Short-acting: eptifibatide (Integrilin), tirofiban (Aggrastat)
WithholdingWithhold 4-8 h before procedure
ReinitiationPatients receiving a glycoprotein IIb/IIIa inhibitor are undergoing PCI or within immediate periprocedural period from cardiac intervention; multidisciplinary, shared decision making recommended
Other
Cilostazol (Pletal)
WithholdingDo not withholdDo not withhold
ReinitiationNANA

Sources:

Patel, Indravadan J., 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.” Journal of Vascular and Interventional Radiology, Society of Interventional Radiology, 19 June 2019, https://www.jvir.org/article/S1051-0443(19)30407-5/fulltext#secsectitle0085.

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