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 | ||
| Withholding | Do not withhold | Withhold 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 |
| Reinitiation | NA | 6-8 h |
| LMWH: enoxaparin (Lovenox), dalteparin (Fragmin) | ||
| Withholding | Do not withhold | Enoxaparin, 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 |
| Reinitiation | NA | 12 h |
| Fondaparinux (Arixtra) | ||
| Withholding | Do not withhold | Withhold 2/3 d (CrCl ≥ 50 mL/min) or 3–5 d (CrCl ≤ 50 mL/min) |
| Reinitiation | NA | 24 h |
| Argatroban (Acova) | ||
| Withholding | Do not withhold | Withhold 2-4 h before procedure; check aPTT |
| Reinitiation | NA | 4-6 h |
| Bivalirudin (Angiomax) | ||
| Withholding | Do not withhold | Withhold 2-4 h before procedure; check aPTT |
| Reinitiation | NA | 4-6 h |
| Warfarin (Coumadin) | ||
| Withholding | Target INR ≤ 3.0; consider bridging for high thrombosis risk cases | Withhold 5 d until target INR ≤ 1.8; consider bridging for high thrombosis risk cases; if STAT or emergent, use reversal agent |
| Reinitiation | NA or same-day reinitiation for bridged patients | Resume 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) | ||
| Withholding | Do not withhold | Withhold 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 |
| Reinitiation | NA | 24 h |
| Betrixaban (Bevyxxa) | ||
| Withholding | Do not withhold | Withhold 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 |
| Reinitiation | NA | 24 h |
| Dabigatran (Pradaxa) | ||
| Withholding | Do not withhold | Withhold 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 |
| Reinitiation | NA | 24 h |
| Edoxaban (Savaysa) | ||
| Withholding | Do not withhold | Withhold for 2 doses; if procedure is STAT or emergent, use reversal agent (andexanet alfa); consider checking anti-Xa activity especially with impaired renal function |
| Reinitiation | NA | 24 h |
| Rivaroxaban (Xarelto) | ||
| Withholding | Do not withhold | Defer 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 |
| Reinitiation | NA | 24 h |
| Antiplatelet agents: thienopyridines | ||
| Clopidogrel (Plavix) | ||
| Withholding | Do not withhold | Withhold for 5 d before procedure |
| Reinitiation | NA | Reinitiation 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) | ||
| Withholding | Do not withhold | Withhold for 5 d before procedure |
| Reinitiation | NA | Resume the day after procedure |
| Prasugrel (Effient) | ||
| Withholding | Do not withhold | Withhold for 7 d before procedure |
| Reinitiation | NA | Resume the day after procedure |
| Cangrelor (Kengreal) | ||
| Withholding | Defer procedure until off medication; if procedure is emergent, withhold 1 h before procedure; multidisciplinary discussion with cardiology suggest | |
| Reinitiation | Patients receiving cangrelor are undergoing PCI or are within immediate periprocedural period from cardiac intervention; multidisciplinary, shared decision making recommended | |
| Antiplatelet agents: NSAIDs | ||
| Aspirin | ||
| Withholding | Do not withhold | Withhold 3-5 d before procedure |
| Reinitiation | NA | Resume the day after procedure |
| Aspirin/dipyridamole (Aggrenox) | ||
| Withholding | Do not withhold | Withhold 3-5 d before procedure |
| Reinitiation | NA | Resume the day after procedure |
| Short-acting NSAIDs (half-life 2–6 h): ibuprofen, diclofenac, ketoprofen, indomethacin, ketorolac | ||
| Withholding | Do not withhold | No recommendation |
| Reinitiation | NA | NA |
| Intermediate-acting NSAID (half-life 7–15 h): naproxen, sulindac, diflunisal, celecoxib | ||
| Withholding | Do not withhold | No recommendation |
| Reinitiation | NA | NA |
| Long-acting NSAIDs (half-life > 20 h): meloxicam, nabumetone, piroxicam | ||
| Withholding | Do not withhold | No recommendation |
| Reinitiation | NA | NA |
| Antiplatelet agents: glycoprotein IIb/IIIa inhibitors | ||
| Long-acting abciximab (ReoPro) | ||
| Withholding | Withhold 24 h before procedure | |
| Reinitiation | Patients 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) | ||
| Withholding | Withhold 4-8 h before procedure | |
| Reinitiation | Patients 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) | ||
| Withholding | Do not withhold | Do not withhold |
| Reinitiation | NA | NA |
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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