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Periprocedural management of antithrombotic therapy
Guidelines
Key sources
The following summarized guidelines for the evaluation and management of periprocedural management of antithrombotic therapy are prepared by our editorial team based on guidelines from the American Society of Interventional Pain Physicians (ASIPP 2024), the American College of Chest Physicians (ACCP 2022), the American College of Gastroenterology (ACG/CAG 2022), the European Society of Gastrointestinal Endoscopy (ESGE/BSG 2021), the American Heart ...
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Classification and risk stratification
Risk assessment: as per ASIPP 2024 guidelines, use the following risk categorization of interventional techniques
Situation
Guidance
Low risk
Trigger point and intramuscular injections (including piriformis injection)
[eripheral nerve blocks including mandibular and maxillary nerve blocks
Sacroiliac joint and ligament injections and nerve blocks
Facet joint interventions (intra-articular injections, medial branch and L5 dorsal ramus nerve blocks and radiofrequency neurotomy)
Intraarticular injections of extremity joints
Pocket revision and implantable pulse generator/intrathecal pump replacement
Peripheral nerve stimulation trial and implantation
Lumbar transforaminal epidural injections at L3, L4, L5, and S1
Ganglion impar blocks
Sacroiliac joint nerve radiofrequency
Trigeminal branch nerve blocks (mandibular, maxillary, and other branches)
Intermediate risk
Caudal epidural injection
Caudal epidural adhesiolysis
Lumbar interlaminar epidural injection at L5, S1
Cervical, thoracic, and lumbar transforaminal at L1 and L2
High risk
Cervical, thoracic, and lumbar (above L5) interlaminar epidurals
Trigeminal ganglion, ophthalmic division, and sphenopalatine ganglion blocks
Discography and intradiscal procedures (lumbosacral, cervical, and thoracic)
Dorsal column and dorsal root ganglion stimulator trial and implantation
Intrathecal catheter and pump implant
Vertebral augmentation (sacral, lumbar, thoracic, and cervical)
Percutaneous and endoscopic disc decompression procedures
Minimally invasive lumbar decompression
Trigeminal and cranial nerve blocks and stimulation
Sympathetic blocks (stellate ganglion, thoracic sympathetic, splanchnic, celiac plexus, lumbar sympathetic, hypogastric plexus)
Percutaneous adhesiolysis with interlaminar or transforaminal approach (cervical, thoracic, and lumbar)
Intervertebral spinous prosthesis including lateral fusion
Sacroiliac joint fusion
Intracept procedure
B
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Diagnostic investigations
Coagulation tests
As per SIR 2019 guidelines:
Do not obtain screening coagulation laboratory testing in patients with minimal risk factors for bleeding undergoing procedures carrying low risk for bleeding. Consider obtaining coagulation testing in patients receiving warfarin or UFH or in patients with an inherently higher risk of bleeding. Correct INR to within the range of ≤ 2.0-3.0 and consider administering platelet transfusion if the platelet count is < 20×10⁹/L. Correct INR to < 1.8 for femoral access and < 2.2 for radial access in patients undergoing low bleeding risk procedures requiring arterial access.
D
Obtain appropriate preprocedural coagulation testing in patients undergoing procedures with high bleeding risk. Correct INR to within the range of ≤ 1.5-1.8 and consider administering platelet transfusion if the platelet count is < 50×10⁹/L.
B
Perioperative care
General principles
As per ASIPP 2024 guidelines:
Ensure a shared decision-making between the patient, the pain specialist, and the treating physicians if interruption of antiplatelet or anticoagulant therapy is contemplated for discussion of all the appropriate risks associated with continuation or discontinuation of antiplatelet or anticoagulant therapy.
B
Restore or restart antithrombotic therapy during 12-24-hour period for intermediate-risk procedures, and low-risk procedures if the decision was made to hold based on risk factors, and 24-48 hours for major risk procedures, based on postoperative bleeding status. Consider resuming antithrombotic therapy 12 hours after interventional procedures if thromboembolic risk is high, with appropriate assessment and monitoring for clinically significant bleeding.
B
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Patients on VKAs (elective surgeries/procedures)
Patients on VKAs (minor procedures)
Patients on heparins
Patients on DOACs
Patients on antiplatelets
Specific circumstances
Patients with chronic liver disease
As per SIR 2019 guidelines:
Administer plasma and platelet transfusion in patients with chronic liver disease judiciously because of rebalanced hemostasis and given the potential for increased portal pressure and transfusion-related adverse events.
E
Consider adjusting the INR and platelet count thresholds in patients with chronic liver disease undergoing invasive procedures to higher and lower, respectively, than in the general population to minimize unnecessary transfusions. Consider measuring the fibrinogen level and administering cryoprecipitate for replacement if the level is low.
E
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Patients with AF (preprocedural interruption)
Patients with AF (preprocedural bridging)
Patients with AF (postprocedural resumption)
Patient education
General counseling
As per BSG/ESGE 2021 guidelines:
Counsel all patients on antiplatelets or anticoagulants about the increased risk of postprocedural hemorrhage.
B
Counsel all patients on the thrombotic risks of discontinuing antiplatelets or anticoagulants, as well as the hemorrhagic risks of continuing therapy.
B