Perioperative Anticoagulation: Key Principles

1) Balance bleeding and thrombosis risk

Higher bleeding-risk procedures require longer holds and later restarts. Elevated thrombosis risk (e.g., mechanical valves, recent VTE, high AF stroke risk) may necessitate bridging if on warfarin, but **not** for DOACs.

2) Conservative timing wins

When uncertainty exists, extend the hold/restart window conservatively and verify hemostasis. Our calculator surfaces timestamped plans tied to the procedure date/time.

3) Neuraxial safety is special

For neuraxial contexts (epidural/spinal/intrathecal, neurosurgery), use stricter holds and adhere to catheter rules. Some renal thresholds are neuraxial hard-stops (e.g., avoid neuraxial with dabigatran CrCl <30).

4) Warfarin has governance

• Stop 5 days pre-procedure; verify INR <1.5 close to procedure time; correct or delay if ≥1.5 within 24–48 h.
• Restart: 12–24 h for low/mod bleeding risk; 48–72 h for high/neuraxial—if hemostasis is secure.
• Bridge only when thrombotic risk is high; prefer UFH if CrCl <30.

5) DOACs are never bridged

Baseline holds/restarts vary by bleeding risk and renal function (especially for dabigatran). For very high thrombosis risk, MDACC notes rare exceptions—consult Hematology.

6) Catheter gating

If a neuraxial catheter is present, withhold anticoagulants while in place. Earliest restarts after removal: DOAC +24 h, LMWH +4 h, UFH +1 h—then use the **later of** baseline window vs these gaps.

See this in action with the AnticoagPlanner calculator.

Sources

• MD Anderson. Peri-Procedure Anticoagulants, V8 (approved 07/15/2025).
• ASRA/Stanford institutional neuraxial catheter timing summaries.