Rivaroxaban Around Surgery: Practical Hold and Restart
Original guidance for clinicians. Conservative and traceable. Not a reproduction of any guideline table. Confirm local policy.
Quick take
Hold rivaroxaban before surgery based on bleeding risk, then restart when hemostasis is secure. Renal function and neuraxial plans influence timing. Do not bridge rivaroxaban.
When to hold rivaroxaban before surgery
Match the hold to the procedure risk. High risk procedures and neuraxial cases get longer holds. If renal function is reduced, extend conservatively and avoid neuraxial approaches at very low clearance.
Neuraxial cautions
For epidural, spinal, or intrathecal techniques, apply stricter holds. If a neuraxial catheter is present, withhold rivaroxaban and plan the restart only after removal and the proper gap.
Catheter gating
No rivaroxaban while a neuraxial catheter is in place. After removal, wait at least removal plus 24 hours for DOACs, then use the later of that time or the baseline post-op window.
When to restart rivaroxaban
Restart when hemostasis is secure. Low or moderate risk procedures generally resume earlier than high risk or neuraxial settings. Clinical course matters.
Special situations
- Renal impairment: hold longer as clearance slows. Avoid neuraxial at very low clearance.
- Very high thrombosis risk: do not bridge rivaroxaban. Consult Hematology if risk is extreme.
Create a timestamped plan that accounts for renal function and neuraxial factors with the AnticoagPlanner calculator.
FAQ
How long to hold Xarelto before surgery
Base it on procedure bleeding risk and renal function. High risk and neuraxial cases require longer holds.
When to restart rivaroxaban after surgery
Only after hemostasis is secure. High risk and neuraxial settings restart later than low or moderate risk cases.
Should rivaroxaban be bridged
No. DOACs are not bridged.
Sources
- MD Anderson. Peri-Procedure Anticoagulants, V8 approved 2025.
- Institutional neuraxial catheter timing summaries derived from ASRA guidance.
Disclaimer: Educational content for clinicians. Supports clinical judgment. Confirm local policy and anesthesia guidance for neuraxial procedures.