VIR PERIPROCEDURAL ANTICOAGULATION GUIDELINES Procedure Category LOW RISK MODERATE RISK HIGH RISK * If on blood thinner or Coumadin held for Angiography (arterial intervention up to 7fr procedure, check INR prior to the procedure* Sheath) TIPS Non-Tunneled venous access (PICC, Central line, Tunneled PICC, temp HD Cath) Thrombolysis / Lysis Check Renal Biopsy Central venous line removal, Tunneled venous line removal Venogram (groin puncture) Thermal Ablation of Tumor Venography (foot or arm access) Venous interventions/ Thrombolysis Nephrotomy tube placement Catheter exchange (biliary, nephrostomy, Mapping Angiogram / Y90 / DEB / Biliary interventions *new access* (PTC & abscess drain) Chemoembolization Biliary Stent) Tunneled venous access (Port Placement, Paracentesis Perm Cath, PICC) Lung Biopsy Thyroid Biopsy Port Removal Spleen Biopsy Superficial Biopsy (lymph node) Transjugular Liver or Kidney Biopsy AAA Repair Superficial abscess drainage or aspiration Spine Procedures (vertebroplasty, vertebral Abscess Tube Check BRTO augmenation, sacroplasty) Percutaneous drain placement, Chest Tube placement Abdomen/Pelvis Uterine fibroid embolization Biopsy (Liver, Deep Lymph node, Spine, Other G-Tube exchange/ replacement organs) Venous Access (trans-lumbar IVC Catheter) Venous Ablation (RF/ Laser) Thoracentesis Venous Sclerotherapy Pulmonary AVM Embolization Ambulatory Phlebectomy Pleurex (Abdominal & Thoracic) Vulva Sclero Denver Shunt IVC Filter Placement Cholecystomstomy Fistula Declot G-Tube Placement AV Fistulagram / plasty Ureteral Stent Placement Renal Cyst Varicocele / Ovarian Vein Embolization Updated 10/5/15 VIR PERIPROCEDURAL ANTICOAGULATION GUIDELINES LOW RISK MODERATE RISK HIGH RISK TESTS INR: Only if Coumadin held INR: Recommended INR: Recommended PLT: Not recommended PLT: Recommended PLT: Recommended THRESHOLDS PLT: < 50,000 Recommend transfusion PLT: < 50,000 Recommend transfusion INR: Correct if > 2.0 INR: Correct if > 1.5 INR: Correct if > 1.5 MEDICATIONS Hold 3-5 days for thyroid bx, superficial bx, Coumadin ambulatory phlebectomy Hold 5 days Hold 5 days Aspirin Do not hold Hold 5 days Hold 5 days Dipyridamole / ASA (Aggrenox) Do not hold Hold 5 days, except peripheral vascular disease Hold 5 days Heparin Hold 2-4 hours prior to procedure Hold 2-4 hours prior to procedure Hold 2-4 hours prior to procedure LMWH Hold 1 dose or 12 hours for thyroid bx, Therapeutic superficial bx, ambulatory phlebectomy Hold 2 doses or 24 hours Hold 2 doses or 24 hours Fondaparinux (t1/2 Hold for 2 days prior to thyroid bx, superficial 17 hrs) bx, ambulatory phlebectomy Hold for 2 days prior to procedure Hold for 2 days prior to procedure Thienopyridines Hold 5 days for thyroid bx, superficial bx, Hold 5 days, except for peripheral vascular Plavix ambulatory phlebectomy disease Hold 5 days Hold 5 days for thyroid bx, superficial bx, Hold 5 days, except for peripheral vascular Prasugrel (Effient) ambulatory phlebectomy disease Hold 5 days Hold 5 days for thyroid bx, superficial bx, Hold 5 days, except for peripheral vascular Ticlopidine (Ticlid) ambulatory phlebectomy disease Hold 5 days Updated 10/5/15 VIR PERIPROCEDURAL ANTICOAGULATION GUIDELINES LOW RISK MODERATE RISK HIGH RISK NSAIDS Short-acting (Half- life 2-6 hrs) Diclofenac Do not hold Do not hold Hold 1 day prior Ketoprofen Do not hold Do not hold Hold 1 day prior Indomethacin Do not hold Do not hold Hold 1 day prior Intermediate- acting (Half-life 7- 15 hrs) Naproxen Do not hold Do not hold Hold 2 days prior Sulindac Do not hold Do not hold Hold 2 days prior Diflunisal Do not hold Do not hold Hold 2 days prior Celecoxib Do not hold Do not hold Hold 2 days prior Long-actind (Half- life >20 hrs) Meloxicam Do not hold Do not hold Hold 10 days prior Nabumetone Do not hold Do not hold Hold 10 days prior Piroxicam Do not hold Do not hold Hold 10 days prior Glycoprotein Iib/IIIa inhibitors Long-acting Abciximab (ReoPro) Hold 12-24 hours prior Hold 24 hours prior Hold 24 hours prior Updated 10/5/15 VIR PERIPROCEDURAL ANTICOAGULATION GUIDELINES LOW RISK MODERATE RISK HIGH RISK Short-acting Eptigibatide (Integrilin) Hold immediately prior Hold 4 hours prior Hold 4 hours prior Tirofiban (Aggrastat) Hold immediately prior Hold 4 hours prior Hold 4 hours prior Direct thrombin inhibitors Rivaroxaban Hold 2 days for thyroid bx, superficial bx, (Xarelto) ambulatory phlebectomy Hold 2 days Hold 2 days Hold 24 hours for thyroid bx, superficial bx, Eliquis ambulatory phlebectomy Hold 2 days Hold 2 days Argatroban Do not hold Hold 5 hours prior Hold 5 hours prior Bivalirudin (Angiomax) Do not hold Hold 5 hours prior Hold 5 hours prior Dabigatran (Pradaxa) Do not hold Hold 5 days prior Hold 5 days prior References: Patel et al. Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image-guided Interventions, JVIR 23 (2012), 727-36. Whinney C, Perioperative Medication Management: General Principles and Practical Applications, Cleveland Clinic Journal of Medicine, Nov 2009; 76(4), S126- 32. Patel et al. Addendum of Newer Anticoagulants to the SIR Consensus Guideline, JVIR 24(5); May 2013, 641-45.Hold 2 days Xarelto, Eliquis package inserts Updated 10/5/15.