Each year, 10% of the millions of people taking antithrombotic agents undergo surgery [1,2]. This situation is managed according to the bleeding risk if the operation is performed under anticoagulation and the thrombotic risk if the treatment is interrupted. In the latter case, the risk is proportional to the duration of the interruption, which is itself a function of the half-life of the drug. Basically, there are several possible scenarios (see Definition of risks).
- Non-haemorrhagic surgery: continuation of treatment without interruption;
- Very bleeding operation: temporary interruption of treatment;
- Patients at low risk of thromboembolism: interruption possible for 1-3 days depending on the substance;
- Patients at high risk of thromboembolism: continue treatment without interruption;
- Patients at high risk of thromboembolism and bleeding operations: substitution of long-acting agents with non-fractionated or low molecular weight heparin.
In any case, the decision is a matter for joint agreement between the anaesthetist, surgeon, attending physician and haematologist, and this discussion should take place well in advance to allow coherent organisation of the management. A haematological consultation is always beneficial in complex cases.
© CHASSOT PG, MARCUCCI Carlo, last update November 2019.
References
- BARON TH, KAMATH PS, McBANE RD. Management of antithrombotic therapy in patients undergoing invasive procedures. N Engl J Med 2013; 368:2113-24
- DUBOIS V, DINCQ AS, DOUXFILS J, et al. Perioperative management of patients on direct oral anticoagulants. Thromb J 2017; 15:14