Title:Perioperative Management of DOACs in Vascular Surgery: A Practical Approach
Volume: 24
Issue: 38
Author(s): George Kouvelos*, Miltiadis Matsagkas, Nikolaos Rousas, Petroula Nana, Konstantinos Mpatzalexis, Konstantinos Stamoulis, Athanasios Giannoukas and Eleni Arnaoutoglou
Affiliation:
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa,Greece
Keywords:
Vascular surgery, anticoagulants, perioperative period, invasive procedures, DOAC, bridging therapy.
Abstract: Background: Approximately 10–15% of patients on DOACs have to interrupt their anticoagulant
before an invasive procedure every year. The perioperative management and monitoring of DOACs have proved
to be challenging, as differences in patients’ status and in the invasiveness of each procedure develop different
situations that need a tailored therapeutic approach to each patient’s needs.
Methods: This review aims to summarize current evidence on the perioperative management of DOACs in patients
undergoing a vascular surgical procedure focusing with a practical approach on three key clinical questions:
(i) can we stop DOAC therapy before the vascular procedure? (ii) is bridging therapy necessary? and (iii) which is
the best perioperative strategy for interruption and resumption of the anticoagulant therapy?
Results: No specific data exist for the perioperative management of vascular surgery patients on DOACs, as most
studies include low number of such patients. Therapeutic strategy on how to handle DOACs perioperatively must
be based on their half-life, the bleeding risk of the invasive procedures, and on the thromboembolic risk of the
patient. Renal function plays a crucial role in such situations, increasing thromboembolic and bleeding risk. In
general, DOACs should be stopped 2 days for high bleed risk, 1 day for low risk and should be resumed 48-72 hrs
after high risk, 24 hrs after low-risk procedure. Bridging is almost never needed.
Conclusion: Further perioperative research studies on patients undergoing vascular surgery are needed to confirm
whether currently accepted therapeutic perioperative strategy is appropriate for these patients.
