Perioperative Management of VKA

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Procedural Bleed Risk, Based on ISTH Guidance Statements

Minimal-bleed-risk surgery/procedure (30-d risk of major bleed approximately 0%)

Low-to-moderate-bleed-risk surgery/procedure (30-d risk of major bleed 0%-2%)

High-bleed-risk surgery/procedurea (30-d risk of major bleed ≥ 2%)

Minor dermatologic procedures (excision of basal and squamous cell skin cancers, actinic keratoses, and premalignant or cancerous skin nevi)
Ophthalmologic (cataract) procedures
Minor dental procedures (dental extractions, restorations, prosthetics, endodontics), dental cleanings, fillings
Pacemaker or cardioverter-defibrillator device implantation

Arthroscopy
Cutaneous/lymph node biopsies
Foot/hand surgery
Coronary angiography
GI endoscopy biopsy
Colonoscopy biopsy
Abdominal hysterectomy
Laparoscopic cholecystectomy
Abdominal hernia repair
Hemorrhoidal surgery
Bronchoscopy biopsy

Major surgery with extensive tissue injury
Cancer surgery, especially solid tumor resection (lung, esophagus, gastric, colon, hepatobiliary, pancreatic)
Major orthopedic surgery, including shoulder replacement surgery
Reconstructive plastic surgery
Major thoracic surgery
Urologic or GI surgery, especially anastomosis surgery
Transurethral prostate resection, bladder resection, or tumor ablation
Nephrectomy, kidney biopsy
Colonic polyp resection
Bowel resection
Percutaneous endoscopic gastrostomy placement, endoscopic retrograde cholangiopancreatography
Surgery in highly vascular organs (kidneys, liver, spleen)
Cardiac, intracranial, or spinal surgery
Any major operation (procedure duration > 45 min)
Neuraxial anesthesia
Epidural injections

Risk Stratification for Patient-specific Periprocedural Thromboembolism

Mechanical heart valve

Atrial Fibrillation

High (> 10%/y risk of ATE or > 10%/mo risk of VTE)

Moderate (4%-10%/y risk of ATE or 4%-10%/mo risk of VTE)

Low (< 4%/y risk of ATE or < 2%/mo risk of VTE)

Mitral valve with major risk factors for stroke Caged ball or tilting-disc valve in mitral/aortic position Recent (< 3 mo) stroke or TIA

CHA2DS2VASc score ≥ 7 or CHADS2 score of 5 or 6 Recent (< 3 mo) stroke or TIA Rheumatic valvular heart disease

Mitral valve without major risk factors for stroke Bileaflet AVR with major risk factors for stroke

CHA2DS2VASc score of 5 or 6 or CHADS2 score of 3 or 4

Bileaflet AVR without major risk factors for stroke

CHA2DS2VASc score of 1-4 or CHADS2 score of 0-2 (and no prior stroke or TIA)

VTE

Recent (< 3 mo and especially 1 mo) VTE Severe thrombophilia (deficiency of protein C, protein S or antithrombin; homozygous factor V Leiden or prothrombin gene G20210A mutation or double heterozygous for each mutation, multiple thrombophilias) Antiphospholipid antibodies Active cancer associated with high VTE risk

VTE within past 3-12 mo Recurrent VTE Non-severe thrombophilia (heterozygous factor V Leiden or prothrombin gene G20210A mutation) Active cancer or recent history of cancer

VTE > 12 mo ago

Calculate CHA2DS2VASc/ CHADS2 score

Congestive heart ailure: HFrEF, HFmrEF, HFpEF, asymptomatic LVEF ≤ 40%

No (0)

Yes (1)

Hypertension: BP>140/90 mmHg)

No (0)

Yes (1)

Age

< 65 (0)

65 - 74 (1)

≥ 75 (2)

Diabetes mellitus (type 1 or type 2) or treated with glucose lowering therapy

No (0)

Yes (1)

Prior stroke or TIA or arterial thromboembolism

No (0)

Yes (2)

Vascular disease: CAD, PAD, complex aortic plaque on imaging

No (0)

Yes (1)

Sex

Male (0)

Female (1)

CHADS2 score = 0

CHA2DS2VASc score = 0

-

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References

1) Thompson A, Fleischmann KE, Smilowitz NR, de las Fuentes L, Mukherjee D, Aggarwal NR, et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation [Internet]. 2024 Nov 5 [cited 2025 Jun 4];150(19):e351–442. Available from: https://doi.org/10.1161/CIR.0000000000001285

2) Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on atrial fibrillation. Chest 2010;137:263–272.

3) Lip GY, Frison L, Halperin J, Lane D. Identifying patients at risk of stroke despite anticoagulation. Stroke 2010;in press.