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Perioperative Management of VKA

Procedural Bleed Risk, Based on ISTH Guidance Statements

  • 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

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%
Hypertension: BP>140/90 mmHg)
Age
Diabetes mellitus (type 1 or type 2) or treated with glucose lowering therapy
Prior stroke or TIA or arterial thromboembolism
Vascular disease: CAD, PAD, complex aortic plaque on imaging
Sex

CHADS2 score = 0

CHA2DS2VASc  score = 0

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References

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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

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​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.

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

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