Thrombotic and Bleeding Risk Clinical Practice Guidelines (2019)

Society of Interventional Radiology

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

August 30, 2019

The Society of Interventional Radiology released recommendations on the periprocedural management of thrombotic and bleeding risk in patients undergoing percutaneous image-guided interventions in August 2019.[1,2]

A multidisciplinary team (cardiology, hematology, or vascular or internal medicine) approach is recommended for planning optimal periprocedural management in patients at high risk for thromboembolic or bleeding events.

Screening coagulation laboratory testing is not routinely recommended for patients with minimal bleeding risk factors who are undergoing procedures with low bleeding risk, but it may be considered for patients receiving warfarin or unfractionated heparin (UFH) or for those with an inherently higher risk of bleeding. Suggested laboratory value thresholds are as follows:

  • Correct the international normalized ratio (INR) to within a range of 2.0 to 3.0 or less

  • Consider platelet transfusion if the platelet count is below 20 × 109/L

  • For low bleeding risk procedures requiring arterial access, the recommended INR threshold is less than 1.8 for femoral access and below 2.2 for radial access

Obtain appropriate preprocedural coagulation testing for patients undergoing procedures with high bleeding risk. Activated partial thromboplastin time is no longer recommended. Suggested laboratory value thresholds are as follows:

  • Correct the INR to within a range of 1.5 to 1.8 or less

  • Consider platelet transfusion if the platelet count is below 50 × 109/L

In patients with chronic liver disease, judicious use of transfusion of plasma and platelets is recommended owing to the potential for increased portal pressure and transfusion-related adverse events. For patients with chronic liver disease undergoing an invasive procedure, consider adjusting the INR threshold higher and the platelet count threshold lower than in the general population to minimize unnecessary transfusions. It may be useful to measure the fibrinogen level; if it is low, replace with cryoprecipitate.

The guidelines also include a table with management recommendations for nearly two dozen specific anticoagulant and antiplatelet agents.

For more information, please go to Venous Thromboembolism (VTE), Deep Venous Thrombosis (DVT), International Normalized Ratio (INR) Targets: Venous Thromboembolism, and Perioperative Anticoagulation Management.

For more Clinical Practice Guidelines, please go to Guidelines.

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