CAR/CAIR Practice Guidelines: Periprocedural Management of Patient Bleeding Risk

Abstract

French

These practice guidelines, developed by the Canadian Association for Interventional Radiology (CAIR) and the Canadian Association of Radiologists (CAR) with input from hematology experts, provide evidence informed, practical recommendations for managing bleeding risk during image guided procedures. Building on the 2019 Society of Interventional Radiology guideline, they streamline decision making around anticoagulation, antiplatelet therapy, laboratory testing, and transfusion thresholds for use across Canadian radiology departments. A systematic review of post 2019 evidence and expert consensus-informed updates to procedural risk stratification and clarified INR and platelet thresholds. The guidance emphasizes that most radiologic procedures carry very low bleeding risk and generally do not require routine laboratory screening or interruption of anticoagulant or antiplatelet medications, while high risk procedures warrant targeted testing and standardized transfusion thresholds, including those tailored for chronic liver disease. Special sections address lumbar puncture, arterial access, and urgent or emergent procedures. Overall, the guideline highlights individualized clinical judgment, avoidance of unnecessary delays or consultations, and careful consideration of transfusion risks, with the goal of promoting streamlined, safe, and consistent care across Canadian imaging practices.

Keywords

interventional radiology image-guided procedures hemorrhage risk assessment anticoagulants antiplatelet therapy blood coagulation tests ablation techniques lumbar puncture periprocedural management

Introduction

The following guidelines were developed through a collaboration between the Canadian Association for Interventional Radiology (CAIR) and the Canadian Association of Radiologists (CAR), with invaluable input from hematology experts. The document provides practical, evidence-informed recommendations for managing bleeding risk in patients undergoing image-guided procedures. By simplifying complex decisions around anticoagulation, antiplatelet therapy, and transfusion practices, these guidelines aim to support quality improvement and promote optimal patient care.

These guidelines are intended to cover most scenarios in a radiology department but should not be considered absolute rules. They do not replace individualized clinical judgment. Each patient’s circumstances are unique, and radiologists must apply their professional judgment while considering local policies and available resources.

Methodology

The multidisciplinary authorship panel comprised 3 hematologists (JC, MP, RS), 3 interventional radiologists (AM, LMB, RP), and 2 diagnostic radiologists with procedural experience (KH, AG), supported by a CAR staff member with expertise in guideline development (CH). The panel reviewed the 2019 Society of Interventional Radiology (SIR) guidelines with the aim of enhancing their practicality for implementation across Canadian radiology departments. Key objectives included streamlining decision-making around bleeding risk, reducing unnecessary hematology consultations, minimizing unnecessary laboratory testing and transfusions, and minimizing risks to patients.

An extensive literature review was conducted to identify evidence published since 2019, that would potentially alter the recommendations from the SIR. Of 4381 articles screened by title and abstract, 70 progressed to full-text review. An additional 21 relevant articles were identified outside the initial search. Ultimately, 68 of 91 full-text articles were included in the evidence base. Where evidence was lacking, recommendations were informed by expert consensus.

Guiding Principles

Prediction of bleeding risk in image-guided procedures is challenging, with limited evidence to guide practice. However, several guiding principles can help simplify and improve clinical decision-making:

Past bleeding is the most important predictor of bleeding risk. The most important predictor of a bleeding complication is that a patient has had a prior significant bleeding event. A prior bleeding event is a significant enough factor in decision-making that should override any other recommendations in these guidelines.

Laboratory tests are limited predictors of bleeding risk. Although these guidelines attempt to provide a simple and practical set of parameters to follow, each clinical scenario is unique. Laboratory tests such as platelet levels, INR, are limited predictors. Broad use of laboratory tests should be restrained, given the costs and strain on the medical system.

Discontinuation of antiplatelet and/or anticoagulation medication can be more harmful to the patient than the underlying baseline procedure complication rate. Do not ever stop a patient’s antiplatelet medication without consulting their prescribing cardiologist or neurologist, if the patient has a thrombosis, PCI, ablation, coronary stent, or neurological ischemic event within the last year.

Complication rates for image-guided procedures in radiology are very low. Delays or cancellations carry their own risks and costs, including postponed diagnosis and treatment. Per-procedural management of bleeding risk, antiplatelet/anticoagulant use, and blood product administration should be tailored to the patient’s unique medical history and physical attributes, the urgency of the procedure, and the physician’s experience and expertise.

There are complications associated with transfusion of blood products. When a transfusion of a blood product is considered to minimize the risk of bleeding complications, the possibility of serious transfusion complications needs to be considered and discussed with the patient. The most common causes of transfusion-related death and major morbidity are transfusion-related acute lung injury (risk 1 in 10 000) and transfusion-associated circulatory overload (risk 1 in 100).

The risk of bridging generally outweighs its benefits. Bridging anticoagulation – using full dose anticoagulants with a short half-life during the periprocedural period, to minimize “gaps” in anticoagulation – is not recommended for most patients. Randomized trials show that withholding bridging therapy results in similar rates of clotting but significantly less major bleeding compared to bridging, particularly in patients who have a low-to-moderate risk of clotting.^1,2 Bridging may be considered in select high-risk populations (eg, mechanical heart valves, very recent thrombosis); an expert in thrombosis medicine should advise on these patients.

For ease of reference, Table 1 divides procedures into low-risk and high-risk of bleeding complications. Table 2 provides a summary of recommendations for periprocedural management of bleeding risk, including pre-procedural INR and platelet screening. Please see the guideline’s Supplemental Material for a print-friendly summary of recommendations.

Table 1.

Classification of Procedure Risk.

Low-risk
• Breast procedures (ablations, biopsies including vacuum-assisted and large-gauge, drainage insertions, localizations) • Catheter exchanges (gastrostomy, biliary, nephrostomy, nephroureterostomy, ureteric stents, abscess drains, gastrostomy/gastrojejunostomy including conversions, etc.) • Chest tube placement for pleural effusion (tunneled and non-tunneled) • Diagnostic arteriography and arterial interventions, sheath size 6 Fr or less, all radial access • Diagnostic venography and venous interventions • Dialysis access interventions (fistulograms, fistula declotting, angioplasty, and stenting) • Facet joint injections and medial branch nerve blocks (thoracic and lumbar spine) • IVC filter placement and removal • Lumbar puncture • MSK injections (joints, tendons, and muscles) • Nerve blocks (sacral lateral branch blocks, hypogastric, celiac plexus) • Paracentesis • Peritoneal drains (tunneled/non-tunneled) • Superficial abscess drainage or biopsy (palpable lesion, lymph node, soft tissue, thyroid, superficial bone, eg, extremities and bone marrow aspiration) • Superficial MSK ablations • Suprapubic catheter insertion • Thoracentesis • Transjugular liver biopsy • Tunneled venous catheter placement/removal (including ports) • Venous access and removal (PICC, Hickman, ports, tunneled and non-tunneled dialysis line insertion)
High-risk
• Ablations (liver, renal, lung) • Advanced thoracic venous intervention (SVC recanalization) • Arterial procedures (sheath size 7 Fr or greater) • Biliary procedures (PTC, biliary drain, cholecystostomy) • Cervical blocks and epidural injections • Deep fluid/abscess drainage • Feeding catheter insertions (gastrostomy, gastrojejunostomy, direct jejunostomy) • Lung biopsy, lung nodule coil localization • Lumbar CSF drain insertion • Nephrostomy • Solid deep organ biopsy (liver, renal, prostate), deep lymph node/soft tissue biopsy (retroperitoneal, pelvic, mediastinal) • Transjugular intrahepatic porto-systemic shunt (TIPS)/direct portal vein access • Venous and pulmonary artery thrombectomy* • Vertebroplasty/kyphoplasty

These patients are almost always fully anticoagulated; do not interrupt anticoagulation prior to the procedure. Follow the ISTH guidelines for platelet thresholds in patients with thrombocytopenia.³

Table 2.

Laboratory Testing Recommendations.

Procedure	Normal liver function	Chronic liver disease
Low-risk	Platelet and INR: do not screen. However, if bloodwork has already been performed: INR: correct to within range of 2.0-3.0 Platelet: transfuse if <20 × 10⁹/L	Platelet and INR: do not screen. However, if bloodwork has already been performed: INR: N/A Platelet: transfuse if <20 × 10⁹/L
High-risk	Routinely screen platelet and INR INR: correct to <1.8 Platelets: transfuse if <50 × 10⁹/L	Routinely screen platelet and INR INR: correct to <2.5 Platelet: transfuse if <30 × 10⁹/L

Note. These recommendations are based on the 2019 Society of Interventional Radiology guidelines,⁴ but have been simplified to remove fibrinogen, and to give an absolute cutoff for INR and platelets. Laboratory tests are considered valid if within 12 weeks for a stable outpatient and within 72 hours for an inpatient.

Platelet transfusions should be administered as close as possible to the procedure, ideally immediately before or during it in the imaging department once the procedure is confirmed to be proceeding as planned. Platelet units are pathogen-reduced, have a small volume (180 mL), and the platelets are suspended in platelet additive solution – all 3 mitigate the risk of transfusion reactions and make them safe to transfuse in the Diagnostic Imaging Department.

For additional context regarding testing thresholds for patients with chronic liver disease, see Appendix A.

Low-Risk Procedures

Low-risk procedures are commonly performed with the additional safety of imaging guidance. Most patients undergoing low-risk procedures in the radiology department have a very low rate of hemorrhagic complications – usually less than 1%. These procedures are considered safe to perform without the need to perform pre-procedure blood work or to routinely discontinue anticoagulant or antiplatelet medications. Patients with a prior history of bleeding or who are high-risk for bleeding (eg, bleeding disorder) may require hematology referral for pre-procedure assessment of bleeding risk. Routine preprocedural testing of INR, platelet count, or fibrinogen level are not required. If testing is performed or recently available, an INR of less than 3.0 and a platelet count above 20 × 10⁹/L are considered acceptable thresholds (and fibrinogen level >1.0 g/L for patients with underlying liver disease). These thresholds are unchanged from prior SIR 2019 guidelines.⁴

Thoracentesis, Chest Tubes, and Paracentesis

Despite traversing the pleural space, thoracentesis and non-tunneled chest tubes are low-risk procedures, commonly performed in acutely ill patients. There is low bleeding risk ranging from 0.2% to 0.4% even with uncorrected lab values and continuation of antiplatelet and/or or anticoagulation.^5-8 Paracenteses are a common procedure, including in patients with cirrhosis-associated coagulopathy, and increasingly with imaging guidance. Bleeding risk is <0.2%⁹ with no association established between bleeding and INR, platelet count, user experience, or image guidance.^9-12

Superficial Biopsy or Abscess Drainage

Superficial biopsy and abscess drainage refers to procedures that do not penetrate the pleural or abdominal cavities (including peritoneal and retroperitoneal spaces). These procedures typically involve:

Palpable lesions

Lymph nodes (neck, axilla, inguinal, or other superficial sites that can be easily compressed)

Breast tissue

Soft tissue

Thyroid

Superficial bones (including extremities)

Bone marrow aspiration

Most of these procedures are performed using smaller gauge needles, typically ranging from 25G to 18G.¹³ However, sarcoma protocols and breast biopsies require larger gauges, ranging from 14G to greater than 9G. Notably, the use of 9G needles or larger, even in patients on full-dose antiplatelet therapy, has not been associated with clinically significant bleeding in breast procedures, especially when vacuum assistance is used.^14,15

Bone marrow biopsies carry a bleeding risk of less than 0.03%, with no observed correlation to thrombocytopenia.^16-18 There are limited data on bleeding risks for superficial lymph node and soft tissue biopsies. However, due to their superficial location, compression at the biopsy site is generally effective in managing bleeding risk. It is reasonable to extrapolate safety data from other superficial procedures to these sites. The panel consensus is to continue classifying these procedures as low-risk.

Suprapubic Catheter Insertion

Percutaneous access to the bladder is extraperitoneal, in a contained space. The risk profile of suprapubic catheter insertions is therefore comparable to insertions of other superficial drains. Suprapubic catheter insertion carries an estimated bleeding risk of 0.4%.¹⁹ In the rare scenario of bleeding post insertion, the relatively superficial and contained potential space should allow for control of hemorrhage by applying pressure.

Musculoskeletal Procedures

Low-risk musculoskeletal (MSK) procedures include injections, nerve blocks, trigger point injections, and joint aspirations, further detailed in Table 1. Common spine procedures, such as lumbar punctures and facet blocks, are considered low risk. Available data indicates that MSK procedures carry a bleeding risk of less than 1%.^20-22

Catheter Exchange or Removal

Catheter exchanges (ex. nephrostomy) are typically performed over a wire through an already established tract, which has often matured over weeks to months. Thus, it is accepted that these are low-risk. Similar rationale applies to drain removal. If there is concern regarding removal in the event of a recently placed catheter, the inserting service may be contacted for guidance. Tunneled catheters are included in this rationale, with limited available literature not supporting pre-removal lab values.²³

Venous Procedures

Low-risk venous procedures include diagnostic venography, select venous interventions, IVC filter placement/removal, non-tunneled venous access/removal, and tunneled venous access/removal as outlined in Table 1. These procedures are considered low-risk primarily due to the low-pressure nature of the venous system, which generally results in less significant bleeding compared to arterial procedures.

Tunneled catheter placement has been shown to be safe even in patients with elevated INR, thrombocytopenia, or taking full dose anticoagulation, with bleeding risk estimated at less than 0.5%.^24,25 For non-tunneled and peripheral catheters, the available data are of lower quality, but current evidence suggests no significant difference in bleeding risk between thrombocytopenic and non-thrombocytopenic patients.^26-28 Given this evidence, it is reasonable to extrapolate risk from tunneled catheter data. Further, a recent small study showed even in critically ill patients with severe thrombocytopenia, bleeding risk was not elevated in ultrasound guided central venous catheter placement, nor was platelet administration found to reduce risk of bleeding.²⁹ Recent guidance from the Association for the Advancement of Blood & Biotherapies and International Collaboration for Transfusion Medicine Guidelines indicates that platelet transfusion is recommended for patients undergoing IVC placement when platelet count is <10.³⁰

High-Risk Procedures

In image guided procedures, high-risk interventions include both common and rare procedure types, as listed in Table 1. The panel recommends adhering to the SIR 2019 guidelines for management of patient bleeding risk, which are summarized in Table 2. These guidelines are generally conservative, and some deviation may be appropriate in specific cases. Mounting evidence suggests that certain procedures may be safely performed while patients are on anticoagulants, and particularly while on antiplatelet therapy. These procedural variants are described below.

Solid Organ Biopsy

Most solid organ biopsies, including those of the liver, lung, kidney, adrenal glands, and prostate are considered high-risk procedures. This classification also applies to lymph nodes that are not easily accessible or located in areas where compression for hemostasis is challenging, such as retroperitoneal, mediastinal, and deep pelvic nodes. Among these, renal biopsies carry the highest bleeding risk at 1.6%, with low platelets – but not antiplatelet use – identified as a risk factor.³¹ A recent meta-analysis found no significant association between aspirin use and bleeding complications during renal biopsy.³² Therefore, kidney biopsy may be considered in patients on aspirin when clinically indicated, regardless of dose.

Liver biopsy has an overall bleeding risk of 0.7%.³³ Low platelet counts are a known risk factor, particularly in patients with chronic liver disease.^33,34 A recent retrospective study demonstrates safety of the application of the SIR 2019 guidelines to liver biopsy, with potential applicability to other organ biopsies.³⁵

Lung Biopsy

Bleeding after percutaneous (CT-guided) lung biopsy is one of its most clinically significant complications, typically self-limited but occasionally catastrophic. A large meta-analysis reported radiographic pulmonary hemorrhage in approximately 18% and hemoptysis in 4% of cases following core needle biopsy, compared with 6.4% and 1.7%, respectively, after fine-needle aspiration (FNA).³⁶ Once bleeding occurs, it can be difficult to control, and even a seemingly minor amount of intrapulmonary or airway hemorrhage can be fatal in frail or hypoxemic patients.

Ablation

Thermal ablations, including cryoablation, microwave ablation, and radiofrequency ablation, are generally considered high-risk procedures. A meta-analysis of 7 randomized studies evaluating RFA or microwave ablation for hepatocellular carcinoma (HCC) reported a bleeding risk of 0.98%.³⁷ Ablation techniques may cauterize the needle tract, potentially reducing bleeding risk. In certain patients where interruption of anticoagulation or antiplatelet therapy poses a significant risk (eg, mechanical heart valves, recent coronary stents), radiologists may weigh the risks and proceed with ablation while continuing these medications. Liver ablations are frequently performed in cirrhotic patients with thrombocytopenia. A recent large study did not demonstrate an association between bleeding post-ablation and thrombocytopenia in cirrhotic patients.³⁸

Deep Collection Drainage

Drain insertion of deeper collections, particularly in locations where bleeding control by compression is difficult, is also considered a high-risk procedure. However, the evidence regarding bleeding risk is limited. Transgluteal drain insertion, which is likely among the more complex approaches, has a reported complication rate of 2%.³⁹

This classification does not apply to pleural space procedures. Pleural drain insertions and thoracentesis are generally considered low-risk. In contrast, drain insertion into the lung parenchyma should be considered equivalent to lung biopsies and therefore classified as high-risk.

Spine Procedures

Spine procedures, including vertebroplasty, kyphoplasty, ablations, biopsies, are all considered high-risk procedures, with potential risk of cord compression in the context of significant epidural bleeding. Spine biopsy bleeding complication rates are estimated at less than 1%.⁴⁰ Lumbar punctures are not to be included in the high-risk group, as described below.

Genitourinary

Procedures involving the urinary tract, such as de novo nephrostomy tube placement, nephroureterostomy drain placement, and ureteric stone manipulation, are considered high-risk and comparable in bleeding risk to deep drain insertions. The estimated bleeding risk for percutaneous nephrostomy tube insertion ranges from 0.5% to 1.5%.^41-43 Recent evidence suggests that antiplatelet therapy does not significantly increase bleeding risk, allowing for some flexibility in discontinuation prior to nephrostomy tube placement.⁴⁴

Venous Interventions

Due to the low pressure of the venous circulation, almost all venous interventions are considered low-risk. Practically, the majority of these are performed with additional anticoagulation. However, venous interventions in the thorax, particularly in the context of SVC I recanalization, are best considered as high-risk. Potential bleeding in the pericardial or pleural space is more challenging to control, and warrants a more careful approach.

Feeding Catheters

De novo insertions of feeding catheters, including gastrostomy catheters, gastrojejunostomy catheters, direct jejunostomy catheters, and more advanced procedures such as direct endoscopic ultrasound-guided gastrojejunostomy track formation, are similarly considered high-risk procedures. Evidence regarding the impact of anticoagulation and antiplatelet therapy on bleeding risk is mixed. A single-center case series of 574 adults reported an upper gastrointestinal bleeding rate of 1.4% (8 of 574 patients).⁴⁵ In an endoscopic approach study, bleeding complication rate occurred in 0.2% of patients not on antiplatelet therapy, compared to 2.9% in those receiving antiplatelet agents.⁴⁶ A more recent study of 1234 patients found an association between bleeding and low platelet counts, antiplatelet therapy, and heparinization following gastrostomy insertion.⁴⁷ However, a large retrospective analysis reported no bleeding events in patients on therapeutic anticoagulation or antiplatelet therapy.⁴⁸ Over-the-wire exchanges, or exchanges through mature tracts of these catheters are considered low-risk procedures.

Biliary Interventions

Due to the proximity of biliary structures to arterial vessels and their intra-organ course through the liver, most de novo biliary procedures are considered high-risk. These include cholecystotomy, percutaneous transhepatic cholangiography (PTC), and biliary drain insertion and stenting. Reported bleeding complication rates for biliary drain insertion range widely from 0.61% to 15.85%, with more recent studies using ultrasound guidance falling at the lower end of this range.⁴⁹ Over-the wire exchanges, or through mature track exchanges are considered low-risk.

Transjugular Intrahepatic Porto-Systemic Shunt (TIPS) Creation

Transjugular intrahepatic portosystemic shunt (TIPS) procedures are considered high-risk due to the potential for breaching the liver capsule and puncturing a large, pressurized portal vein outside of liver parenchyma or a hypertrophied hepatic artery. TIPS revisions, such as angioplasty or stenting of an existing shunt without the formation of a new tract, are considered low-risk procedures.

Special Note on Lumbar Punctures

Background

Lumbar puncture is a common procedure performed across a wide range of medical services, both with and without image guidance. Abnormal laboratory values and medications that may impact the risk of bleeding are frequently encountered in patients undergoing this procedure. Lumbar puncture has an exceptionally low risk of spinal hematoma, estimated at 17 in 10 000 procedures⁵⁰ and is therefore considered a low-risk procedure for most patients.

Due to the rarity of spinal hematomas, data on neurological outcomes are limited. One comprehensive review of case reports found favorable neurological recovery in 57% of patients, suggesting a risk of approximately 7 per 10 000 for spinal hematoma with unfavorable neurological outcome.⁵¹ Decisions regarding transfusion of platelets or plasma, or withholding antiplatelet or anticoagulant therapies, must balance the theoretical reduction in bleeding risk against the known risks of transfusion-related complications and thrombotic events from medication interruption.⁵² There is no evidence that thrombocytopenia, abnormal coagulation tests, or withholding medications alters the risk of bleeding complications. The risks associated with platelet and plasma transfusion (Appendix B), as well as the potential for serious thrombotic complications from medication interruption, are likely to outweigh any benefit in reducing bleeding risk.

Lumbar CSF drain insertions should be considered separately from lumbar punctures. There is little evidence regarding their safety and complication rates. However, given the usual 14-gauge needle size required, this procedure is best considered high-risk.

Observational Studies Regarding Platelet or INR Thresholds

Numerous large retrospective studies totaling 317 840 lumbar punctures finds no increase in the risk of bleeding or neurological complications in patients with thrombocytopenia, on anti-platelet agents, on anti-coagulants, or with elevated tests of coagulation (Appendix C).

Randomized trials evaluating platelet or plasma transfusion prior to lumbar puncture are lacking, with systematic reviews estimating that over 47 000 participants would be needed to detect a meaningful reduction in major bleeding complications, highlighting the impracticality of such studies and the potential value of large-scale observational data instead.^53,54 Retrospective studies of patients on antiplatelet therapy undergoing lumbar puncture found no increase in complications such as spinal hematoma or neurological deficits, even among those continuing agents like ASA or adenosine diphosphate receptor antagonists.^55,56

Special Note on Angiography, Sheaths, and Closure Devices

Background

Most of the literature on the safety of arterial access with sheaths for endovascular arterial procedures originates from cardiology studies conducted over 25 years ago, which may not fully apply to modern practice due to advances like radial access, ultrasound guidance, and improved closure devices. Larger sheath sizes (≥7 Fr) are associated with increased risk of hematoma and pseudoaneurysm formation, but not necessarily major bleeding.⁵⁷ Overall bleeding risk remains low,²⁸ even in anticoagulated patients, based on large cardiology cohort studies.^58-60 Factors that may elevate the risk of a procedure using a 6 Fr sheath include: difficult arterial access in the context of obesity, underlying significant arterial disease at the site of access (which increases the risk of failure of vascular closure device use), and a patient history of significant bleeding following prior procedures.

Recommendations

Use the 6 to 7 Fr threshold between low- and high-risk as a guiding principle, not an absolute rule

Consider patient-specific factors that increase risk, including difficult arterial access (eg, obesity), significant arterial disease/stenosis at access site, prior history of bleeding complications

Procedures with sheaths ≥7 Fr may be performed without interrupting anticoagulation or antiplatelet therapy in select scenarios, including recent coronary stent insertion, mechanical heart valves, planned intra-procedural anticoagulation, favorable anatomy for closure device use. Stroke thrombectomy is commonly performed with sheath sizes of 8 Fr or greater, while the patient is receiving active thrombolytics or already on anticoagulation.

The final decision on how to proceed should involve shared decision-making between the operator and patient.

Managing Anticoagulation and Antiplatelet Medications

The following tables provide general guidance on the timing of anticoagulant and antiplatelet therapy around procedures with varying bleeding risk. These recommendations aim to balance the risk of perioperative bleeding with the need to prevent thromboembolic events. Table 3 addresses anticoagulant drugs, while Table 4 covers antiplatelet agents. The details regarding how to transfusion components and coagulation factor replacements (eg, prothrombin complex concentrates and fibrinogen) were considered out of scope and the reader is directed to recently published guidelines.^30,54,61,62

Table 3.

General Guidance on the Periprocedural Management of Anticoagulant Drugs.

Anticoagulant	Suggested last dose before low-risk procedures (0%-2% major bleed risk at 2 d)	Suggested last dose before high-risk procedures (>2 major bleed risk at 2 d)	Suggested first dose after high-risk procedures (>2% major bleed risk at 2 d)	Other considerations
Warfarin	No need to discontinue, unless concerns that patient will have a supratherapeutic INR on day −1	5 d	Same day, evening; consider bridging LMWH on day after procedure if patient has high thrombotic risk	If the patient’s INR is consistently supratherapeutic, you may elect to check INR on day −1 to ensure it is ≤1.8. Oral vitamin K can be administered if it is not below this level. If you are considering bridging after a procedure, consult the appropriate service (eg, internal medicine, thrombosis medicine, hematology)
Dabigatran (Pradaxa^®)	No need to discontinue	Evening, 2 d prior. (3 d if eGFR <50 mL/min)	1 d after	Ensure you have a current eGFR
Rivaroxaban (Xarelto^®)	No need to discontinue	2 d	1 d after
Apixaban (Eliquis^®)	No need to discontinue	Evening, 2 d	1 d after
Edoxaban (Savaysa^®)	No need to discontinue	2 d	1 d after
Therapeutic dose low molecular weight heparin (LMWH): dalteparin, enoxaparin, tinzaparin	No need to discontinue	24 h	1 d after	Starting prophylactic dose LMWH on day +1, prior to restarting therapeutic dose LMWH, is an option for patients with high risk for thromboembolism. If you are considering this strategy, consult the appropriate service (eg, internal medicine, thrombosis medicine, hematology)
Prophylactic dose low molecular weight heparin (LMWH): dalteparin, enoxaparin, tinzaparin	No need to discontinue	12 h	Same day, evening
IV unfractionated heparin (any dose)	No need to discontinue	4-6 h	6 h	Some institutions use “low-dose” and “standard-dose” IV unfractionated heparin regimens; periprocedural recommendations are the same for both. When resuming UFH post-operatively in a patient with high risk for bleeding, you may elect to avoid a bolus dose and commence with a similar or lower intensity infusion rate.
Subcut unfractionated heparin (prophylactic dose)	No need to discontinue	8 h	Same day, evening
Fondaparinux (Arixtra^®) (therapeutic dose)	No need to discontinue	2 d (3 d if eGFR <50 mL/min)	1 d after	Ensure you have a current eGFR
Fondaparinux (Arixtra^®) (prophylactic dose)	No need to discontinue	2 d (3 d if eGFR <50 mL/min)	Same day, evening	Ensure you have a current eGFR
Bivalirudin	No need to discontinue	2 h	4 h
Argatroban	No need to discontinue	2 h	4 h

Table 4.

General Guidance on the Periprocedural Management of Antiplatelet Drugs.

Antiplatelet	Suggested last dose before low-risk procedure (0%-2% major bleed risk at 2 d)	Suggested last dose before non-low-risk procedure (2%-4% major bleed risk at 2 d)	Suggested first dose after non-low-risk procedure (2%-4% major bleed risk at 2 d)
ASA	No need to discontinue	5 d	Same day, evening
Ticagrelor	No need to discontinue	3 d	Same day, evening
Clopidogrel	No need to discontinue	5 d	Same day, evening
Prasugrel	No need to discontinue	7 d	Same day, evening
ASA/dipyridamole (Aggrenox)	No need to discontinue	3 d	Same day, evening

How Should We Manage Anticoagulants Before Urgent (6-24 Hours) or Emergent (<6 Hours) Procedures

For direct oral anticoagulants (dabigatran, rivaroxaban, apixaban, edoxaban), a DOAC level can be measured if available. DOAC levels refer to anti-factor Xa assays for rivaroxaban, apixaban, and edoxaban, and dilute thrombin time for dabigatran. If the anti-factor Xa level is <50 ng/mL or the dilute thrombin time is <50 seconds, there is likely minimal residual anticoagulant effect; you can proceed with the procedure without considering a reversal agent. If the DOAC level is at or above these cutoffs, or is unknown, consider a reversal agent. Reversal agents for DOACs comprise prothrombin complex concentrates (for apixaban, edoxaban, or rivaroxaban), and idaracizumab (for dabigatran). A guide to reversal agents for DOACs in the setting of bleeding – which also applies to reversal in the setting of urgent or emergent procedures is available from Thrombosis Canada.⁶³

If a patient is receiving UFH, and there is insufficient time to stop the drug before a procedure, protamine sulfate can be used to reverse the anticoagulant effect; 1 mg of protamine reverses 100 U of UFH. A practical approach to calculate the amount of heparin to be reversed is to take 100% of the UFH dose given in the previous hour + 50% of the UFH dose given in the hour before + 25% of the UFH dose given in the hour before that; this is an estimate of the amount of UFH to be reversed. The usual initial dose of protamine is 20 to 50 mg by slow IV infusion over 15 to 20 minutes due to the risk of anaphylactoid reactions. Protamine is much less effective for LMWH than for UFH, although it should still be used if necessary.

No reversal agent is currently available in Canada for fondaparinux.

Andexanet alfa is a specific reversal agent that rapidly reverses the anticoagulant activity of all factor Xa inhibitors (UFH, LMWH, fondaparinux, and oral direct factor Xa inhibitors such as rivaroxaban, apixaban, and edoxaban). At this time it has not been approved for public reimbursement in any provincial or territorial jurisdiction in Canada, hence it is not widely available.

How Should We Assess Our Patient’s Unique Bleeding and Thrombotic Risks?

The above tables provide general guidance on periprocedural management of anticoagulant and antiplatelet drugs. It is acceptable to deviate from the general guidance provided, based on local practice patterns. This guidance may also be modified depending on a patient’s unique bleeding and thrombotic risks.

A patient’s perioperative risk for thrombosis involves estimating the risk for arterial thrombotic events (including stroke and systemic embolism for patients with atrial fibrillation or a mechanical heart valve), and the risk for venous thromboembolism (including a history of venous thromboembolism, inherited or acquired thrombophilias, or active cancer).

A patient’s perioperative risk for bleeding should consider procedure-related factors, as outlined in the tables above. It should also consider medications, including allopathic medications like aspirin, and non-allopathic and complementary therapies. Risk assessment should also account for a personal or family history of bleeding disorders or excessive bleeding, and comorbidities which may increase bleeding risk (eg, age >65, EtOH use, hypertension, stroke, renal dysfunction, liver dysfunction). Ultimately, the best predictor of whether a patient will bleed with a procedure is whether they have bled with previous procedures.

Patients with an elevated bleeding risk may require a longer hold prior to a procedure, and/or a delayed or modified restart after a procedure. Patients with an elevated thrombosis risk may require “bridging anticoagulation” – a strategy of administering a short acting parenteral anticoagulant while their usual oral anticoagulant is interrupted, to decrease the amount of time that a patient is not covered with anticoagulation. Inferior vena cava (IVC) filters should not be routinely used in the periprocedural setting. IVC filters have shown no reduction in pulmonary embolism (PE) or mortality compared to standard pharmacologic prophylaxis, while filter placement is associated with increased risks such as deep vein thrombosis (DVT), filter-related complications (eg, migration, fracture, thrombosis), and low retrieval rates.⁶⁴

Patients who are felt to have an unusually high bleeding or thrombotic risk should be referred to the appropriate service (eg, internal medicine, thrombosis medicine, hematology) for their advice on periprocedural management.

Limitations

These recommendations reflect expert consensus in areas where high-quality evidence is limited. Key gaps include the lack of observational studies to quantify bleeding risk for cervical nerve blocks, uncertainty around the safety and classification of peripheral nerve cryo-thermolysis, and insufficient validation of emerging tests such as ROTEM. Further research is needed to strengthen these recommendations, and the Working Group welcomes the opportunity to update and refine this guidance as new evidence becomes available.

Conclusion

These guidelines are designed to make everyday decisions about patient management more practical for radiologists managing bleeding risk during image-guided procedures. They build on the 2019 SIR recommendations,⁴ but adapt them for Canadian practice, adding clarity where evidence was limited and simplifying steps that were challenging to implement. Our aim throughout is straightforward: to help teams prepare patients safely, reduce unnecessary delays, and keep care consistent across departments. Most image-guided procedures are very safe, with a low risk of complications, so in most cases, routine bloodwork or stopping antiplatelet and anticoagulant medications is not needed.

Footnotes

Appendix A

Appendix B

Appendix C

Acknowledgements

The authors would like to thank the members of the Canadian Association of Radiologists and the Canadian Association for Interventional Radiology who took the time to provide their feedback and peer review during the drafting of these guidelines.

ORCID iDs

Kelly Harper

Casey Hurrell

Menaka Pai

Alexandre Menard

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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