Low Bleeding Risk

CNS = central nervous system; DVT = deep vein thrombosis; INR = International Normalized Ratio; IVC = inferior vena cava; PE = pulmonary embolism; PT = prothrombin time.

Screening coagulation laboratory testing before low bleeding risk procedures should be considered for patients with risk factors for bleeding or those receiving warfarin or heparin drip if there is concern for supratherapeutic levels.

Thresholds for laboratory parameters are based largely on scientific consensus established in the literature from limited-quality studies and the consensus of the Writing Group and Standards Committee volunteers. INR ranges, reflecting the upper limits of thresholds, have been provided in the recommendations, as the varying degrees of bleeding risk within procedural categories should be taken into consideration. For example, an INR < 1.8 may be acceptable for a liver biopsy but an INR < 1.5 may be preferred before an aortic intervention, as the strategies and success of controlling unanticipated bleeding differ between the 2 procedure types. Similarly, an INR < 2.0 may be preferred for catheter placement procedures in which a subcutaneous tunnel is planned. Recommendations for patients with cirrhosis differ.

Low bleeding risk procedures involving percutaneous and venous access have been performed safely at INRs within the range of 2.0–3.0 (32–34). For low bleeding risk procedures that require arterial access, the recommended INR thresholds are < 1.8 for femoral access and < 2.2 for radial access (4). Interventions involving the creation of a subcutaneous tunnel (eg, pacemaker insertion, pleural or venous catheter placement) have traditionally been grouped into the low bleeding risk category. Preprocedure DOAC interruption > 24 h vs < 24 h was not identified as a potential risk factor for major bleeding events.

Injection and pain-management procedures follow the classification outlined by the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. These guidelines consider spine procedures with risk of spinal or epidural hematoma to be high bleeding risk procedures given that bleeding in this area could be difficult to manage and be associated with morbid consequences for the patient.

IVC filter placements and uncomplicated IVC filter removals would fall into the low bleeding risk category. For IVC filter removal, consider the anticipated technical complexity of the procedure (ie fractured legs, legs penetrating outside of IVC, tilt) and dwell time. Laboratory Parameters for High Bleeding Risk Procedures and Recommendation sets a platelet threshold of > 30 10^9/L for transjugular liver biopsy.

Clinical and technical nuances involved in catheter-directed lysis procedures and complex IVC filter retrieval cases should govern the target thresholds for INR and platelet count on an individual patient basis. For example, the INR target for complex IVC filter retrieval may be higher for patients in whom the interventionalist chooses to maintain anticoagulation medications during the case. Similarly, the bleeding risk for planned overnight lysis with lytic agents may be different than the bleeding risk in which only mechanical removal of clot is planned. However, both procedures are listed in the high bleeding risk category given that advanced techniques and/or medications will be used that may increase the complexity and procedural bleeding risk.

Transjugular intrahepatic portosystemic shunts are classified as high bleeding risk procedures, as tearing of the portal vein may be a fatal complication. Most patients who undergo transjugular intrahepatic portosystemic shunt creation will have chronic liver disease.