1 Select a procedure
Musculoskeletal & Pain
Oncology & Tumour Therapy
Women's Health
Vascular Health
Vascular Access & Intervention
Diagnostics
2 Patient thrombotic risk factors (optional — tick any that apply)
3 Select the antithrombotic agent
This is guideline-based general information only. Clinical judgement should always be used, and this does not replace an individual assessment — please seek further advice from our rooms or the relevant specialist for any specific patient.
Discuss a specific patient
Not sure, or a borderline case?
Get in touch with our rooms directly — especially for patients with a high thrombotic risk, renal impairment, or a procedure with a variable risk classification.
Contact our roomsCommon questions
How many days before a procedure should warfarin be stopped?
For high bleeding-risk procedures, warfarin is generally held for 5 days beforehand, with INR confirmed below 1.8 before proceeding. For low bleeding-risk procedures, warfarin is generally not withheld at all.
Do I need to stop apixaban or rivaroxaban before a procedure?
For high bleeding-risk procedures, apixaban and rivaroxaban are generally held for approximately 48 hours (longer with reduced kidney function). For low bleeding-risk procedures, DOACs are generally not withheld.
Is it safe to continue aspirin before a biopsy or injection?
For low bleeding-risk procedures such as superficial biopsies and joint injections, aspirin is not routinely withheld. For high bleeding-risk procedures, current SIR guidance recommends holding aspirin for 3–5 days, weighed against the patient's individual thrombotic risk.
How long before a procedure should clopidogrel be stopped?
Clopidogrel is generally held for 5 days before a high bleeding-risk procedure. It is not routinely withheld for low bleeding-risk procedures. Patients with a coronary stent placed within the last 12 months should not stop clopidogrel without first consulting their cardiologist.
Which interventional radiology procedures are considered low bleeding risk?
Low bleeding-risk procedures generally include image-guided joint injections, superficial biopsies, dialysis access interventions, IVC filter placement and uncomplicated removal, and peripheral arterial procedures with a sheath under 6 French.
Which procedures are considered high bleeding risk for anticoagulation purposes?
High bleeding-risk procedures generally include deep solid organ biopsy, tumour ablation, thrombolysis, complex IVC filter removal, and arterial procedures involving the aorta, pelvis, mesenteric vessels or a sheath of 7 French or larger.
What guidelines govern periprocedural anticoagulation management?
The primary reference is the Society of Interventional Radiology (SIR) 2019 consensus guidelines for periprocedural management of thrombotic and bleeding risk, which are endorsed by CIRSE (the Cardiovascular and Interventional Radiological Society of Europe).
Should a patient with a mechanical heart valve stop anticoagulation before a procedure?
Patients with a mechanical mitral valve or an older-generation mechanical aortic valve are considered high thrombotic risk. For these patients, minimising time off anticoagulation and considering bridging therapy is generally recommended, and this should be discussed directly with the proceduralist and treating cardiologist rather than decided from a general reference alone.
Quick reference: standard hold times before a high-risk procedure
Per SIR 2019 consensus recommendations (Table 6, Patel et al.). Applies to procedures classified as high bleeding-risk; low bleeding-risk procedures are generally performed without interrupting any of these agents.
| Agent | Typical hold before a high-risk procedure | Typical resumption after |
|---|---|---|
| Aspirin | 3–5 days (patient-specific — weigh indication and thrombotic risk) | Day after |
| NSAIDs | No firm recommendation; ~5 half-lives if felt necessary | — |
| Clopidogrel / Ticagrelor | 5 days | 6h (no load) / 24h (loading dose) — ticagrelor: day after |
| Prasugrel | 7 days | Day after |
| Warfarin | 5 days (confirm INR < 1.8) | Day after (same day if bridged) |
| Apixaban | 4 doses / ~48h (CrCl ≥ 50) or 6 doses / ~72h (CrCl < 50) | 24h |
| Rivaroxaban | 2 doses / ~48h (CrCl ≥ 30) or 3 doses / ~72h (CrCl 15–30) | 24h |
| Dabigatran | 4 doses / ~48h (CrCl ≥ 50) or 6–8 doses / ~72–96h (CrCl 30–50) | 24h |
| Edoxaban | 2 doses / ~48h | 24h |
| Unfractionated heparin (IV) | 4–6 hours | 6–8h |
| LMWH — prophylactic dose | 1 dose (~12–24h) | 12h |
| LMWH — therapeutic dose | 2 doses / 24 hours | 12h |
| Fondaparinux | 2–3 days (CrCl > 50) / 3–5 days (CrCl < 50) | 24h |
| Argatroban | 2–4 hours | 4–6h |
This tool provides general, guideline-informed educational information for clinicians and does not constitute individualised medical advice for any specific patient. It is based on the 2019 SIR consensus guidelines (endorsed by CIRSE), which are themselves explicit that these are not fixed rules and do not establish a legal standard of care — a physician may and should deviate from them as necessitated by the individual patient, practice setting, or available resources. For fasting requirements and guidance on metformin, other diabetes medications, or blood pressure/cholesterol medications, see our separate periprocedural fasting & medications guide or the interactive diabetes & regular medications guide.
Bleeding-risk categorisation for arterial procedures in the SIR framework depends on both sheath/catheter size and the vascular territory involved (peripheral vs aortic/pelvic/mesenteric/CNS) — the specific access and target for a planned case should be confirmed. Spine procedures with any risk of spinal or epidural bleeding, and cervical facet blocks, are treated as high bleeding-risk and are often further guided by regional-anaesthesia (ASRA/ESRA) neuraxial recommendations rather than the standard peripheral IR framework.
Patient thrombotic risk (mechanical valves, recent VTE, high-risk atrial fibrillation, recent coronary stents, active malignancy, and similar factors) can change whether bridging anticoagulation or multidisciplinary input is needed, regardless of the procedure's bleeding-risk category. Clinical judgement should always be used, and further advice should be sought from our rooms, the treating cardiologist, haematologist, or other relevant specialist for any patient where the picture is complex or the stakes of getting it wrong are high.
- Patel IJ, Rahim S, Davidson JC, et al. Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions — Part II: Recommendations. Endorsed by CIRSE. J Vasc Interv Radiol. 2019;30(8):1168-1184.
- Davidson JC, Rahim S, Hanks SE, et al. Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions — Part I: Review of Anticoagulation Agents and Clinical Considerations. J Vasc Interv Radiol. 2019;30(8):1155-1167.
- Narouze S, Benzon HT, Provenzano D, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications (second edition): guidelines from ASRA, ESRA, AAPM, INS, NANS and WIP. Reg Anesth Pain Med. 2018;43:225-262.
- Singhal A. Clarification of Lumbar Puncture Risk Categorization in Consensus Guidelines for Periprocedural Management of Thrombotic and Bleeding Risk. J Vasc Interv Radiol. 2022;33(9):1121-1122.
- Patel IJ, Davidson JC, Nikolic B, et al. Addendum of newer anticoagulants to the SIR consensus guideline. J Vasc Interv Radiol. 2013;24(5):641-645.