Table 12. High bleeding risks: Guidelines for managing anticoagulation during procedures/surgeries.

PROCEDURE/SURGERY	BLEEDING RISK	DIAGNOSIS	THROMBO RISK	PROTOCOL *
(High bleeding risk) • Cutaneous: More complex procedures, i.e. hair transplantation, blepharoplasty, or facelifts. • Oral: More complex procedures such as complicated extractions, gingival and alveolar surgeries. • Opthalmic: Retinal surgery, complex lid and orbital surgery, patients who need retrobulbar anesthesia for ophthalmic procedures. • GI procedures: colonoscopic or gastric polypectomy, laser ablation and coagulation, endoscopic sphincterotomy, pneumatic or bougie dilation of strictures, percutaneous endoscopic gastrostomy, EUS-guided fine needle aspiration. • Cardiac procedures: Pacemaker/ICD insertion have more bleeding potential than bleeding from cardiac catheterization site. • Intracavitory surgery:Intraabdominal surgeries, intrathoracic surgeries, intracranial surgeries, • Neurosurgical procedures, neuraxial anesthesia and spinal puncture. • Orthopedic. • Genito-urinary: Transurethral resection of the prostate? • Obstetric-gynecologic. • plastic surgery. • Any procedures or surgeries that bleeding can not be controlled or stopped with simple intervention. Others:	.	VTE/pulmonary emboli **	.	.
	High	--- < 1 month	High	2 †
	High	--- 1-3 months	High	[4,2)
	High	--- Recurrent	Low	[5,4)
	.	Acute Arterial Emboli	.	.
	High	--- < 1 month	High	2, (4) †
	High	--- > 1 month	Low	4, (5)
	.	Non Valvular atrial fibrillarion (NVAF)	.	.
	High	Atrial fibrillation	Low	5, (4)
	High	---With risk factors (1)	High	4, (2)
	.	Heart Valve Prostheses	.	.
	High	Bileaflet AV ††	Low	5, [4]
	High	Other valves, multiple or with additional risk factors (2)	High	2, (4)

• For more urgent surgery, please review Section Managing High INR or Bleeding, "8. Patient who requires more rapid or urgent INR reversal before procedure/surgery". Large dose of intravenous Vit K may cause a period of warfarin resistance up to a week, when restart it
• * = In parathesis representing other choices.
• ** = Mechanical methods to help reduce DVT should be applied appropriately.
• (1) = Risk Factors: History of TIAs, CVA, systemic emboli, hypertension, LV systolic dysfunction, recurrent CHF, DM, rheumatic mitral valve disease, CAD, thyrotoxicosis.
• (2) = Risk factors: Atrial fibrillation, severe LV systolic dysfunction, recurrent CHF, previous thromboembolism, and hypercoagulable conditions.
• † Elective surgeries should be avoided in the first month after an acute venous or arterial thromboembolism. If the surgery is required within 2 weeks after an acute episode of venous thromboembolism and anticoagulation cannot be used, the patient should have venacaval filter inserted.
• †† = St. Jude Medical bileaflet aortic valve, CarboMedics bileaflet aortic valve, Medtronic-Hall tilting disk aortic valve.
• The availability of the low molecular weight heparin (LMWH) makes it convenient to use full dose heparin as an outpatient. Remember that the LMWH has a longer half-life than the unfractionated heparin (UFH).
• Note that protocols with post operative full dose heparin (#2, #3) are associated with more post operative bleeding and should be use when the risk of thromboemboli is significantly out weigh the bleeding problem. If these protocols are used, starting the full dose heparin should be delayed up to 24-48 hours.. This approach may not be beneficial in case the warfarin can be started early.
• Post operative SC heparin may be helpful in prevention of post operative venous thromboembolism with less bleeding complication.