Table 11. Low bleeding risks: Guidelines for managing anticoagulation during procedures/surgeries.

PROCEDURE/SURGERY	BLEEDING RISK	DIAGNOSIS	THROMBO RISK	PROTOCOL
(Low bleeding risk) •Cutaneous: Local skin surgery, i.e. Mohs micrographic surgery, simple excisions, biopsy and repairs. • Oral: Simple dental procedures, i.e. simple tooth extraction, dental hygiene, restorations, endodontics, prosthetics and periodontal therapy. (Some dentists give antifibrinolytic agents such as tranexamic acid or Epsilon amino caproic acid mouthwash to help control local bleeding.) • Opthalmic: cataract extraction, trabeculectomy. • GI procedures: EGD w or w/o biopsy, flex sig w or w/o biopsy, colonoscopy w or w/o biopsy, diagnostic ERCP, biliary stent w/o sphincterectomy, endosonography w/o fine needle aspiration, push enteroscopy of the small bowel. • Miscellaneous: Joint and soft tissue aspirations and injections. Minor podiatric procedures, i.e. nail avulsions and phenol matrixectomy Others:	.	VTE/pulmonary emboli ** ††	.	.
	Low	--- < 1 month	High	1, 2
	Low	--- 1-3 months	High	1, 2
	Low	--- Recurrent	Low	5, 1
	.	Acute Arterial Emboli ††	.	.
	Low	--- < 1 month	High	1, 2
	Low	--- > 1 month	Low	5, 1
	.	Non Valvular atrial fibrillarion (NVAF)	.	.
	Low	Atrial fibrillation	Low	5, 1
	Low	--- With risk factors (1)	High	1,2,3,4
	.	Heart Valve Prostheses	.	.
	Low	Bileaflet AV †	Low	5, 1
	Low	Other valves, multiple or with additional risk factors (2)	High	1,2,3,4
			See "Thrombo embolic Risks" section



• 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.
• ** = 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,
• (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..
• Post operative SC heparin may be helpful in prevention of post operative venous thromboembolism with less bleeding complication.