Table 3.1-1. Empiric perioperative bleeding risk classification with clinical implications for VKA- and DOAC-treated patients

Bleeding risk


Clinical implications


– Cataract surgery

– Dermatologic procedures (eg, biopsy)

– Gastroscopy or colonoscopy without biopsies

– Permanent pacemaker insertion or internal defibrillator placement (if bridging anticoagulation is not used)

– Selected procedures with small-bore needles (eg, thoracentesis, paracentesis, arthrocentesis)

– Dental extractions (≤2 teeth)

– Endodontic (root canal) procedure

– Subgingival scaling or other cleaning

Continue VKAs and DOACs without interruptiona


– Abdominal surgery (eg, cholecystectomy, hernia repair, colon resection)

– Other general surgery (eg, breast surgery)

– Other intrathoracic surgery

– Other orthopedic surgery

– Other vascular surgery

– Noncataract ophthalmologic surgery

– Gastroscopy or colonoscopy with biopsies

– Coronary angiographyb

– Selected procedures with large-bore needles (eg, bone marrow biopsy, lymph node biopsy)

– Complex dental procedure (eg, multiple tooth extractions)

– Interrupt VKAs for 5 days

– Interrupt DOACs for 1 day before and 1 day after surgery/procedure


– Any surgery or procedure with neuraxial (spinal or epidural) anesthesia

– Neurosurgery (intracranial or spinal)

– Cardiac surgery (eg, CABG, heart valve replacement)

– Major vascular surgery (eg, aortic aneurysm repair, aortofemoral bypass)

– Major orthopedic surgery (eg, hip/knee joint replacement surgery)

– Lung resection surgery

– Urologic surgery (eg, prostatectomy, bladder tumor resection)

– Extensive cancer surgery (involving, eg, pancreas, liver)

– Intestinal anastomosis surgery

– Reconstructive plastic surgery

– Selected procedures involving vascular organs (eg, kidney biopsy, prostate biopsy) or high bleeding risk interventions (eg, colonic polypectomy, endoscopic sphincterotomy, spinal injection, pericardiocentesis)

– Interrupt VKAs for 5 days

– Interrupt DOACs for 2 days before and 2 days after surgery/procedure

a There may be selected patients in whom VKA or DOAC interruption is warranted.

b The radial approach may be considered as carrying minimal bleeding risk compared with the femoral approach.

CABG, coronary artery bypass graft; DOAC, direct oral anticoagulant; VKA, vitamin K antagonist.