Perioperative Management of Acitrom (Vitamin K Antagonist) Before Surgery
Acitrom (a vitamin K antagonist similar to warfarin) should be stopped approximately 5 days before surgery and resumed 12-24 hours after surgery when adequate hemostasis is achieved. 1
Preoperative Management
Timing of Discontinuation
- Stop Acitrom approximately 5 days before surgery to allow INR to normalize 1
- The exact timing depends on the patient's current INR and the target INR for the procedure 1
- For minor dental procedures, dermatologic procedures, or cataract surgery, consider continuing Acitrom with local hemostatic measures instead of stopping 1
Bridging Therapy Recommendations
- For patients with high thromboembolism risk (mechanical heart valve, atrial fibrillation with high CHADS2 score, recent VTE), use bridging anticoagulation during Acitrom interruption 1
- For patients with low thromboembolism risk, no bridging is recommended 1
- When bridging is needed, use therapeutic-dose LMWH with the last dose administered approximately 24 hours before surgery 1
Risk Stratification for Bridging Decisions
High Thromboembolism Risk (Bridging Recommended)
- Mechanical heart valve (mitral position, older aortic valve, or stroke/TIA within 6 months) 1
- Atrial fibrillation with CHADS2 score ≥5 or recent stroke/TIA within 3 months 1
- Recent VTE within 3 months or severe thrombophilia 1
Low Thromboembolism Risk (No Bridging Needed)
- Bileaflet aortic valve without risk factors 1
- Atrial fibrillation with CHADS2 score ≤2 without prior stroke/TIA 1
- VTE >12 months ago with no other risk factors 1
Surgery-Specific Considerations
High Bleeding Risk Procedures
- For high bleeding risk procedures (neurosurgery, major surgery >45 minutes), ensure complete normalization of INR 1
- If bridging with LMWH is used, resume therapeutic-dose LMWH 48-72 hours after surgery rather than within 24 hours 1
Low-to-Moderate Bleeding Risk Procedures
- For procedures with lower bleeding risk, consider shorter interruption periods 1
- For minimal bleeding risk procedures (minor dermatologic, dental, or cataract procedures), consider continuing Acitrom with local hemostatic measures 1
Postoperative Management
Resuming Acitrom
- Resume Acitrom 12-24 hours after surgery (evening of or next morning) when adequate hemostasis is achieved 1
- Initial dose can be the patient's usual maintenance dose 1
- If bridging is used, continue LMWH until the INR returns to the therapeutic range 1
Monitoring After Resumption
- Check INR 5-7 days after resuming Acitrom to ensure therapeutic levels 1
- Monitor for signs of bleeding or thromboembolism during the transition period 1
Special Considerations
- For patients with coronary stents, defer elective surgery for at least 6 weeks after bare-metal stent placement and 6 months after drug-eluting stent placement 1
- For urgent surgery in patients on Acitrom, consider prothrombin complex concentrate rather than fresh frozen plasma for rapid reversal 2
- The risk of surgical bleeding if anticoagulants are continued is often lower than the risk of thrombosis if they are withdrawn inappropriately 3