No Bridging Required for This Patient
For a patient with calf vein DVT 40 days ago on a DOAC undergoing bladder surgery, bridging anticoagulation is not recommended. 1
Rationale Based on Thrombotic Risk Stratification
The 2022 American College of Chest Physicians guidelines classify VTE thrombotic risk into three categories, and this patient falls into the moderate risk category (VTE within 3-12 months), not high risk. 1 High-risk VTE requiring bridging consideration is defined as DVT within the first 3 months, especially within 1 month. 1 At 40 days post-DVT, this patient is beyond the highest-risk window.
Key Evidence Against Bridging with DOACs
DOACs have short half-lives (1-3 days), which minimizes the perioperative period without anticoagulation, thereby reducing thrombotic risk regardless of baseline VTE proximity. 1
Multiple guidelines explicitly state no need for preoperative heparin bridging when interrupting DOACs, except in very high thrombotic risk situations. 1
The French Working Group on Perioperative Hemostasis specifically notes: "There is no need for preoperative heparin bridging (UFH or LMWH) except for very thrombotic high-risk." 1
Perioperative DOAC Management for Bladder Surgery
Preoperative DOAC Interruption
Bladder surgery carries high bleeding risk due to the vascular nature of the procedure and difficulty achieving surgical hemostasis. 1
Timing of last DOAC dose depends on the specific agent and renal function: 1
For apixaban or rivaroxaban (Factor Xa inhibitors):
- If CrCl ≥30 mL/min: Stop 2 days before surgery for low bleeding risk, 3 days before for high bleeding risk 1
- Given bladder surgery is high-risk, use the 3-day interruption window
For dabigatran (direct thrombin inhibitor):
Postoperative Resumption Strategy
Resume therapeutic DOAC 48-72 hours postoperatively once surgical hemostasis is confirmed. 1
Interim prophylaxis approach: 1
- Start prophylactic-dose LMWH 6-8 hours after surgery if there are concerns about bleeding
- Continue prophylactic LMWH until 48-72 hours post-surgery
- Resume therapeutic DOAC 12 hours after the last prophylactic LMWH dose 1
Critical Pitfalls to Avoid
Do not bridge with therapeutic-dose heparin preoperatively. This significantly increases bleeding risk (31-fold increase in clinically relevant bleeding) without meaningful reduction in VTE recurrence for patients on DOACs. 1
Verify renal function before and after surgery. Bladder procedures can affect renal function, requiring DOAC dose adjustment. 1
Do not perform neuraxial anesthesia if DOAC interruption time is insufficient, particularly with dabigatran in elderly patients or those with renal impairment. 1
Special Consideration for Early-Phase VTE
While this patient at 40 days does not qualify, if surgery were occurring during the acute treatment phase (first 3 weeks for rivaroxaban, first 7 days for apixaban when higher loading doses are used), a multidisciplinary discussion would be warranted as standard protocols may not apply. 1 However, at 40 days, the patient should be on standard maintenance dosing, making this concern irrelevant.