Medication Management for Port Placement
For port placement, anticoagulants (warfarin, DOACs, heparin) should be held, while antiplatelet therapy management depends on bleeding versus thrombotic risk—aspirin can typically be continued, but P2Y12 inhibitors (clopidogrel, ticagrelor, prasugrel) should be discontinued 5-7 days before the procedure. 1, 2
Anticoagulant Management
Hold all anticoagulants before port placement:
- Warfarin: Discontinue and ensure INR normalizes to <1.5 before the procedure 1
- Unfractionated heparin: Hold before placement, but can resume 2-6 hours after the procedure 1
- Oral anticoagulants (DOACs): Hold for placement, but resume with the evening dose after the procedure 1
- Low molecular weight heparin (LMWH): Discontinue 24 hours prior to the procedure 3, 4
Port placement is considered a high-risk bleeding procedure due to the percutaneous nature and proximity to major vessels, making anticoagulation interruption necessary. 1
Antiplatelet Therapy Management
Aspirin (Low-Dose)
Continue aspirin throughout the perioperative period whenever possible 1, 2, 3
- Aspirin presents minimal bleeding risk for most procedures and the thrombotic risk of discontinuation typically outweighs bleeding concerns 2, 3
- This is particularly critical in patients with coronary stents or high cardiovascular risk 2
P2Y12 Inhibitors (Clopidogrel, Ticagrelor, Prasugrel)
Discontinue 5-7 days before port placement if thrombotic risk is acceptable: 2, 5, 4
- Clopidogrel: Stop 5 days before procedure 2
- Ticagrelor and Prasugrel: Stop 5-7 days before procedure 6
- Resume as soon as possible postoperatively (typically within 12-24 hours if hemostasis achieved) 2, 5
Critical exception—patients with recent coronary stents:
- Drug-eluting stents <6-12 months: Maintain aspirin, discontinue P2Y12 inhibitor only if absolutely necessary, and resume immediately postoperatively 2
- Bare-metal stents <4-6 weeks: Consider maintaining both aspirin and P2Y12 inhibitor if surgery cannot be delayed 2
- Never discontinue both aspirin and P2Y12 inhibitor simultaneously in patients with recent stents—this significantly increases stent thrombosis risk 2
Additional Medications to Consider
NSAIDs (excluding aspirin)
- May continue for low-risk procedures, but consider holding 1-4 days before port placement given the moderate bleeding risk 6
Phosphodiesterase Inhibitors
- Dipyridamole (Persantine), cilostazol (Pletal): Can be continued 4, 6
- Aggrenox (aspirin + dipyridamole): Consider discontinuing 3 days prior for moderate-risk procedures 6
Herbal Supplements with Bleeding Risk
Hold for 2 weeks before surgery: 1
- Garlic, ginkgo, ginseng, turmeric, vitamin E, feverfew, ginger, saw palmetto 1
- Fish oil/omega-3: Can be continued (prior bleeding concerns not supported by evidence) 1
Risk Stratification Framework
Port placement should be classified as a moderate-to-high bleeding risk procedure because it involves:
- Percutaneous access through tissue 1
- Proximity to major vessels (subclavian/internal jugular) 6
- Potential for difficult-to-compress bleeding sites 6
Assess thrombotic risk factors: 2
- Recent coronary stent (<12 months for drug-eluting, <6 weeks for bare-metal) 2
- History of stent thrombosis 2
- Mechanical heart valves 5
- Atrial fibrillation with high stroke risk 1
Critical Pitfalls to Avoid
- Never substitute antiplatelet therapy with heparin or LMWH in patients with coronary stents—this does not protect against stent thrombosis 2
- Do not discontinue both aspirin and P2Y12 inhibitors simultaneously in high-risk patients 2
- Ensure preprocedural laboratory assessment includes platelet count >50,000/mL and INR <1.5 1
- Administer preprocedural antibiotics (first-generation cephalosporin) to reduce peristomal infection risk 1
Multidisciplinary Coordination
Involve cardiology consultation for patients with: 2