How long should rivaroxaban (Xarelto) be held before an above knee amputation?

Rivaroxaban Management for Above Knee Amputation

Hold rivaroxaban for 2 days (48 hours) before an above knee amputation, with the last dose given 3 days prior to surgery (skipping 2 doses). 1

Bleeding Risk Classification

Above knee amputation is classified as a high-bleeding-risk procedure due to:

• Extensive tissue dissection and bone transection
• Large vascular exposure
• Significant wound surface area
• Prolonged operative time
• Risk of postoperative hematoma formation

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Preoperative Interruption Protocol

For patients with normal or mildly impaired renal function (CrCl ≥50 mL/min):

• Hold rivaroxaban for 2 days before surgery (skip 2 doses)
• This corresponds to 4-5 drug half-lives (rivaroxaban half-life: 8-9 hours)
• Results in minimal residual anticoagulant effect (≤6%) at time of surgery

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For patients with moderate renal impairment (CrCl 30-50 mL/min):

• Hold rivaroxaban for 3 days before surgery (skip 2 doses)
• Extended duration accounts for prolonged drug elimination

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For patients with severe renal impairment (CrCl 15-29.9 mL/min):

• Hold rivaroxaban for 4 days before surgery (skip 3 doses)
• One-third of rivaroxaban is eliminated renally as unchanged active drug, necessitating longer interruption

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Critical Management Points

Do NOT use bridging anticoagulation:

• The rapid offset and onset of rivaroxaban obviate the need for heparin bridging with UFH or LMWH
• Perioperative bridging increases major bleeding risk threefold (4.8% vs 1.6%) without reducing thromboembolic events

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Verification of anticoagulation status (optional):

• Prothrombin time (PT) with rivaroxaban-sensitive reagents can confirm low drug levels
• A PT close to control suggests low serum concentration
• This is not routinely required but may be useful in high-risk scenarios

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Postoperative Resumption

Resume rivaroxaban 48-72 hours after surgery once adequate hemostasis is established:

• Therapeutic anticoagulation is achieved within 2-4 hours of rivaroxaban administration
• For high thromboembolic risk patients, consider reduced dose (10 mg once daily) for first 2 days, then full dose (20 mg once daily)
• The rapid onset of action requires careful assessment of surgical hemostasis before resumption

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Common Pitfalls to Avoid

• Do not hold for only 24 hours: This is appropriate only for low-to-moderate bleeding risk procedures, not major amputations 1
• Do not use prophylactic hemostatic blood products: Even with high rivaroxaban concentrations, avoid prophylactic use before emergency surgery 4
• Do not forget renal function assessment: Failure to adjust for renal impairment can result in inadequate drug clearance and increased bleeding risk 1, 2
• Do not resume too early: Postoperative wound complications and hematoma formation are significant concerns in amputation surgery 5