What surgeries are considered intermediate?

Intermediate-Risk Surgeries

Intermediate-risk surgeries are defined as procedures with a 30-day major bleeding risk of 0-2% and a cardiac event risk of 1-5%, encompassing intraperitoneal, intrathoracic, carotid endarterectomy, head and neck, orthopedic, and prostate surgeries. 1

Bleeding Risk Classification (0-2% 30-Day Major Bleeding Risk)

The 2022 American College of Chest Physicians guidelines classify the following as low-to-moderate (intermediate) bleeding risk procedures 1:

Musculoskeletal Procedures

• Arthroscopy 1
• Foot/hand surgery 1
• Orthopedic surgery (general category) 1

Gastrointestinal Procedures

• GI endoscopy with biopsy 1
• Colonoscopy with biopsy 1
• Laparoscopic cholecystectomy 1

Gynecologic Procedures

• Abdominal hysterectomy 1

General Surgery Procedures

• Abdominal hernia repair 1
• Hemorrhoidal surgery 1

Other Procedures

• Cutaneous/lymph node biopsies 1
• Coronary angiography (particularly via radial approach) 1
• Bronchoscopy with biopsy 1
• Prostate surgery 1

Cardiac Risk Classification (1-5% Risk of MACE)

The ACC/AHA guidelines define intermediate cardiac risk procedures as 1:

Major Intra-Cavity Operations

• Intraperitoneal surgery 1
• Intrathoracic surgery 1

Vascular Procedures

• Carotid endarterectomy 1

Head and Neck Surgery

• Major head and neck operations 1

Important Clinical Considerations

Procedure Duration Matters

Any operation lasting >45 minutes automatically elevates to high-risk category regardless of the procedure type. 1 This is a critical pitfall—a seemingly intermediate-risk procedure can become high-risk based solely on operative time.

Complexity Variability

The same procedure can shift between risk categories based on individual patient factors and surgical complexity. 1 For example:

• An inguinal hernia repair may be low-to-moderate risk in a straightforward case but high-risk if technically complex 1
• Dental extractions are typically minimal risk but become intermediate risk with poor dentition or compromised gingival integrity 1
• Colonoscopy screening is minimal risk but becomes intermediate risk if polyp resection is anticipated 1

Anesthesia Type Override

Any procedure performed with neuraxial (spinal or epidural) anesthesia is automatically classified as high-risk due to the devastating consequences of epidural hematoma and potential lower limb paralysis. 1 This overrides the baseline procedural risk classification.

Anticoagulation Management Implications

For intermediate-risk procedures, some residual anticoagulant effect is acceptable (2-3 drug half-life interruptions pre-procedure), unlike high-risk procedures requiring 4-5 half-life interruptions. 1 This allows for shorter pre-operative interruption periods and earlier post-operative resumption of anticoagulation.

Access Site Considerations

Coronary angiography via femoral approach may require 1-2 days of anticoagulant interruption, while radial approach can be performed under full anticoagulation. 1 The access site fundamentally changes the risk stratification.