Can anticoagulation therapy be held prior to surgery in a patient with Antiphospholipid Syndrome (APLS)?

Anticoagulation Management Prior to Surgery in Antiphospholipid Syndrome

Anticoagulation should NOT be simply held prior to surgery in patients with antiphospholipid syndrome (APLS)—instead, bridging therapy with heparin or low molecular weight heparin (LMWH) is required to minimize the catastrophic risk of perioperative thrombosis in these hypercoagulable patients. 1, 2

Critical Understanding of APLS Perioperative Risk

Patients with APLS face uniquely dangerous perioperative periods when thrombotic risk peaks 2:

• Preoperatively during warfarin withdrawal - when anticoagulation is being reversed
• Postoperatively during the hypercoagulability period - despite heparin or warfarin therapy
• Postoperatively before adequate anticoagulation is re-established - the gap period 2

Minor alterations in anticoagulation, surgical stress, and infection can trigger widespread thrombosis in APLS patients 2. The underlying thrombotic risk is further amplified by anticoagulant withdrawal, immobilization, and intimal injury from surgery itself 3.

Recommended Bridging Protocol

All APLS patients on vitamin K antagonists (VKAs) require bridging therapy—this is not optional 1:

• Discontinue warfarin 5 days before elective surgery to allow INR normalization 1

• Initiate bridging with either:

  • Intravenous unfractionated heparin (UFH) infusion, OR
  • Subcutaneous LMWH at full anticoagulation doses 1

• Continue bridging therapy until 4-6 hours before surgery (for UFH) or give last LMWH dose 24 hours preoperatively 1, 3

• Target INR ≤1.5 at time of surgery to reduce major bleeding risk 1

Postoperative Anticoagulation Resumption

Resume anticoagulation as early as surgically safe 1, 3:

• Restart heparin or LMWH within 12-24 hours postoperatively if hemostasis is adequate 3
• Overlap with warfarin until therapeutic INR (2.5, range 2.0-3.0) is achieved 4, 1
• Continue lifelong anticoagulation with adjusted-dose VKA (target INR 2.5) as the preferred agent over DOACs in confirmed APLS 4

Evidence-Based Outcomes

A single-center study of 43 APLS patients undergoing 48 elective surgeries demonstrated that optimal guideline-based anticoagulation management reduced complications from 33% to 7% (OR 0.14,95% CI 0.02-0.81) 1. However, even with proper bridging, thrombotic events still occurred in 3 patients, all of whom had INR ≤1.5 at surgery 1.

Critical Pitfalls to Avoid

Never simply hold anticoagulation without bridging 1, 2:

• The thrombotic risk in APLS is not comparable to other anticoagulated patients
• All three thrombotic events in the largest perioperative APLS series occurred despite bridging therapy 1
• Catastrophic APLS can be triggered by inadequate perioperative anticoagulation 2, 3

Avoid DOACs as primary therapy in APLS 4:

• Current guidelines suggest VKAs over DOACs for confirmed APLS (weak recommendation, low-certainty evidence)
• DOACs have not been adequately studied in the APLS population for perioperative management

Ensure multidisciplinary coordination 2:

• Involve hematology for anticoagulation protocol
• Surgical team must understand the non-negotiable need for bridging
• Anesthesia must be aware of thrombotic and bleeding risks 3

The balance is precarious: patients with INR ≤1.5 had fewer major bleeds (6% vs 29%, OR 0.19) but all thrombotic events occurred in this group 1. This underscores that APLS patients cannot be managed with standard perioperative protocols—they require specialized bridging strategies that accept modestly higher bleeding risk to prevent potentially fatal thrombosis.