Do we need to hold Eliquis (apixaban) for an intra-arterial (IA) angiogram for peripheral arterial disease (PAD)?

From the Guidelines

Eliquis (apixaban) should be held for 24-48 hours before an IR angiogram for peripheral arterial disease (PAD), depending on the patient's renal function and bleeding risk, as recommended by the 2020 ACC expert consensus decision pathway 1. For patients with normal renal function, holding for 24 hours is often sufficient, while those with impaired renal function may need 48 hours. This recommendation is based on the fact that Eliquis is a direct oral anticoagulant (DOAC) that inhibits factor Xa and has a half-life of approximately 12 hours. Temporary discontinuation reduces the risk of bleeding complications during the invasive procedure. However, the decision to hold Eliquis should always be individualized based on the patient's thrombotic risk versus bleeding risk. Some key considerations include:

• Patient's renal function:
  • For transradial PCI, hold for 24 hours if creatinine clearance ≥30 ml/min, and 36 hours if creatinine clearance 15-29 ml/min 1.
  • For transfemoral PCI, hold for 48 hours if creatinine clearance ≥30 ml/min, and guide duration by agent-specific anti-Xa level or 72 hours if creatinine clearance less than 29 ml/min 1.
• Patient's thrombotic risk:
  • Patients with high thrombotic risk (recent venous thromboembolism, mechanical heart valves, or atrial fibrillation with high CHA₂DS₂-VASc score) may require bridging therapy with shorter-acting anticoagulants. Always consult with both the interventional radiologist performing the procedure and the provider who prescribed the anticoagulant to determine the optimal management strategy for each specific patient.

From the FDA Drug Label

Apixaban tablets should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding [see Warnings and Precautions (5. 2)] . Apixaban tablets should be discontinued at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding or where the bleeding would be non-critical in location and easily controlled.

Holding Eliquis (apixaban) for IR angiogram for PAD:

• The decision to hold apixaban should be based on the risk of bleeding associated with the procedure.
• For procedures with a moderate or high risk of bleeding, apixaban should be discontinued at least 48 hours prior to the procedure.
• For procedures with a low risk of bleeding, apixaban should be discontinued at least 24 hours prior to the procedure. 2 2

From the Research

Holding Eliquis for IR Angiogram in PAD Patients

• There is no direct evidence in the provided studies that specifically addresses the need to hold Eliquis (apixaban) for an IR angiogram in patients with Peripheral Artery Disease (PAD) 3, 4, 5, 6, 7.
• The studies primarily focus on the use of apixaban in various clinical settings, including its efficacy and safety in treating venous thromboembolism 4, 7, its potential benefit in patients undergoing infrapopliteal angioplasty for critical limb ischemia 3, and the management of PAD in general 5, 6.
• However, it is known that apixaban is an anticoagulant that works by inhibiting factor Xa, and its use may need to be managed carefully in procedures that carry a risk of bleeding, such as IR angiograms.
• The decision to hold Eliquis or any anticoagulant before a procedure should be based on the individual patient's risk of thromboembolism and bleeding, as well as the specific procedure being performed, and should be made in consultation with the patient's healthcare provider 3, 4, 5, 6, 7.

Management of Anticoagulation in PAD Patients Undergoing IR Angiogram

• The management of anticoagulation in patients with PAD undergoing IR angiogram is crucial to balance the risk of thromboembolism and bleeding 5, 6.
• Dual antiplatelet therapy (DAPT) has been shown to reduce mortality and the risk of repeat peripheral revascularizations in patients with PAD, without a significant increase in bleeding complications 5.
• However, the use of anticoagulants like apixaban in this setting is not well established, and more research is needed to determine the optimal anticoagulation strategy for patients with PAD undergoing IR angiogram 3, 4, 7.

Clinical Considerations

• Patients with PAD undergoing IR angiogram should be carefully evaluated for their individual risk of thromboembolism and bleeding, and the decision to hold or continue anticoagulation therapy should be made on a case-by-case basis 3, 4, 5, 6, 7.
• The healthcare provider should consider the patient's medical history, the specific procedure being performed, and the potential risks and benefits of holding or continuing anticoagulation therapy 3, 4, 5, 6, 7.