Clinical strategies for perioperative management of direct oral anticoagulants in patients treated for venous thromboembolism

초록

Purpose: Venous thromboembolism (VTE) is increasing in prevalence in Korea. Direct oral anticoagulants (DOACs)-including apixaban, rivaroxaban, edoxaban, and dabigatran-are now the standard treatment of VTE. A growing number of patients on these agents require procedures or surgery, yet optimal perioperative management remains unclear. Current Concepts: Appropriate perioperative management of DOACs is essential to minimize both bleeding and thromboembolic complications. Procedure-related hemorrhagerisk can be categorized as minimal (e.g., minor dental or cataract procedures), low to moderate (e.g., arthroscopy, cutaneous or lymph node biopsies, laparoscopic cholecystectomy, or inguinal hernia repair), or high risk (e.g., cancer or orthopedic surgery). Given the rapid onset and short half-life of DOACs, bridging therapy is rarely needed. For procedures with minimal bleeding risk, DOACs can generally be continued or withheld only on the day of the procedure. For low to moderate bleeding risk, the recommendation is to stop DOACs one day before and resume one day after the procedure. For high-risk procedures, DOACs should be discontinued two days prior and restarted two days post-procedure. Discussion and Conclusion: With Korea's aging population and improved cancer survival rates, clinicians are increasingly encountering patients on DOACs in the perioperative setting. However, some practitioners continue to rely on outdated practices based on warfarin or antiplatelet therapy. Improved outcomes require individualized DOAC management, tailored according to the specific agent, procedure-related bleeding risk, thromboembolic risk, and renal function. Promoting adherence to current, evidence-based protocols will optimize safety and efficacy for patients undergoing procedures while receiving DOAC therapy.

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