Perioperative Management of Apixaban Before Hepatic Surgery for Cancer

Preoperative Management

The American College of Chest Physicians guidelines classify hepatic surgery for cancer as a high bleeding risk procedure due to the liver being a highly vascular organ 1
For high bleeding risk procedures like hepatic surgery, the American College of Chest Physicians recommends stopping apixaban 2 days before surgery (skip 4 doses) for patients with normal or mildly impaired renal function (CrCl ≥50 mL/min) 4, 3
This corresponds to approximately 4-5 half-lives of apixaban, allowing for minimal (≤6%) residual anticoagulant effect at the time of surgery 3

Apixaban has a half-life of 7-8 hours in patients with normal renal function 4, 2
Approximately 25% of apixaban is cleared renally, making it less dependent on kidney function than some other DOACs 2

The American College of Chest Physicians recommends resuming apixaban 2-3 days (48-72 hours) after hepatic surgery, once adequate hemostasis has been established 2, 3
For patients at high risk for thromboembolism, consider using a reduced dose (2.5 mg twice daily) for the first 2-3 days after resumption 2

The American College of Chest Physicians does not recommend bridging anticoagulation with heparin or low-molecular-weight heparin during the perioperative period for patients on apixaban 3, 2
The rapid offset and onset of action of apixaban obviates the need for bridging with short-acting anticoagulants 1

Routine coagulation tests like INR or aPTT may be insensitive to residual apixaban effect 3
If needed, DOAC-calibrated anti-factor Xa levels can be used to measure apixaban levels before surgery 3
Consider measuring apixaban levels if surgery is urgent (within 24 hours) 3