Management of Anticoagulation for Cold Knife Cone Cervical Biopsy
Pre-Procedure Protocol
- Warfarin should be discontinued 5 days before a cold knife cone cervical biopsy, with INR checked prior to the procedure to ensure it is <1.5, as recommended by the American College of Gastroenterology 1, 2, 3
- Cold knife cone cervical biopsy is considered a high-risk endoscopic/surgical procedure due to its potential for significant bleeding, according to the American Society for Gastrointestinal Endoscopy 1, 4
Patient Risk Stratification
- Patients without venous thromboembolic events for more than 3 months are considered low thrombotic risk, as defined by the American Geriatrics Society 7, 8
- Patients who have previously experienced a thromboembolic event are considered high thrombotic risk, as defined by the American Geriatrics Society 7, 8
Protocol for Low Thrombotic Risk Patients
- Stop warfarin 5 days before the procedure, as recommended by the American College of Cardiology 2, 3
- Check INR prior to the procedure to ensure it is <1.5, as recommended by the American College of Gastroenterology 2, 6
Protocol for High Thrombotic Risk Patients
- Stop warfarin 5 days before the procedure and commence daily therapeutic dose of Low Molecular Weight Heparin (LMWH) two days after stopping warfarin, as recommended by the American College of Chest Physicians 2, 3, 6
- Administer the last dose of LMWH at least 24 hours prior to the procedure, as recommended by the American College of Chest Physicians 3, 6
Important Considerations
- All patients should be advised of the thrombotic risks of discontinuing warfarin and the hemorrhagic risks of continuing therapy, as recommended by the American Heart Association 1, 6
- Even when temporarily discontinued, warfarin therapy is associated with an increased risk of post-procedure bleeding compared to non-anticoagulated patients, as reported by the American College of Gastroenterology 3, 5