# Blood thinners around cancer surgery, biopsy and endoscopy: when to stop, whether to bridge, when to restart

Source: https://onco.cc/protocols/antithrombotic-interruption-around-surgery/  
OnCo record `antithrombotic-interruption-around-surgery` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

If you take a blood thinner and need an operation, biopsy or endoscopy, your team will make a written plan saying exactly when to take your last dose and when to restart. Aspirin is often continued. Warfarin is usually stopped five days before, and the newer tablets (apixaban, rivaroxaban, edoxaban, dabigatran) one to three days before. Most people do not need heparin injections in the gap.

## Summary

The CHEST 2022 guideline (44 recommendations, GRADE) makes two strong recommendations: against heparin bridging in atrial fibrillation, and to continue a vitamin K antagonist for pacemaker or defibrillator implantation; the rest are conditional, and the panel states that most perioperative questions remain uncertain. BRIDGE (n=1884, AF, warfarin) found no bridging noninferior for arterial thromboembolism (0.4% vs 0.3%) with less major bleeding (1.3% vs 3.2%). PAUSE (n=3007, AF, apixaban, dabigatran, rivaroxaban) omitted the DOAC 1 day before a low-bleeding-risk and 2 days before a high-bleeding-risk procedure, resumed 1 day or 2 to 3 days after, without bridging or coagulation testing, with low rates of bleeding and stroke. ASH 2018 recommends strongly against periprocedural LMWH bridging for people on anticoagulation for VTE. For endoscopy, BSG/ESGE 2021 continue aspirin for all procedures (strong, low), continue P2Y12 inhibitors and warfarin for low-risk procedures, stop P2Y12 inhibitors 7 days and warfarin 5 days before high-risk procedures in people at low thrombotic risk (INR below 1.5), take the last DOAC dose 3 days before a high-risk procedure (5 days for dabigatran with CrCl 30 to 50), and resume up to 2 to 3 days after (strong, moderate). Unlike CHEST, BSG/ESGE still bridge with LMWH for warfarin in high thrombotic risk (mechanical valves, AF with mitral stenosis, VTE within 3 months). Coronary stents: liaise with a cardiologist before stopping a P2Y12 inhibitor.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: perioperative anticoagulation management; bridging anticoagulation; heparin bridging; stopping warfarin before surgery; stopping DOAC before surgery; periprocedural antithrombotic management; stopping clopidogrel before biopsy

## Connected records

- protocols: [Anticoagulants and antiplatelet drugs around elective endoscopy and endoscopic biopsy](https://onco.cc/protocols/anticoagulants-and-antiplatelets-before-endoscopy/), [Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations](https://onco.cc/protocols/vte-prophylaxis-after-cancer-surgery/), [Routine tests before planned surgery, by size of operation and fitness](https://onco.cc/protocols/routine-preoperative-tests/)
- technologies: [Cancer-associated thrombosis prevention and treatment](https://onco.cc/technologies/cancer-associated-thrombosis/)
- drugs: [Aspirin](https://onco.cc/drugs/aspirin/)
- terms: [Biopsy](https://onco.cc/terms/biopsy/), [Core needle biopsy and fine-needle aspiration (FNA)](https://onco.cc/terms/core-needle-biopsy/)

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