Perioperative Management of Antiplatelet and Anticoagulant Therapy in Patients Undergoing Interventional Techniques: A Critical and Analytical Summary of the 2024 Guidelines of the American Society of Interventional Pain Physicians (ASIPP).

Abstract

Background: The frequency of performance of interventional techniques in chronic pain patients receiving anticoagulant and antiplatelet therapy continues to increase. Understanding the importance of continuing chronic anticoagulant therapy, the need for interventional techniques, and determining the duration and discontinuation or temporary suspension of anticoagulation also when bridging therapy is appropriate is crucial to avoiding devastating complications, primarily when neuraxial procedures are performed. In 2024, the American Society of Interventional Pain Physicians (ASIPP) published updated guidelines for the perioperative management of antiplatelet and anticoagulant therapy in patients undergoing interventional techniques.

Study design: A critical and analytical review and structured synthesis of a consensus clinical practice guideline developed by review of the literature, best evidence synthesis, and modified Delphi consensus.

Objectives: The present investigation summarizes the 2024 updated guidelines of the American Society of Interventional Pain Physicians (ASIPP) on the perioperative management of antiplatelet and anticoagulant therapy in patients undergoing interventional techniques. The summary is organized around the recommendations, presenting for each the underlying evidence, the assigned evidence level and strength of recommendation, and the practical consequences for risk stratification, drug cessation, bridging, resumption, and documentation.

Methods: A multidisciplinary panel convened by ASIPP reviewed the literature on bleeding risk during interventional pain procedures, practice patterns, thrombotic risk, and perioperative management of antithrombotic therapy. Relevant literature was identified through searches of PubMed, the Cochrane Library, and Google Scholar from 1966 through 2023, supplemented by review of contemporary guidelines. Evidence and recommendations were graded using the modified ASIPP approach, Grading of Recommendations, Assessment, Development and Evaluation (GRADE), considerations of clinical relevance and pragmatism, and the Agency for Healthcare Research and Quality (AHRQ) strength-of-recommendation methods, with the rating scheme derived from the National Guideline Clearinghouse Extent Adherence to Trustworthy Standards (NEATS) instrument. Institute of Medicine (IOM) standards were followed. Consensus required at least 80% agreement among eligible panelists without a primary conflict of interest.

Results: Thirty-four authors participated, and 29 voted. Twenty recommendations were initially developed, of which 16 achieved 100% acceptance; the set was consolidated to 18 through second and third rounds of voting, with 16 of 18 achieving unanimous acceptance and the remaining two reaching 94% and 89%. The dissent concerned the risk classification of transforaminal epidural injections and is reported by name in the source document. One hundred nineteen relevant publications were identified, of which 80 met the criteria for inclusion; meta-analysis was not feasible. Interventional techniques were stratified into low, moderate or intermediate, and high risk using a composite score summing five domains, each rated 1 to 4: anatomical, procedural, bleeding, antithrombotic, and medical or physiologic risk. Scores ranged from 5 to 18 across 50 procedures, yielding 19 low-risk, 7 moderate-risk, and 24 high-risk procedures. Of the 18 recommendations, 12 rested on moderate evidence, 5 on low evidence, and one on low to moderate evidence; 13 carried a moderate strength of recommendation, one moderate to strong, one high, one low to moderate, and two weak. On several occasions in the low and moderate categories, the panel recommended explicitly against cessation of antithrombotic therapy.

Limitations: The continued paucity of literature, with discordant recommendations across societies.

Conclusion: Suggested revision: The 2024 ASIPP guidelines place greater emphasis on the thromboembolic consequences of antithrombotic interruption and therefore favor selective rather than routine cessation, particularly for low-risk procedures. However, important uncertainty remains regarding several procedural classifications, optimal interruption and resumption intervals, and the comparative magnitude of bleeding and thromboembolic risk. Patient-specific assessment and shared decision-making remain essential.