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Perioperative anticoagulation management is a common and complex clinical challenge. In this episode of CLOT Conversations, Drs. James Douketis and Joseph Shaw discuss new ISTH guidance on surgical and procedural bleed risk stratification in anticoagulated patients.

The discussion explores why updated guidance was needed, addressing inconsistencies in prior schemas, and introduces a more detailed, procedure-specific framework. The authors outline a three-tier classification—minimal, low/moderate, and high bleed risk—and its implications for anticoagulation management.

The episode focuses on real-world application, including patient-specific factors, procedural variability, and interdisciplinary communication. It also highlights evidence gaps and ongoing research such as PAUSE2 and ACE-HIGH.

https://www.jthjournal.org/article/S1538-7836(26)00055-3/abstract [Subscription required for full paper]

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Which DOAC bleeds less in acute VTE?

In this episode, we explore the COBRRA trial comparing apixaban vs rivaroxaban and what it means for clinical practice.

The COBRRA trial provides the first direct, randomized comparison of apixaban and rivaroxaban for the treatment of acute venous thromboembolism (VTE).

In this episode of CLOT Conversations, Dr. Lana Castellucci discusses findings from this landmark study and how they should influence anticoagulant selection.

Key insights include:

• Apixaban reduced clinically relevant bleeding by more than 50% compared to rivaroxaban
• Differences in bleeding risk emerged early and persisted over the 3-month treatment period
• Recurrent VTE and mortality rates were similar between groups
• Dosing strategies and early treatment phase appear to play a key role

We also explore real-world considerations, including medication adherence, patient preference, and how to approach populations not included in the trial, such as cancer-associated thrombosis and higher body weight.

This episode provides practical, evidence-based guidance for clinicians managing acute DVT and pulmonary embolism.

Listen now to learn how the COBRRA trial may change your approach to DOAC selection.

Access the publication here:

Castellucci LA, Chen VM, Kovacs MJ, Lazo-Langner A, Greenstreet P, Kahn S, Côté B, Schulman S, De Wit K, Douketis J, Suryanarayan D. Bleeding risk with apixaban vs. rivaroxaban in acute venous thromboembolism. New England Journal of Medicine. 2026 Mar 12;394(11):1051-60.

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Major bleeding remains the principal complication of oral anticoagulation. In patients with device-detected subclinical atrial fibrillation, the decision to anticoagulate requires careful balancing of stroke prevention against bleeding risk.

In this episode of CLOT Conversations, Dr. Deborah Siegal discusses a prespecified subanalysis of the ARTESiA randomized clinical trial, recently published in JAMA Cardiology. ARTESiA demonstrated a 37% reduction in stroke and systemic embolism with apixaban compared to aspirin — but at the cost of increased major bleeding.

This subanalysis goes deeper, examining the site, severity, and clinical course of bleeding events. Most bleeding was gastrointestinal and non-critical. Rates of intracranial and fatal bleeding were low and similar between treatment arms. The majority of events were not clinical emergencies, and many were defined by hemoglobin decline rather than catastrophic presentation.

We explore what these findings mean for individualized risk assessment, the importance of modifiable bleeding risk factors such as NSAID use, and how physicians and patients can approach shared decision-making in subclinical AF.

Abstract (subscription required for full paper):

Siegal DM, Sticherling C, Healey JS, McIntyre WF, Christensen LS, Parkash R, Vanassche T, Conen D, Gold M, Granger CB, Nielsen JC. Major Bleeding With Apixaban vs Aspirin: A Subanalysis of the ARTESiA Randomized Clinical Trial. JAMA cardiology. 2025 Dec;10(12):1305-14.

https://jamanetwork.com/journals/jamacardiology/fullarticle/2841075

Support the show

https://thrombosiscanada.ca

Take a look at our healthcare professional and patient resources, videos and publications on thrombosis from the expert members of Thrombosis Canada