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Thromb Haemost
DOI: 10.1055/a-2780-9033
Review Article

Perioperative Management of Patients Receiving Factor XI Inhibitors

Authors

  • Carmen K. M. Cheung 

    1   Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
    2   Department of Medicine, McMaster University, Hamilton, Ontario, Canada
    3   Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada

  • Stephanie Carlin

    2   Department of Medicine, McMaster University, Hamilton, Ontario, Canada
    3   Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
    4   Hamilton Health Sciences, Hamilton, Ontario, Canada

  • Thomas C. Scheier

    2   Department of Medicine, McMaster University, Hamilton, Ontario, Canada
    3   Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada

  • Raymond S. M. Wong

    1   Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong

  • Jeffrey I. Weitz

    2   Department of Medicine, McMaster University, Hamilton, Ontario, Canada
    5   Thrombosis and Atherosclerosis Research Institute and Hamilton Health Sciences, Hamilton, Ontario, Canada
    6   Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
    7   Department of Medical Sciences, McMaster University, Hamilton, Ontario, Canada

  • John W. Eikelboom

    2   Department of Medicine, McMaster University, Hamilton, Ontario, Canada
    3   Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
    4   Hamilton Health Sciences, Hamilton, Ontario, Canada

  • James D. Douketis

    2   Department of Medicine, McMaster University, Hamilton, Ontario, Canada
    4   Hamilton Health Sciences, Hamilton, Ontario, Canada
    5   Thrombosis and Atherosclerosis Research Institute and Hamilton Health Sciences, Hamilton, Ontario, Canada
    8   Department of Medicine, St. Joseph's Healthcare Hamilton, and McMaster University, Hamilton, Ontario, Canada
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Graphical Abstract

Abstract

Factor XI inhibitors, including antisense oligonucleotides (ASOs), monoclonal antibodies (mAbs), and small-molecule inhibitors, are an emerging class of anticoagulants that offer the potential to prevent and treat thrombosis with a low risk of bleeding. As these agents move toward broader clinical use, it is essential to carefully review perioperative management due to their novel mechanisms and limited real-world experience. Data from clinical trials suggest a reassuring bleeding profile, even among high-risk groups such as patients with end-stage renal disease on hemodialysis and those on concurrent antiplatelet therapy. Many invasive procedures in patients receiving ASOs or mAbs have been reported, with few bleeding complications and little need for hemostatic prophylaxis or anticoagulant interruption. While small-molecule inhibitors may offer more flexibility due to their short half-lives, perioperative outcomes for these agents remain underreported. In emergencies, hemostasis may be achieved with factor XI concentrate for ASOs or bypassing agents for other factor XI inhibitors; however, these options may be limited by availability and potential thrombotic risks. Perioperative management strategies for factor XI inhibitors remain provisional and may require refinement as new evidence becomes available. Further research is needed to identify assays that better measure the anticoagulant effect of factor XI inhibitors, develop tailored protocols for both major and minor surgeries, and create specific reversal agents.

Keywords

factor XI inhibitors - perioperative - surgery - procedure - anticoagulation - bleeding

Supplementary Material



Publication History

Received: 02 October 2025

Accepted after revision: 03 January 2026

Accepted Manuscript online:
05 January 2026

Article published online:
14 January 2026

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