Perioperative Management of Patients Receiving Factor XI Inhibitors

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.