Bleeding Risk Assessment and Management Strategies for Elective Surgery and Invasive Procedures: A Systematic Review

Patients with suspected or confirmed bleeding disorders present a distinct challenge during elective surgery and invasive procedures, as hemostatic abnormalities are heterogeneous and evidence to guide risk stratification and management remains limited, especially when routine laboratory testing is inconclusive. This systematic review aimed to synthesize available evidence on bleeding risk assessment approaches, perioperative bleeding outcomes, and hemostatic management strategies in individuals with established inherited bleeding disorders, as well as less clearly defined phenotypes such as low von Willebrand factor levels and bleeding disorders of unknown cause undergoing elective surgery or invasive procedures. We searched major electronic databases and supplementary sources for studies reporting perioperative or periprocedural bleeding outcomes and preventive or therapeutic hemostatic interventions. Due to substantial heterogeneity in study design, populations, procedures, outcome definitions, and management approaches, findings were synthesized narratively. Overall, the evidence suggests that a structured bleeding history is central to perioperative risk evaluation and may be more informative than routine coagulation screening for predicting bleeding complications, while bleeding assessment tools and laboratory parameters are inconsistently incorporated into decision-making. Hemostatic strategies, including antifibrinolytics, desmopressin, factor concentrates, and blood products, varied widely across studies and were often guided by expert judgment rather than standardized pathways. The evidence base was limited by retrospective designs, small sample sizes, and inconsistent reporting of outcomes. These findings highlight the need for prospective studies and standardized perioperative assessment and management pathways to improve procedural safety while avoiding unnecessary interventions.