Time of VTE prior to surgery
Risk of recurrent VTE after stopping anticoagulation
Management
Pre-op
Post-op
Within 1 month
Approaches 50 % if stopped prior to 1 month
Avoid surgery if possible
Bridge with IV heparin or LMWH
Bridge from warfarin with IV heparin or LMWH
Consider IVC filter
1–3 months prior
Risk decreases sharply after 1 month
Delay surgery if possible
Bridge with IV heparin or LMWH
Consider bridge therapy from warfarin with IV heparin or LMWH
At 1 month ≈ 8 %
At 3 months ≈ 4 %
>3 months prior
3 months of anticoagulation is a reasonable amount of time prior to surgery
No bridging unless severe hypercoagulable state is present
Prophylaxis-dose LDUH or LMWH until on therapeutic anticoagulation
Most patients will have completed VTE therapy after 3 months—if they are still receiving anticoagulation, there is usually an additional risk factor or indication
Consider bridging with IV heparin or therapeutic-dose LMWH if severe hypercoagulable state
Use of Rivaroxaban
Rivaroxaban has recently been approved for treatment of acute thromboembolism (DVT or PE). Perioperative management of this agent should be discussed with a pharmacist.
Rivaroxaban dosing in general should be reduced in patients with impaired renal function (based on creatinine clearance) and not used in patients with creatinine clearance <30 mg/dl [8].
Consideration of Inferior Vena Cava Filters
The function of an inferior vena cava (IVC) filter is to provide a mechanical interruption in the vena cava to prevent major pulmonary embolism. Anticoagulation is still indicated once surgical bleeding risk is low enough. Data on the use and efficacy of filters are scant. Possible indications for IVC filters are the following:
Potentially retrievable IVC filters may be considered when the contraindication to anticoagulation is likely to be temporary (e.g., <2 weeks). Ability to remove a filter decreases with time—retrieval should generally occur by 3 months [12, 13]. A time course for possible retrieval should always be discussed with the proceduralist.
Perioperative Management
The main concerns for perioperative management are prevention of VTE in all patients, resumption of anticoagulation in those patients who are chronically receiving it, and diagnosis and treatment of new postoperative VTE.
VTE Prophylaxis for All Patients
VTE prophylaxis recommendations are shown in Table 31.2. The suggested types of prophylaxis for each type of surgery are based on the 2012 ACCP guidelines [4, 5], which do not make specific dose recommendations for all methods of pharmacologic prophylaxis. Specific dosing recommendations (e.g., for LMWH) are further derived from the University of Washington Department of Pharmacy Anti-coagulation Services website [8]. Be aware that decisions regarding timing and method of prophylaxis are usually at the discretion of the surgeon with consideration to the risk of surgical bleeding. For further dose-related questions, one should discuss with a clinical pharmacist. In general, the current guidelines favor individualized assessment taking into account both patient risks and surgical risks of VTE [5].
Type of surgery | First line | Second line | Notes |
|---|---|---|---|
Orthopedic surgery | |||
Hip replacement (THA), knee replacement (TKA), hip fracture surgery (HFS) | LMWH (enoxaparin 30 mg SC q 12 h or dalteparin 5,000 U SC once daily) Start ≥ 12 h pre-op, and give the first post-op dose after ≥12 h post surgery Treatment duration: minimum 10–14 days | LDUH, fondaparinux, warfarin, aspirin, IPC Treatment duration: minimum 10–14 days | Treated duration recommended to extend for up to 35 days ACCP guidelines “suggest” LMWH in preference to the other options. With the exception of fondaparinux, the second-line options listed may not be as effective Use of aspirin alone remains controversial Consider IPC in addition to pharmacologic while hospitalized If increased bleeding risk: IPC or no prophylaxis Newer anticoagulants (THA, TKA only): see text |
Knee arthroscopy | No prophylaxis | ||
General surgery, abdomen/pelvis surgery | |||
Very low risk <0.5 % (e.g., ambulatory same-day surgery) | Early ambulation | ||
Low risk ~1.5 % (e.g., certain laparoscopic procedures, more minor abdominal, gynecologic, urologic procedures) | IPC | ||
Moderate risk ~3 % (e.g., major abdominal, nonmalignant gynecologic, thoracic, cardiac surgery) | LMWH, LDUH | IPC | Use IPC if high risk for major bleeding or if consequences of bleeding would be particularly severe |
High risk ~6 % (e.g., abdominal/gynecologic malignancy surgery, bariatric (see below for bariatric specifics)) | LMWH, LDUH +/−ES/IPC | IPC | Use IPC if high risk for major bleeding or if consequences of bleeding would be particularly severe. If bleeding risk diminishes, add back pharmacologic prophylaxis |
Extend duration if abd/pelvic cancer surgery | |||
If cannot use LMWH or LDUH, and not at high risk of bleeding, can use low-dose aspirin (160 mg), fondaparinux, or IPC | |||
Bariatric | LMWH high-dose prophylaxis (e.g., enoxaparin 40 mg SC q 12 h for BMI >40) +/−IPC | LDUH +/−IPC | Consult with clinical pharmacist for weight-based dosing. Consider higher doses of LDUH if this option is chosen |
Cardiac surgery | IPC | If prolonged hospital course due to non-hemorrhagic complications, add LDUH or LMWH | |
Thoracic surgery | Moderate risk of VTE: LDUH, LMWH can add ES/IPC if high risk of VTE | Moderate risk of VTE: IPC | If high risk of bleeding, use IPC |
Craniotomy | IPC | If high risk of VTE, add pharmacologic prophylaxis once bleeding risk is acceptable | |
Spinal surgery | IPC | LMWH, LDUH
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