Perioperative Management of Venous thromboembolism (VTE)

Recommended duration of anticoagulant prophylaxis

The recommendations are as follows:

1. Provoked DVT (with reversible surgical or nonsurgical provoking factor): 3 months

2. Unprovoked isolated distal DVT (has low risk of recurrence): 3 months

3. Unprovoked proximal DVT or PE: Indefinite therapy if D-dimer positive after 1 month after 3 months of therapy or second VTE episode or based on patient preference if no bleeding risk

4. Cancer: Indefinite therapy or until cancer is active

pulmonary embolism xray

Recommended delay of surgery in Acute VTE

It is advised to delay surgery until the patients receive atleast 1 month and preferably 3 months of anticoagulation whenever feasible.

However, where surgery needs to be performed:

  • Within 1 month of acute VTE: Intravenous UFH should be administered while the INR is less than 2.
  • Within 2 weeks of acute VTE: Intravenous heparin may be withheld 6 hours preoperatively and 12 hours postoperatively, if the surgery is short.¬†
  • If the acute event was within 2 weeks of major surgery and/or patients have a higher risk of postoperative bleeding, a vena caval filter should be inserted preoperatively or intraoperatively.
  • Warfarin should be withheld for only 4 doses if the most recent episode of VTE occurred 1-3 months before surgery. If the patient has been anticoagulated for 3 or more months, 5 doses of warfarin can be withheld before surgery. Preoperatively, subcutaneous UFH or LMWH is needed only for immobilized inpatients with an INR of less than 1.8.

References:

Kearon C, Akl EA. Duration of anticoagulant therapy for deep vein thrombosis and pulmonary embolism. Blood. 2014 Mar 20;123(12):1794-801. doi: 10.1182/blood-2013-12-512681. Epub 2014 Feb 4. PMID: 24497538.

https://www.medscape.com/answers/285265-94364/what-is-the-perioperative-anticoagulation-management-of-patients-with-venous-thromboembolism-vte


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