Can a patient with thoracic outlet syndrome on Lovenox (enoxaparin) be cleared for surgery to fix a broken finger?

Management of Thoracic Outlet Syndrome Patient on Lovenox Undergoing Finger Surgery

A 17-year-old boy with thoracic outlet syndrome on Lovenox can be cleared for finger fracture surgery with appropriate perioperative anticoagulation management, including discontinuation of Lovenox 12-24 hours before surgery and resumption postoperatively.

Understanding the Patient's Condition

• Thoracic outlet syndrome (TOS) is a condition caused by compression of neurovascular structures (brachial plexus, subclavian artery, and/or subclavian vein) at the superior thoracic outlet 1, 2
• TOS can be classified into three types:
  • Neurogenic TOS (95% of cases) - compression of the brachial plexus 3
  • Venous TOS (4-5% of cases) - compression of the subclavian vein 3, 4
  • Arterial TOS (1% of cases) - compression of the subclavian artery 3, 4
• The patient is on Lovenox (enoxaparin), suggesting venous TOS with possible thrombosis requiring anticoagulation 1

Perioperative Management Considerations

Anticoagulation Management

• For patients on Lovenox requiring surgery, the anticoagulant should be discontinued before the procedure 1
• Lovenox should be stopped 12-24 hours before planned surgery to minimize bleeding risk 1
• For patients with upper limb DVT (which may occur in venous TOS), the standard initial treatment is 3 months of anticoagulation 1
• Postoperatively, Lovenox can be restarted once adequate hemostasis is achieved, typically 12-24 hours after surgery 1

Surgical Considerations for TOS Patients

• The presence of TOS itself does not contraindicate finger fracture surgery 2
• The primary concern is managing the anticoagulation to prevent both bleeding complications and thrombotic events 1
• In patients with venous TOS on anticoagulation, temporary interruption of anticoagulation with appropriate bridging is the standard approach for necessary surgeries 1

Risk Assessment and Monitoring

• Factors that may increase perioperative risk in this patient include:
  • Severity of the TOS (whether there is active thrombosis) 1
  • Duration of anticoagulation therapy prior to surgery 1
  • Presence of post-thrombotic syndrome 1
• Close monitoring for signs of recurrent thrombosis or bleeding complications is essential in the perioperative period 1

Postoperative Care

• Resume Lovenox once adequate hemostasis is achieved, typically 12-24 hours after surgery 1
• Consider physical therapy for both the operated finger and TOS management 2, 4
• Monitor for signs of recurrent thrombosis, including arm swelling, pain, or discoloration 5
• Long-term anticoagulation may not be necessary if the TOS is surgically corrected or if the initial thrombotic event was provoked and has resolved 1

Pitfalls to Avoid

• Do not continue Lovenox up to the time of surgery due to increased bleeding risk 1
• Do not delay resumption of anticoagulation for too long after surgery in patients with high thrombotic risk 1
• Do not overlook the potential for postoperative complications related to TOS, such as positional compression during surgery or immobilization 5
• Remember that venous compression is often present with arm abduction in asymptomatic individuals, so imaging findings must be carefully correlated with clinical symptoms 6