Can a 17-year-old patient with Thoracic Outlet Syndrome (TOS) on baby aspirin (acetylsalicylic acid) and Lovenox (enoxaparin) be cleared for surgery for a finger fracture?

Management of a 17-Year-Old with Thoracic Outlet Syndrome on Anticoagulation Therapy for Finger Fracture Surgery

The 17-year-old patient with Thoracic Outlet Syndrome (TOS) who is on baby aspirin and Lovenox (enoxaparin) should temporarily discontinue Lovenox 24 hours before surgery while maintaining aspirin therapy throughout the perioperative period for finger fracture repair.

Anticoagulation Management Considerations

Preoperative Management

• Lovenox (enoxaparin) should be discontinued 24 hours prior to the finger fracture surgery to reduce bleeding risk 1
• Baby aspirin (acetylsalicylic acid) should be maintained throughout the perioperative period as it presents minimal bleeding risk for this type of surgery 1
• The finger fracture surgery represents an intermediate to minor hemorrhagic risk procedure that can safely proceed with aspirin alone 1
• A multidisciplinary discussion between the surgeon, anesthesiologist, and vascular specialist should occur to confirm this plan 1

Risk Assessment

• TOS patients, particularly those with venous or arterial variants, have increased thrombotic risk requiring careful anticoagulation management 2, 3
• The risk of thrombosis from complete anticoagulant discontinuation outweighs the bleeding risk of maintaining aspirin during minor orthopedic surgery 1
• Finger fracture surgery typically involves limited tissue disruption with controllable bleeding sites, making it compatible with continued aspirin therapy 1

Postoperative Management

• Lovenox should be resumed 12-24 hours after surgery if adequate hemostasis has been achieved 1
• Close monitoring for signs of both bleeding and thrombotic complications should be implemented postoperatively 1
• Early mobilization should be encouraged to reduce thrombotic risk 3

Special Considerations for Adolescent Patients

• Pediatric dosing of anticoagulants differs from adult dosing and should be carefully calculated based on weight 1
• The management approach for adolescents with TOS should follow principles similar to adults but with appropriate dose adjustments 1
• Aspirin dosing for thromboprophylaxis in adolescents is typically 1-5 mg/kg daily 1

Type-Specific TOS Management

• The management approach may vary depending on whether the patient has neurogenic (95% of cases), venous (4-5%), or arterial (1%) TOS 4
• Venous and arterial TOS variants carry higher thrombotic risks and may require more aggressive anticoagulation management 3, 5
• For patients with venous TOS on Lovenox, bridging with unfractionated heparin could be considered if there is high thrombotic concern 1

Potential Complications to Monitor

• Signs of bleeding: excessive bruising, prolonged bleeding from surgical site, hematoma formation 1
• Signs of thrombosis: increasing arm pain, swelling, discoloration, or paresthesia 3
• Postoperative physical therapy should be initiated as soon as the surgical wound allows to prevent TOS symptom exacerbation 3

Follow-up Recommendations

• Reassess the need for continued anticoagulation therapy 2-4 weeks after surgery 1
• Consider vascular studies if symptoms of TOS worsen following surgery 6
• Long-term anticoagulation management should be determined based on the specific type of TOS and presence of ongoing thrombotic risk factors 4, 5