What is the recommended management for a patient with Deep Vein Thrombosis (DVT) undergoing lower limb surgery?

Management of a Patient with DVT Posted for Lower Limb Surgery

For patients with DVT requiring lower limb surgery, we recommend delaying elective procedures until completion of the 3-month acute anticoagulation treatment period whenever possible. If surgery cannot be delayed, bridging therapy with LMWH should be initiated when the INR falls below 2.0, with the last dose given the morning of the day before surgery. 1

Timing of Surgery

• If the DVT is recent (<3 months), elective procedures should be postponed until the completion of the initial 3-month anticoagulation treatment period 1
• For urgent or emergency procedures that cannot be delayed, a bridging anticoagulation protocol must be implemented 1

Preoperative Management

For patients requiring more urgent procedures who cannot wait for completion of the 3-month anticoagulation period:

• Discontinue oral anticoagulants 5 days before the planned procedure 1
• Initiate bridging therapy with LMWH when the INR falls below 2.0 1
• Administer the last dose of LMWH on the morning of the day before surgery 1
• For patients on DOACs (preferred agents for VTE), follow specific discontinuation timelines based on the agent and renal function 1, 2

Risk Stratification

The approach to perioperative management depends on the patient's thromboembolism risk:

• High risk (requiring bridging): Recent VTE (<3 months), active cancer 1
• Moderate risk: VTE within past 3-6 months
• Low risk (no bridging needed): VTE >6 months ago with no other risk factors 1

Postoperative Management

• Resume warfarin on the evening after surgery once hemostasis has been achieved 1
• Restart therapeutic-dose LMWH no sooner than 48 hours postoperatively, once adequate hemostasis is confirmed 1
• Prophylactic-dose LMWH can be initiated 12 hours after surgery 1
• Continue anticoagulation for the recommended duration based on the initial indication (minimum 3 months for provoked DVT) 1

Specific Anticoagulation Options

• LMWH (preferred for bridging): Enoxaparin 1.5 mg/kg once daily or 1 mg/kg twice daily 1
• Fondaparinux: 5-10 mg daily (weight-based) for treatment; not typically used for bridging 3
• Rivaroxaban: Must be discontinued at least 24 hours before surgery; longer with renal impairment 4

Mechanical Prophylaxis

• For patients at high bleeding risk where anticoagulation must be temporarily held, use mechanical thromboprophylaxis with graduated compression stockings and/or intermittent pneumatic compression (IPC) 1
• Early ambulation should be encouraged as soon as possible after surgery 1

Common Pitfalls and Caveats

• Avoid premature discontinuation of anticoagulation without bridging in high-risk patients, as this significantly increases thromboembolism risk 4
• Avoid restarting therapeutic anticoagulation too early after surgery (less than 48 hours), as this increases bleeding risk 1
• Don't forget to resume long-term anticoagulation after the perioperative period for the recommended duration based on the initial DVT indication 1, 2
• Consider IVC filter placement only in patients with absolute contraindications to anticoagulation, not as routine practice 1

Special Considerations

• For patients undergoing orthopedic surgery, extended thromboprophylaxis (up to 35 days) may be warranted due to continued risk 1
• DOACs (apixaban, rivaroxaban, edoxaban, dabigatran) are now preferred over vitamin K antagonists for most patients with VTE, but require careful perioperative management 1, 2
• For patients with cancer-associated thrombosis, LMWH or specific oral Xa inhibitors (apixaban, edoxaban, rivaroxaban) are preferred 1