Does anabolic-androgenic steroid (AAS) use contraindicate varicose vein surgery?

Anabolic-Androgenic Steroids Do Not Contraindicate Varicose Vein Surgery, But Increase Thrombotic Risk

AAS use is not an absolute contraindication to varicose vein surgery, but it significantly increases perioperative thrombotic risk and requires careful risk stratification and enhanced thromboprophylaxis. The primary concern is the procoagulant state induced by AAS, not a direct surgical contraindication.

Understanding the Thrombotic Risk from AAS

AAS abuse creates a prothrombotic environment through multiple mechanisms:

• AAS stimulates synthesis of coagulation factors and creates a procoagulant distribution of cardiovascular risk markers, including dyslipidemia and atherosclerosis proneness, resulting in increased global coagulation 1
• AAS use is associated with documented cases of deep vein thrombosis and pulmonary embolism, with clear temporal correlation to intramuscular injections 2
• Indirect experimental data demonstrates that androgens affect platelet aggregation, coagulation proteins, and the vascular system in ways that facilitate thrombosis 3
• AAS causes impaired vascular reactivity and endothelial dysfunction, with significantly impaired endothelial-independent dilatation in active users compared to non-users 4

Clinical Decision-Making Algorithm

Step 1: Assess Urgency of Surgery

• For elective varicose vein surgery in active AAS users, strongly consider delaying surgery for 3 months after AAS discontinuation to allow vascular function improvement, as studies show recovery of vascular reactivity following discontinuation 4
• For urgent/emergent varicose vein surgery (e.g., bleeding varices), proceed with surgery but implement maximum thromboprophylaxis 5

Step 2: Risk Stratification

Evaluate the following high-risk features in AAS users:

• Duration and dose of AAS use (higher doses and longer duration increase thrombotic risk) 1, 6
• Cardiovascular risk factors including hypertension, adverse lipid profiles (elevated LDL, depressed HDL), and left ventricular hypertrophy 6, 4
• Personal or family history of thromboembolism 1, 3
• Concurrent use of other prothrombotic agents 6

Step 3: Perioperative Management

For patients proceeding with surgery:

• Implement pharmacological VTE prophylaxis with low molecular weight heparin or unfractionated heparin according to standard high-risk protocols, as AAS users should be considered high-risk for thrombosis 1, 3
• Consider mechanical prophylaxis (sequential compression devices) in addition to pharmacological prophylaxis for layered protection 5
• Resume thromboprophylaxis ≤24 hours after surgery when adequate hemostasis is achieved 5
• Extend thromboprophylaxis duration beyond standard protocols given the persistent prothrombotic state 1

Step 4: Special Considerations for Bleeding Anorectal Varices

If the varicose vein surgery involves bleeding anorectal varices (portal hypertension-related):

• Use non-selective beta-adrenergic blockers for prevention/prophylaxis, but temporarily suspend during acute bleeding 5
• Consider vasoactive drugs (terlipressin or octreotide) to reduce splanchnic blood flow and portal pressure 5
• Administer short-course prophylactic antibiotics (strong recommendation) 5
• Follow a "step-up" approach: medical management → local procedures → radiological interventions → surgical procedures if bleeding persists 5

Critical Pitfalls to Avoid

• Do not assume AAS use is benign or irrelevant to surgical planning—the thrombotic risk is real and documented with case reports of DVT/PE temporally related to AAS injections 2
• Do not use standard-risk VTE prophylaxis protocols—AAS users require high-risk stratification 1, 3
• Do not neglect cardiovascular optimization—address hypertension, dyslipidemia, and other modifiable risk factors preoperatively 6, 4
• Do not fail to counsel patients on AAS discontinuation—vascular function improves after a 3-month washout period 4

Nuances in the Evidence

The evidence linking AAS to thrombosis comes primarily from case reports, observational studies, and mechanistic research rather than randomized trials 1, 3. However, the biological plausibility is strong with documented effects on coagulation factors, platelet function, and vascular reactivity 1, 4. The temporal relationship in case reports is compelling, with thrombotic events occurring shortly after AAS administration 2.

The absence of direct contraindication in surgical guidelines reflects the rarity of this specific clinical scenario rather than evidence of safety—no guideline specifically addresses AAS use and varicose vein surgery because it is an uncommon combination requiring individualized risk assessment based on thrombosis literature 5.