What is the most important thing to assure before performing a thrombectomy on a 35-year-old female patient with a significant family history of malignancy, including colonic and breast cancer?

Pre-Thrombectomy Assessment in Cancer Patients

Before performing thrombectomy in this 35-year-old woman with significant family cancer history, the surgeon must ensure adequate platelet count (>50 × 10³/μL for most procedures), assess bleeding risk including acquired von Willebrand disease if platelets are elevated, confirm absence of active bleeding or high bleeding risk, and verify appropriate VTE prophylaxis planning for the perioperative period. 1, 2

Critical Preoperative Assessments

Hematologic Parameters

• Platelet count must be verified to ensure adequate hemostasis for the procedure. Patients require platelet counts >50 × 10³/μL for most invasive procedures to minimize bleeding risk 3
• Exclude pseudothrombocytopenia by collecting blood in heparin or sodium citrate tubes if initial platelet count is abnormal 3
• Coagulation testing is essential for patients undergoing high-risk surgical procedures, specifically to evaluate for acquired von Willebrand disease and other coagulopathies 2

Bleeding Risk Assessment

• Active bleeding or high bleeding risk represents an absolute contraindication to pharmacologic thromboprophylaxis and must be carefully evaluated before any major surgical intervention 1
• The surgeon must assess the extent of planned dissection and adequacy of anticipated intraoperative hemostasis, as cancer surgery carries greater bleeding risk independent of prophylaxis type 1
• Drug interactions must be reviewed, particularly if the patient is on anticoagulants or antiplatelet agents that may need to be held perioperatively 2

VTE Risk Stratification

Cancer-Specific Considerations

Given her significant family history of malignancy (colonic and breast cancer), this patient may harbor occult malignancy or genetic predisposition requiring heightened VTE awareness:

• All patients undergoing major surgical intervention for malignant disease should receive pharmacologic thromboprophylaxis with either UFH or LMWH unless contraindicated 1
• The presence of malignant disease doubles the risk for DVT, with fatal PE occurring in 1-5% without perioperative thromboprophylaxis 1
• VTE risk factors to document include: restricted mobility, obesity, previous VTE history, advanced age, higher stage of disease, and prolonged anesthesia duration 1

Prophylaxis Planning

• Pharmacologic prophylaxis should commence preoperatively or as early as possible postoperatively 1
• Mechanical methods (compression stockings, intermittent pneumatic compression) should be added to pharmacologic prophylaxis but never used as monotherapy unless pharmacologic methods are contraindicated 1
• Combined pharmacologic and mechanical prophylaxis improves efficacy, especially in highest-risk patients 1

Duration of Thromboprophylaxis

Standard Duration

• Minimum 7-10 days of pharmacologic thromboprophylaxis is required for all major cancer surgery 1

Extended Duration Indications

Extended prophylaxis for up to 4 weeks postoperatively should be offered if the patient has high-risk features including: 1

• Restricted mobility
• Obesity
• History of VTE
• Major open or laparoscopic abdominal or pelvic surgery for cancer
• Residual malignant disease after operation

The evidence for extended prophylaxis is strong, with reduction in symptomatic DVT from 1.7% to 0.2% (number needed to treat = 66) 1

Common Pitfalls to Avoid

• Proceeding without adequate hematologic control substantially increases thrombotic risk, particularly venous thromboembolism 2
• Failing to assess for acquired von Willebrand disease in patients with extreme thrombocytosis can lead to unexpected severe bleeding 2
• Using mechanical prophylaxis alone when pharmacologic methods are not contraindicated—mechanical methods should supplement, not replace, pharmacologic prophylaxis 1
• Inadequate thromboprophylaxis duration—up to 40% of VTE events occur 21 days after surgery, and VTE is responsible for 46% of deaths within 30 days after surgery 1
• Stopping anticoagulation too early in patients with active cancer, as treatment for 6 months or longer is usually needed 1