From the Guidelines
Patients with increased risk or prior history of deep vein thrombosis (DVT) should receive both mechanical and pharmacological prophylaxis unless contraindicated, with low molecular weight heparin (LMWH) being the preferred pharmacological agent, as recommended by the American College of Chest Physicians evidence-based clinical practice guidelines 1.
Key Considerations
- Mechanical methods include early mobilization, graduated compression stockings, and intermittent pneumatic compression devices.
- Pharmacological prophylaxis typically involves LMWH, such as enoxaparin 40mg subcutaneously once daily or 30mg twice daily, starting 12 hours before surgery or 6-12 hours postoperatively.
- For patients on long-term anticoagulation, warfarin should be discontinued 5 days before surgery and bridged with LMWH until 24 hours pre-surgery.
- Postoperatively, LMWH should be restarted 12-24 hours after surgery when hemostasis is established, with warfarin resumed when the patient can take oral medications.
High-Risk Patients
- For high-risk patients, extended prophylaxis for 28-35 days is recommended, particularly for orthopedic and cancer surgeries, as supported by the guidelines for treatment and prevention of venous thromboembolism among patients with cancer 1.
- Direct oral anticoagulants (DOACs) like rivaroxaban or apixaban may be used in specific cases but require appropriate timing for discontinuation (24-48 hours) before surgery.
Risk Stratification
- Risk stratification using tools like the Caprini score helps determine prophylaxis duration and intensity.
- Close monitoring for bleeding complications and thrombotic events is essential throughout the perioperative period, with adjustments made based on the patient's clinical status and surgical bleeding risk, as emphasized by the American Society of Clinical Oncology guideline 1.
Additional Considerations
- Combined mechanical prophylaxis and anticoagulation may be considered in high-risk patients, as suggested by the guidelines for perioperative care for pancreaticoduodenectomy: enhanced recovery after surgery (ERAS) society recommendations 1.
- The optimal duration of prophylactic anticoagulation in the postoperative setting continues to be discussed and studied, with some recommendations supporting extended prophylaxis for up to four weeks in high-risk patients undergoing major cancer surgery 1.
From the FDA Drug Label
14.5 Prophylaxis of Thromboembolic Events Following Abdominal Surgery in Patients at Risk for Thromboembolic Complications Abdominal surgery patients at risk included the following: Those undergoing surgery under general anesthesia lasting longer than 45 minutes who are older than 60 years with or without additional risk factors; and those undergoing surgery under general anesthesia lasting longer than 45 minutes who are older than 40 years with additional risk factors. Risk factors included neoplastic disease, obesity, chronic obstructive pulmonary disease, inflammatory bowel disease, history of deep vein thrombosis (DVT) or pulmonary embolism (PE), or congestive heart failure.
To manage surgery on patients with increased risk or prior history of DVT, fondaparinux sodium can be used as a prophylactic measure. The recommended dose is 2.5 mg SC once daily, started postoperatively.
- Key considerations:
- Patients with a history of DVT or PE are considered at risk for thromboembolic complications.
- Fondaparinux sodium has been shown to be effective in reducing the risk of VTE in patients undergoing abdominal surgery.
- The treatment should be continued for 7 ± 2 days.
- Patients with serum creatinine level more than 2 mg/dL (180 micromol/L), or platelet count less than 100,000/mm^3 should be excluded from the trial.
- Fondaparinux sodium was associated with a VTE rate of 4.6% compared with a VTE rate of 6.1% for dalteparin sodium 2.
From the Research
Management of Surgery on Patients with Increased Risk or Prior History of DVT
To manage surgery on patients with increased risk or prior history of Deep Vein Thrombosis (DVT), several strategies can be employed:
- Assessment of Risk Factors: Identify patients with increased risk of VTE, including those with a prior history of DVT, trauma, older age, use of oral contraceptives or hormone replacement therapy, and prolonged travel 3.
- Prophylaxis Methods: Use mechanical and pharmacological methods for VTE prophylaxis, including graduated compression stockings, intermittent pneumatic compression devices, and low-molecular-weight heparins (LMWHs) 4, 3.
- Timing of Prophylaxis: Initiate prophylaxis close to the time of surgery, and consider continuing it after discharge, especially for high-risk patients 5.
- Choice of Anticoagulant: Select an appropriate anticoagulant, such as LMWHs, vitamin K antagonists, or fondaparinux, based on the patient's risk factors and type of surgery 4, 5, 6.
- Monitoring and Education: Monitor patients for signs of DVT and pulmonary embolism, and educate them on the risks and benefits of anticoagulant prophylaxis 3.
Specific Recommendations for Different Types of Surgery
- General, Gynecologic, Vascular, and Major Urologic Surgery: Use low-dose unfractionated heparin or LMWHs for VTE prophylaxis 4.
- Elective Hip or Knee Replacement and Surgery for Hip Fracture: Use vitamin K antagonists, LMWHs, or fondaparinux for VTE prophylaxis 4, 5.
- Neurosurgery: Use graduated elastic stockings, and consider combining with LMWHs for VTE prophylaxis 4.
- Plastic Surgery: Use mechanical methods, such as intermittent pneumatic compression devices, and consider chemoprophylaxis with LMWHs for high-risk patients 3.
Comparison of Different Anticoagulants
- Factor Xa Inhibitors and LMWHs: Fondaparinux, rivaroxaban, and bemiparin have been shown to be effective in reducing the risk of DVT and VTE, but may increase the risk of major bleeding 6.
- Enoxaparin and Dalteparin: These LMWHs have been shown to be effective in preventing DVT in high-risk patients, without increasing the risk of major bleeding 7.