Is a male patient with polycythemia vera and elevated hemoglobin (Hb) levels a suitable candidate for surgery?

Surgical Fitness for Male with Hemoglobin 18 g/dL

A male patient with hemoglobin of 18 g/dL likely has polycythemia vera and requires mandatory preoperative hematologic optimization before elective surgery, including hematocrit reduction to <45% through phlebotomy and/or cytoreductive therapy, maintained for at least 3 months prior to the procedure. 1

Critical Distinction: Polycythemia Vera vs. Normal Variant

A hemoglobin of 18 g/dL in a male exceeds the diagnostic threshold for polycythemia vera (>16.5 g/dL), which is a myeloproliferative neoplasm requiring JAK2 mutation testing and comprehensive hematologic evaluation before proceeding with elective surgery. 2 This is not simply an elevated hemoglobin—it represents a disease state with substantially elevated perioperative risks.

• Over 95% of patients with these hemoglobin levels harbor JAK2 gene variants, distinguishing true polycythemia vera from secondary causes like smoking or sleep apnea. 2
• The diagnosis must be confirmed before surgical clearance, as management differs fundamentally from patients with normal hemoglobin levels. 1

Perioperative Risk Profile

Patients with polycythemia vera face catastrophic perioperative complications, with 7.7% experiencing vascular occlusion and 7.3% suffering major hemorrhage even with optimal management. 1 This dual risk of both thrombosis and bleeding makes these patients among the highest-risk surgical candidates.

Thrombotic Complications

• Arterial thrombosis occurs in 16% of patients at or before diagnosis, with venous thrombotic events in 7%, often involving unusual sites like splanchnic veins. 2
• Hyperviscosity from elevated red blood cell mass directly predisposes to perioperative thrombosis. 3
• Extreme thrombocytosis (platelet count ≥1,000 × 10⁹/L) paradoxically increases both bleeding and thrombotic risk through acquired von Willebrand disease. 2, 4

Hemorrhagic Complications

• Acquired von Willebrand disease develops with extreme thrombocytosis, creating unexpected severe bleeding risk during surgery. 1, 2
• The bleeding risk is substantial (7.3% major hemorrhage rate) and must be assessed through coagulation testing before high-risk procedures. 1

Mandatory Preoperative Requirements for Elective Surgery

Hematocrit Control (Non-Negotiable)

Hematocrit must be maintained at <45% for 3 months prior to elective surgery through phlebotomy and/or cytoreductive therapy to reduce thrombosis risk. 1 This is the single most critical intervention.

• Additional phlebotomy may be necessary immediately before surgery to ensure hematocrit remains <45%. 1
• Normalization or near-normalization of complete blood count is required without causing prohibitive cytopenias. 1

Cytoreductive Therapy Optimization

• Initiate or optimize cytoreductive therapy (hydroxyurea or interferon) if not already established. 1, 2
• Hydroxyurea can typically be continued perioperatively—stopping it unnecessarily is a common pitfall that increases thrombotic risk. 1

Coagulation Assessment

For high-risk surgical procedures, coagulation testing to evaluate for acquired von Willebrand disease is mandatory. 1 Failing to identify this coagulopathy leads to unexpected severe intraoperative bleeding.

Antiplatelet and Anticoagulation Management

• Discontinue aspirin one week prior to surgery. 1
• Restart aspirin 24 hours after surgery or when bleeding risk is acceptable. 1
• Withhold anticoagulant therapy based on the half-life/type of agent prior to surgery, then restart when bleeding risk is acceptable. 1

Multidisciplinary Team Assessment

Multi-disciplinary management is not optional—it requires coordination between hematology/oncology, surgery, and anesthesiology. 1

Hematologist/Oncologist Role

• Disease optimization and hematocrit control through phlebotomy and cytoreductive therapy. 1
• Comprehensive review of bleeding and thrombosis history. 1
• Assessment for acquired von Willebrand disease in patients with extreme thrombocytosis. 1

Surgeon Role

• Assess procedure-specific bleeding risk, particularly for orthopedic and cardiovascular surgery which carry the highest thrombotic risk. 1
• Consider extended prophylaxis with low molecular weight heparin (LMWH) for high-risk procedures. 1

Anesthesiologist Role

• Perioperative planning with awareness of dual thrombotic and hemorrhagic risks. 1
• Close postoperative surveillance for symptoms of arterial or venous thrombosis and bleeding. 1

Emergency Surgery Considerations

If surgery cannot be delayed, proceed with the procedure but implement intensive postoperative surveillance for thrombosis and bleeding. 1 However, elective surgery should never proceed without adequate hematologic control, as this substantially increases thrombotic risk, particularly venous thromboembolism. 1

Common Pitfalls to Avoid

• Proceeding with elective surgery without adequate hematologic control (hematocrit <45% for 3 months) substantially increases thrombotic risk. 1
• Failing to assess for acquired von Willebrand disease in patients with extreme thrombocytosis leads to unexpected severe bleeding. 1
• Stopping cytoreductive therapy unnecessarily—hydroxyurea can typically be continued perioperatively. 1
• Inadequate thromboprophylaxis for high-risk procedures—polycythemia vera patients require extended LMWH prophylaxis for orthopedic and cardiovascular surgeries. 1
• Restarting aspirin too early—wait until adequate hemostasis is achieved, typically 24 hours postoperatively. 1

Prognosis Context

Untreated polycythemia vera patients may survive only 6 to 18 months, whereas adequate treatment extends life expectancy to more than 10 years. 3 This underscores the importance of proper diagnosis and management before subjecting these patients to surgical stress. Median survival from diagnosis ranges from 14.1 to 27.6 years with appropriate management. 2