A 57-year-old woman comes to the office for perioperative evaluation prior to decompressive lumbar laminectomy surgery scheduled in 3 weeks. For the past 2 years she has experienced gnawing pain in the left buttock and thigh. The patient was once able to walk in the grocery store and get some relief by leaning forward on the cart, but now walking even short distances is intolerable. She has had occasional mild stress incontinence since the birth of her third child 20 years ago but no recent change in bladder or bowel function. She has tried physical therapy and nonsteroidal anti-inflammatory drugs with minimal relief. A month ago, the patient came to the emergency department with asymmetric leg swelling and was found to have a thrombosis in the left popliteal vein. Her reduced mobility due to pain was thought to be a contributing factor. She has no history of heart disease or diabetes. The patient had an uncomplicated cholecystectomy 10 years ago. Medications include apixaban and amitriptyline. She is not aware of any family history of blood clots.
Blood pressure is 136/86 mm Hg and pulse is 94/min. Pulse oximetry is 98% on room air. BMI is 17 kg/m². Examination shows normal jugular venous pressure, clear lungs, and normal S1 and S2. Straight-leg raise to 90 degrees is negative. There is flexion in response to stimulation of the plantar surface of the left foot. Trace pretibial edema is present bilaterally.
Serum chemistry demonstrates normal renal function.
Which of the following is the most appropriate recommendation for perioperative management of this patient's anticoagulation?

Question

Quizplus · Accepted Answer

11ec193a_9844_b5d5_853d_69ffe4bb8273_MD0002_00 Perioperative management of anticoagulant therapy involves evaluation of surgical bleeding risk, thromboembolic risk, and timing of anticoagulation interruption. High-bleeding-risk surgeries/procedures such as laminectomy necessitate a temporary interruption of chronic anticoagulation. However, venous thromboembolism (VTE) within 3 months is considered a condition of very high risk for perioperative thromboembolism. In patients with very high thrombotic-risk conditions that are transient (eg, VTE within 3 months, embolic stroke due to atrial fibrillation within 3 months), high-bleeding-risk surgeries should, whenever possible, be delayed until thrombotic risk becomes more acceptable. If delay is not possible (eg, urgent surgery), anticoagulation interruption should be minimized. surgeries/procedures Although this patient's spinal stenosis is causing bothersome symptoms, she has no neurologic indication (eg, focal weakness, urinary incontinence) for urgent surgery. Therefore, postponing elective surgery until she has completed 3 months of anticoagulation for a provoked deep vein thrombosis is most appropriate. (Choice B) Due to the relatively rapid onset of action of direct oral anticoagulants (eg, apixaban, rivaroxaban), bridging with low-molecular-weight heparin (LMWH) is rarely used in combination with these agents. Bridging with LMWH or unfractionated heparin is generally indicated in patients taking warfarin who are at very high thrombotic risk and must undergo a high-bleeding-risk procedure. (Choices C and D) Apixaban has a half-life of 8-15 hours and should be discontinued approximately 48 hours before an elective procedure. A longer interval (eg, 72 hours) should be considered for high-bleeding-risk procedures and for patients with renal insufficiency (creatinine clearance <50 mL/min). Stopping apixaban for an elective surgery is not recommended in this patient with transient, very high thrombotic risk. (Choice E) Temporary inferior vena cava (IVC) filter placement is indicated in patients with an acute VTE within 3-4 weeks who must undergo a high-bleeding-risk procedure that cannot be delayed. Low-bleeding-risk procedures (eg, pacemaker insertion, central venous catheter removal) can often be performed with minimal interruption in anticoagulation and usually do not require delay or IVC filter placement. Educational objective: In patients with a transient, very high thrombotic-risk condition (eg, venous thromboembolism within 3 months), elective high-bleeding-risk surgeries/procedures should be postponed until the thrombotic risk becomes more acceptable. __________ References: Perioperative management of the direct oral anticoagulants: a case-based review. (http://www.ncbi.nlm.nih.gov/pubmed/27637308) Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/22315266)

A 57-Year-Old Woman Comes to the Office for Perioperative Evaluation