72 – How long after a diagnosed DVT and/or PE can a patient undergo elective orthopaedic procedure?

Kristen Combs, Augustus Demanes, Eleni Moka, Mary Mulcahey, Ronald Navarro.

Response/Recommendation: In the absence of definitive evidence, the opinion of this workgroup is that elective orthopaedic surgery should be delayed by 6 months in patients with a recently diagnosed deep venous thrombosis (DVT) and/or pulmonary embolism (PE).

Strength of Recommendation: Consensus.

Rationale: Patients with active or recently diagnosed DVT or PE may be at a higher risk of developing another episode of venous thromboembolism (VTE).  The objective of this systematic review was to determine when it would be safe to subject such a patient to elective orthopaedic procedure.  There is a dearth of literature related to this subject matter.  A few studies exist that support delaying non-orthopaedic elective surgery for three months while on anti-coagulation for DVT treatment¹.  A longer time interval between a DVT and subsequent surgery may decrease the risk of recurrence, but no specific time frame has been reported in the orthopaedic literature².  If surgery must be performed, bridging therapy can be considered, and in those who have received less than one month of anti-coagulation, placement of an inferior vena cava filter may be recommended^1,3.  For minor procedures with minimal anticipated blood loss, one study suggests patients may continue with anti-coagulation through the peri-operative period⁴.  Another study concluded that most patients on long-term warfarin may discontinue the use five days prior to an elective surgery, and most do not require heparin bridging in the peri-operative period⁵.  The optimal peri-procedural management of patients taking direct-oral anticoagulants is determined on an individual case basis^6,7.

To our knowledge, no literature exists that provides a definitive answer to the posed question.  However, given the fact that patients with a recent diagnosis of VTE may be on anticoagulation treatment and are also at increased risk of subsequent VTE, the opinion of this workgroup is that elective orthopaedic procedure should be delayed for a minimum of three months and preferably for six months.  This period of waiting allows for the patient to be treated for the diagnosed VTE and also may provide opportunity to determine the cause of VTE.  In patients in whom surgical procedure is emergent or urgent, the period of waiting could be shortened.

References:

1.         PulmCCM. Managing anticoagulation for surgery and invasive procedures (Review). PulmCCM. Published June 7, 2013. Accessed September 10, 2021. https://pulmccm.org/review-articles/managing-anticoagulation-for-surgery-and-invasive-procedures-review-nejm/

2.         Liem TK, Huynh TM, Moseley SE, et al. Symptomatic perioperative venous thromboembolism is a frequent complication in patients with a history of deep vein thrombosis. J Vasc Surg. 2010;52(3):651-657. doi:10.1016/j.jvs.2010.04.029

3.         Kim H, Han Y, Ko G-Y, et al. Clinical Outcomes of a Preoperative Inferior Vena Cava Filter in Acute Venous Thromboembolism Patients Undergoing Abdominal-Pelvic Cancer or Orthopedic Surgery. Vasc Specialist Int. 2018;34(4):103-108. doi:10.5758/vsi.2018.34.4.103

4.         Spyropoulos AC, Douketis JD. How I treat anticoagulated patients undergoing an elective procedure or surgery. Blood. 2012;120(15):2954-2962. doi:10.1182/blood-2012-06-415943

5.         Jaffer AK, Brotman DJ, Chukwumerije N. When patients on warfarin need surgery. Cleve Clin J Med. 2003;70(11):973-984. doi:10.3949/ccjm.70.11.973

6.         O’Donnell M, Kearon C. Perioperative management of oral anticoagulation. Cardiol Clin. 2008;26(2):299-309, viii. doi:10.1016/j.ccl.2007.12.012

7.         Spyropoulos AC, Al-Badri A, Sherwood MW, Douketis JD. Periprocedural management of patients receiving a vitamin K antagonist or a direct oral anticoagulant requiring an elective procedure or surgery. Journal of Thrombosis and Haemostasis. 2016;14(5):875-885. doi:10.1111/jth.13305