Dear Dr Akgun, To help answer your question, I would say the time of surgery depends on the urgency of the surgery, severity and type of thromboembolic event. If the thrombus is resolved and the INR is in a lower range, LMWH is used in the perioperative period. All other profilactic steps are taken during this period and when the patient bleeding risk is reduce the INR level can be increased accoding to the patients condition. I hope this helps. Best regards

Is it thrombosis in the lower limb or chest or brain?

If it is in the lower limb, If it is not an urgent procedure then one may wait for at least 6 months with the patients on anticoagulants. If it urgent then try and get an INR within the operable range and go ahead.

If it is in the lungs the as much as possible avoid an abdominal operation. If is  urgent then the risk of non-operation should be weighed against the complications of pulmonary embolism

Tahnk you Rudolph, it is in the lung and surgery has planned for a gastric carcinoma. We have postponed surgery for a while but not sure the optimal time of surgery after the acute thromboembolism. We wonder there is any guideline or paper adressing this issue.

Hello,

This is a difficult question indeed. Generally speaking, if the surgery is elective, then one should wait 6 months. In your case however, the patient has a gastric cancer, this will progress unless treated.  Presumably,  there is no role for neo adjuvant treatment in this case, which might buy you some time?

If not, then have you considered an ivc filter to prevent further embolism reaching the lungs,  and then operating. Put the patient on therapeutic LMWH, omit on day of Surgery, time surgery to coincide at least 12 hours or more after last dose. After surgery give a dose of prophylactic LMWH, restart the therapeutic dose once you are confident enough time has elapsed since surgery for bleeding not to be a problem, maintain prophylactic dose until then.

That should help, and is some kind of solution to a complex problem. Also, liaise with your haematologist for advice. Explain to the patient risks of operating. 

Best wishes,

Gurpreet Singh Ranger 

Dear Dr AKGUN

if you had to perform a major surgery after a thromoboeltic event, change warfarin to low molecular weight heparin with therapeutic dosage such as enaxaparine 1mg/kg  or heparin 1000 I,U. five days before surgery and 12 hours before surgery change dose from therapeutic to prophylactic .if the threat of progressive thrombosis is exist you can insert IVC filter and during surgery , also use intermittant pneumatic compressive devices (IPC). After surgery ,when the danger of bleeding is finished start heparin or enaxaparin  again with therapeutic dose.

After a major thromboembolic events, most of the patients are put on therapeutic dose of LMWH (enoxaparin 1 mg/kg) and that is continued for at least 3 months after the event. More often LMWH is changed to warfarin. So, elective procedures are better to be postponed until the duration of heparin therapy is completed.  But such long waiting time may not be feasible in a case of gastric cancer, which again is a RISK FACTOR for thrombosis. So, if the patient is on oral anticoagulant, please switch to heparin or LMWH at least 2 weeks before the planned surgery and check the PT, aPTT and INR. The heparin/ LMWH should be stopped 24 hours before the surgery and should be restarted as soon as there is no risk of bleeding (mostly within 12 hours. In the stop gap, please ensure adequate hydration, mobilization of legs if possible and also pneumatic compression devices. 

That is a good question. I have been searching the topic and I have only found a reference addressing the issue of perioperative anticoagulation management (Perioperative Management of Oral Anticoagulation Martin O'Donnell MB, MRCP; Clive Kearon MB, MRCP. Cardiology Clinics, 2008-05-01, Volume 26, Issue 2, Pages 299-309). Regarding other perioperative risk (i.e. cardiac and pulmonary) I could not find any articles. I would obtain a cardiac echo prior to surgery if I need to intervene in a semiurgent setting before 3 months (i.e. symptomatic hernia, symptomatic cholelithiasis).