VTE prevention in surgical settings: A top priority in clinicians checklist. Episode 4 - Dr. Abhay Bhave and Prof. Juan Arcelus

This podcast focus on: 
•    Thromboprophylaxis recommendations for patients under special situations like:

  1. Renal impairment
  2. Liver cirrhosis
  3. Low platelets count

•    Current recommendation for vena cava filter insertion
•    Approach to operate a patient with cancer-associated thrombosis on anticoagulation

Time stamp

Name

Transcription

00:06 - 00:46

Unknown

Okay, welcome to VTE Unplugged, a brand new podcast series curated by Sanofi. The aim of VTE Unplugged is to bring latest in the field of venous thromboembolism management delivered by renowned experts in this field. Today, let's listen to our ongoing discussion on VTE prevention in surgical settings, a top priority in clinician's checklist. In the previous episode, our experts discussed about the thromboprophylaxis recommendations for patients undergoing various types of surgeries, like general abdominal and pelvic surgeries, cancer surgeries, bariatric and non-bariatric surgeries among obese patients and many others too. Now we will take this discussion forward.

00:51 - 01:19

Dr. Abhay Bhave

I now turn our attention to a very practical issue that we have when we are managing patients who have had a surgery done namely in situations, where there is an underlying liver disease or liver cirrhosis or where the platelets are low or when the patient has got a renal dysfunction, now in these special situations, how do you view thromboprophylaxis, how do you manage such patients?

01:20 - 05:20

Professor Juan Arcelus

Well, this is a situation that we see more often every day, we're operating more elderly patients. We are operating patients with more comorbidities. So, we are now, well, we have to face that, it’s very difficult for me to give one advice with so many potential situations. So, these patients, some of those that you mentioned from a cytopenia, renal failure, liver failure, they by definition have a potentially increased risk for bleeding. However, surprisingly, they also have in many situations increase risk for thrombosis. So, I think here you have to be extremely careful with the balance. So, the timing, the dosing, particularly in renal failure, patients, you know, that the different low molecular weight heparins have a different dependency on the renal excretion, like the DOACs as you know, dabigatranis very much dependent on the renal clearance as compared to apixaban.

 

So yeah, you have to be careful. There are some nomograms, some recommendations about how to adjust the dose, depending on the creatinine level or other filtration rate, we have to admit that unfractionated heparin, which is not that much dependent on the renal discretion, because it is bound to the endothelium. And if there's particular, it is to some degree also metabolizein the liver, unfractionated heparin can be an option. Patients with thrombocytopenia, you have to contact the hematologist unit. I mean, I think the approach to these patients has to be multi-disciplinary. They are difficult and they need the best knowledge and experience from the anesthesiologist from the thrombologist, from the surgeon, from the hematologist, etcetera. They need to be very individually addressed. Otherwise you end the things change. There is a very dynamic process postoperatively the number of platelets or renal function.

 

So, yeah, yeah, they have to be very carefully monitored. I can tell you that there is a clot, clot test, if you want a global clotting test. That I'm very, very, that was the reason I went with Caprini by the way that he had experienced with thromboelastography. And I did my PhD thesis with thromboelastography. The classical thromboelastography or the copy called ROTEM, which is a copy of thromboelastography. In my experience, in the US experience with liver transplant, in the US experience with cardiac surgery, in the Austrian experience in obstetrics, in many trauma patients, I mean, trauma units thromboelastography can be very useful to give you what is the global hemostasis situation of the patient. You can have a high INR low PTT. You can have a bunch of situations that you want to know what is the global situation? I have been always very, very happy when I have made that decision based on TEG, because, you know, it's a very interesting global, can be expensive, you know, it has disposables, but it's an option. So, I'm sorry. I cannot give more specific because each of these patients, of course, some renal failure patients, you can use this mupirocin, some of these liver patients, you can use prothrombin. I mean in prothrombin complex, very carefully, of course, vitamin K. You have to optimize the patients when they come to the operating room and optimize the postoperative care. But did we imply, as I said before, the best knowledge for the best specialists, otherwise you canrun into problems when people are really in severe renal failure patients or severe liver or major liver surgery patients.

05:22 - 06:09

Dr. Abhay Bhave

Thank you, Professor Arcelus. I think what you're trying to convey to us is that it's an individual therapy based on several dynamics. You could use instruments such as TEG or any other methodology to understand the coagulation better prior to giving thromboprophylaxis. So, thank you very much for those take-home points. Now in VTE unplugged, we've always said that we will also give our audience at least some controversial aspect that we would like your views on. And I couldn't think of anything more than the insertion of the IVC filter. So, what's your take on inserting IVC filters, what's the current recommendation and how do you go about handling the situation?

06:10 - 09:57

Professor Juan Arcelus

Well, first of all, if you look at the last 30 years, I think we all admit now that they have been abused, that there have been, there has been an over indication of filters, because we were not aware that a permanent filter would eventually end up clotting that caver in a high percentage of patients. So, for today, current practice, primary prophylaxis, patients are high risk, trauma bariatrics. They don't have an indication patient without a DVT. If you put the filter, probably you're going to cost the DVT, the prep peak study show that you can, if you put filters in patients with an ongoing DVT, you are going probably to avoid some angiographically detected PE, but you're not going to save lives. So, in a patient without a DVT, please consider very carefully using filters. What are the current guidelines? And I'm referring to a very recent few months ago, guidelines from the American Society of Interventional and vascular, radiologists, and surgeons.

 

Well, the only remaining clear indication for filters is a patient with an active reason VTE, where you, that is anticoagulated. And you have to discontinue anticoagulation, for example, for surgery or where the patient is straightforward contraindicated to use anticoagulants. That's a very bad situation because then you put a filter, but you don't prevent the clotting at the level of the filter. So, when anticoagulation is contraindicated or needs to be discontinued both for patients with PE or DVT. A recent indication, very conditional on individual basis, decision patients with advanced endovascular therapies, you know, thrombectomy aspirations, (inaudible) therapy, you could consider. There was a classical indication that was the patient that was so called properly anticoagulated that remain having recurrent PEs that wasn't indication until a few years ago. Now, it's not anymore, but the guidelines say now is reconsider, how are you anticoagulate in that patient? Because probably if the patient is properly anticoagulated, there is not a reason unless it has a huge floating clot and you keep the patient walking the corridors. So, to summarize the advent of retrievable filters has changed the cope, but that wouldn’t mean that you should put filters more easily, more freely because they could be retrieve removed because in some patients up to 20%, 30% of the removable filters in some US series are never removed. And that's a blockage in the caver that eventually could clot.

 

So, to summarize primary prophylaxis, they don't have a role. Should, should be a very specific situation of a patient with a personal history of VTEs that has a trauma that has, you know, severe chronic venous, and also renal failure you could consider, but most guidelines do not recommend for primary. To avoid PE with an ongoing DVT as I said, if you have to discontinue anticoagulation or you cannot prescribe anticoagulation. Right now in Europe, the years has declined massively even in the US where they were using abusing for many, many years, the years have filters.

10:00 - 10:39

Dr. Abhay Bhave

Thank you very much Professor Arcelus for making it crystal clear for us regarding this contentious issue of IVC filter in session. I'm going to come to another question, which is very important for us and that's in cancer associated thrombosis. So, we've got patients who have got the malignancy and there is a documented thrombus and they are on anticoagulation. But for some reason, some of these patients need a surgical intervention. So, how should we be going about this situation? When are they fit for a surgical event? Do we need a specific amount of time of anticoagulation to have gone in, how do you approach this?

10:40 - 15:10

Professor Juan Arcelus

Yeah, I'm going to approach it generally, not only in cancer, but cancer would make even more, more complicated in the situation. Yeah, we have for, in Spain, I think we have close to 700,000 inhabitants. I mean, citizens that are on chronic oral anticoagulation, either with VKAs or DOAC. So, the population today, there is an increasing number of citizens taking either anti-platelets or anticoagulants. They need surgery and they can need emergency surgery, elective surgery, cancer surgery, different types of surgery, and not only surgery, the lumbar puncture by the neurologist because of meningitis and endoscopy removal of a suspicious polyp, pacemaker insertion, maxilla, maxillofacial surgery. So, there are many situations. So here, here, you have to answer two very important questions. What is the thrombotic risk of the patient and what is their potential bleeding of this procedure? Based on that you have to go to the algorithm and the tables of the main, there are, fortunately, there are many guidelines and then those guidelines will guide you on when to discontinue.

 

Then, you know, for many years we were discontinuing aspirin sometimes one week before surgery, that was a mistake, you can operate on aspirin reducing the dose. For many years, we have been doing bridging. We were discontinuing, discontinuing vitamin K antagonist five to seven days before the operation and shifting telomerase with heparin. Well, the breech trial and many other trials are showing almost every two weeks we have a new trial that bridging is more dangerous in terms of bleeding without increasing the danger in terms of thrombosis that discontinuing the vitamin K five days before, or even not even discontinuing depending on the situation. So, you need to know what is the renal situation of the patient, depending on the agent with heparins DOACs, you have to know what is the thrombosis risk? Here we have, the main categories are atrial fibrillation. Then we have the cardiac valves, and then we have the VTE, those three situations, of course, cardiac, mechanical, the valve or valvular afib should not receive DOACs, but still many, many patients are receiving vitamin K antagonist.

 

So, you have again as we mentioned before, in the particular populations, you have to individualize the decision based on that patient. Again, the anesthesiologist and the surgeon and the thrombosis expert or the pharmacologist, or the hematologist have to make a combined protocol and agreement consensus protocol for the hospital to make things easier. The current trend, as I said, is to avoid bridging discontinuing sometimes in closer proximity to surgery, and also very important, we should not forget that these patients at high risk of thrombosis, we need to balance them carefully postoperatively. And my final sentence the risk related to the heart, the thromboembolic risk coming from the heart or the carotid arteries is more important than the potential VTE in patients that didn't have a VTE, of course, sometimes they say, oh, I have low molecular weight heparin, a moderate dose. They said, no, no, no, no. The patient was in full-blown anticoagulation. Use of the least moderate risk though, but don't have a patient with 20 milligrams of enoxaparin seven days after an operation. If the patient was with an INR two to three before the operation, I mean the week before the operation, that's a problem with my residents. Sometimes they forget that is very important to protect those patients, probably not with the DOAC, but with the low molecular weight heparin, but you cannot give low doses for primary prophylaxis in patients that were receiving secondary prophylaxis, higher doses.

15:13 - 16:15

Dr. Abhay Bhave

Great. Thank you very much. That was Professor Juan Arcelus giving us his thoughts on so many aspects of a patient's surgical journey. So, we learned from you that there is a, there could be a significant risk of VTE in a surgical patient. We need to risk assess our patients with the appropriate Ram that we choose use thromboprophylaxis where we find it appropriate in the right dose for the right time, including even prior to surgery if the situation is right, look at the clinical parameters, see whether the bleeding risk and the clotting risk are matched and see that we are in the right clinical situation. And this will ensure that we can prevent clots even in patients who are undergoing surgery. So, it was a pleasure to listen to your thoughts, and I'm sure our listeners will be richer for their practice after listening to you. So, till the time we plug in again, with another interesting episode on VTE unplugged, stay safe and stay healthy. Thank you, Professor Arcelus.

16:15 - 16:18

Professor Juan Arcelus

Thank you very much Dr. Bhave. It has been a pleasure.

MAT-IN-2103096-1.0-08/2021