According to Dr. Edwards, bridging is not necessary in the vast majority of patients who are on AC prior to the surgery. “There are rare patients who clot within a day or two of stopping AC, but these patients have hematologists who will offer guidance about bridging with IV heparin,” Dr. Edwards said. “Patients with myeloproliferative neoplasms should have their disease well controlled prior to any elective surgery.”
Explore This IssueJanuary 2020
While metabolism, and therefore the half life of direct oral anti-coagulants (DOACs), varies from patient to patient, Dr. Edwards said that she generally holds a DOAC for two days for minor procedures such as a lymph node biopsy, and for four days for major surgeries or surgeries that have very vascular beds, like tonsillectomy. “ENT surgeons must remember that AC is in full effect two hours after a dose of a DOAC,” she said. “There is no lag time, as there is with warfarin. In general, it is safe to restart a DOAC by POD two or three.”
Dr. Edwards added that there is almost no indication for IVC filters in elective surgery. “If a patient is truly hypercoagulable, they will clot above the filter. The rare exception is the patient who develops a VTE after neurosurgery and there is an absolute contraindication to surgery.” Another exception, she said, would be a patient who had a VTE event and needed urgent surgery before he or she could complete three months of AC. “In these circumstances the filter should be removed as soon as possible,” she said.
Renée Bacher is a freelance medical writer based in Louisiana.