Endgames Case Report

Indications for and use of inferior vena cava filters in the preoperative phase

BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f5807 (Published 30 September 2013) Cite this as: BMJ 2013;347:f5807
  1. Prabhat Bakshi, POPS (proactive care of older people undergoing surgery) senior house officer,
  2. Judith Partridge, POPS clinical research fellow,
  3. Jugdeep Dhesi, POPS consultant
  1. 1Department of Ageing and Health, Guys and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
  1. Correspondence to: P Bakshi pbakshi{at}doctors.org.uk

A 66 year old man presented for preoperative assessment and optimisation before a left thoracoabdominal oesophagectomy for oesophageal adenocarcinoma (T3N2). He had undergone three cycles of chemotherapy and developed a deep vein thrombosis in the right popliteal vein. He was started on low molecular weight heparin. His medical history included deep vein thrombosis of the right leg and pulmonary embolism four years ago, myocardial infarction, hypertension, and hypercholesterolaemia.

His history of venous thromboembolism and high ongoing thrombotic risk meant that lifelong anticoagulation was indicated. The need for surgery made it necessary to interrupt therapeutic anticoagulation within two months of his venous thromboembolism. Repeat Doppler scans of the right leg undertaken as part of the preoperative assessment and optimisation process showed residual thrombosis.

Questions

  • 1 How should patients with previous venous thromboembolism be managed preoperatively?

  • 2 When are inferior vena cava filters indicated?

  • 3 What is the evidence for inferior vena cava filters v routine anticoagulation in preventing primary or recurrent pulmonary embolism?

  • 4 What complications are associated with inferior vena cava filters?

  • 5 When should inferior vena cava filters be removed?

Answers

1 How should patients with previous venous thromboembolism be managed preoperatively?

Short answer

Preoperative management depends on the history of venous thromboembolism, the patient’s risk profile, the type of surgery that is planned, and the patient’s renal function. All patients at risk of venous thromboembolism should be prescribed antiembolic stockings and pharmacological thromboprophylaxis unless contraindicated.

Long answer

The importance of thromboprophylaxis in preventing deep vein thrombosis was established more than three decades ago.1 Because deep vein thrombosis can lead to fatal pulmonary embolism—the most common preventable risk factor for inpatient mortality2—perioperative thromboprophylaxis has become the norm in at risk patients. Current National Institute for Health and Care Excellence (NICE) guidelines suggest that any patient at risk of venous thromboembolism (for example, previous venous thromboembolism, cancer surgery, age over 60 years, or serious …

Sign in

Subscribe