How long should VTE be treated VTE Recurrence

How long should VTE be treated?

VTE Recurrence Anticoagulation Provoked § surgery § trauma § pregnancy § medical illness Recurrent VTE 0 VTE 3 mos Time

VTE Recurrence Anticoagulation Recurrent VTE § unprovoked § active cancer § ongoing risk factor § § § high risk thrombophilia major residual DVT male § provoked 0 VTE 3 mos Time

Duration of Treatment for VTE Provoked (transient, reversed risk) Unprovoked duration 3 months indefinite* Continuing risk (unresolved cancer, etc) indefinite* *with periodic reassessment

Objectives 1. Pathogenesis of VTE and risk factors 2. Investigation of suspected DVT, PE 3. The direct oral anticoagulants (DOACs) 4. Management of VTE 5. Management of massive DVT, PE 6. Anticoagulant reversal 7. Perioperative management of anticoagulated patients 8. Prevention of VTE in surgical patients

34 yo woman with phlegmasia after spine #

1 day after catheter thrombolysis

53 yo woman with massive PE after ankle #

1 day after presentation with massive PE

Indications for Catheter-Directed Thrombectomy/Thrombolysis I. In DVT, with extensive clot and severe symptoms (“big clot, can’t walk”) 2. In PE with hypotension, overt right heart failure (increased mortality) Treatment of choice for massive DVT and massive PE

Single Indication for an Filter IVC Recent PROXIMAL DVT PLUS an absolute C/I to full anticoagulation NOT for: - PE without proximal DVT - “Recurrent” VTE/failure of Rx - Primary prophylaxis - Etc

IVC Filters 1. Only if indicated (recent proximal DVT + absolute contraindication to therapeutic anticoagulation) 2. Only retrievable filters are used 3. Anticoagulate the patient as soon as safe 4. When patient anticoagulated, have the filter removed (usually on the same admission)

Objectives 1. Pathogenesis of VTE and risk factors 2. Investigation of suspected DVT, PE 3. The direct oral anticoagulants (DOACs) 4. Management of VTE 5. Management of massive DVT, PE 6. Anticoagulant reversal 7. Perioperative management of anticoagulated patients 8. Prevention of VTE in surgical patients

Vitamin K: Routes & Doses IM NEVER SC NEVER PO If reversal not urgent INR <5 1 mg INR >5 2. 5 mg IV ROUTE OF CHOICE if urgent 10 mg IV for MAJOR bleeding or surgery

Warfarin Reversal FFP NEVER PCC For major bleeding or reversal need urgent (Octaplex®, Beriplex®) - 25 -50 U/kg depending on INR and urgency ** Always give vitamin K 10 mg too

Management of Bleeding on Direct Oral Anticoagulants 1. Specific antidote only for dabigatran (idarucizumab = Praxbind®) 2. Factor Xa inhibitors can be reversed rapidly with PCC (as for warfarin)

Management of Bleeding in Patients Receiving a DOAC 1. Use a local hospital policy 2. And ask for help

Patient with bleeding on dabigatran § When was last dose? § CBC, creatinine § a. PTT If a. PTT >40 sec, consult TE or Transfusion Medicine Mild bleeding § Local hemostatic measures § Hold 1 or more doses of dabigatran Moderate-severe bleeding* § Manage bleeding (compression, surgery) § Fluid diuresis § Transfuse RBCs or platelets if needed (follow Sunnybrook guidelines) § Oral charcoal if dose <2 hrs before Life-threatening bleeding* § Contact Transfusion Medicine § Tranexamic acid (1 G IV followed by 1 G infusion over 8 hours) § Hemodialysis might be helpful § Consider Praxbind* *2. 5 grams x 2

Objectives 1. Pathogenesis of VTE and risk factors 2. Investigation of suspected DVT, PE 3. The direct oral anticoagulants (DOACs) 4. Management of VTE 5. Management of massive DVT, PE 6. Anticoagulant reversal 7. Perioperative management of anticoagulated patients 8. Prevention of VTE in surgical patients

Surgery in Patients Requiring Long-term Anticoagulants 1. Thrombosis risk versus 2. Bleeding risk Need to individualize the approach

Surgery in Patients Requiring Long-term Anticoagulants PRE-operative consideration 1. Thrombosis risk versus 2. Bleeding risk POST-operative consideration

For each case, ask 4 questions 1. Does anticoagulation need to be reversed at all? 2. If so, how long should anticoagulation be stopped before the procedure? 3. Should bridging with LMWH be done? 4. When can anticoagulant be restarted after the procedure (and how)?

Peri-procedure Management of Anticoagulation: 3 Options 1 Very Low Bleeding Risk Procedure 2 Low TE Risk 3 High TE Risk Bridge Procedure

Anticoagulation in Patients Requiring Surgery with Very Low Bleeding Risk 1 warfarin 3. 0 INR 2. 0 No anticoagulant reversal 1. 5 1. 0 -5 INR -4 -3 -2 -1 OR DAYS 1 2 3 4 5 6