Tuesday, October 1, 2013

Blood Clots, Venous Thromboembolism, Pulmonary Embolus and Cosmetic Surgery

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In a previous blog I discussed Bleeding Disorders and Cosmetic Surgery focusing on bleeding tendencies and abnormally low blood clotting. This blog deals with the other side of the coin abnormally high blood clotting. These clots usually form in large veins of the leg or pelvis or in the chambers of diseased hearts.

Because these clots form in a direct pipeline to the heart and lungs without an intervening bed of capillaries to filter out large clots they can be life threatening when they travel up to and get stuck in the hear or lungs, especially when large in size. The chance of this occurring in otherwise normal patients during any surgery under general anesthesia is reduced by applying pneumatic compression devices on the legs to pump venous blood back up to the heart during surgery as stagnant blood is clotting blood. A multitude of factors such as traumatic injuries, cancer, reaction to certain medications (birth control pills) etc can cause or provoke the initial clot formation. Traveling blood clots are the leading cause of death in cancer patients, after the cancer itself. Once a clot occurs the risk of it happening again in one's lifetime is high especially if the first clot was unprovoked by an injury or medication. For unprovoked clots the recurrence rate is 10% after 1 year and 30% after 5 year despite following the recommendation of months of anticoagulation/taking blood thinning medications. For provoked leg blood clots only 1 1/2 to 3 months of anticoagulation is required. Longer durations of anticoagulation (blood thinning) are not more beneficial. The decision of whether or not to do cosmetic surgery on these patients depends on the length of surgery time, patient age, the presence of other diseases like diabetes or cancer, patient sex, the duration of anticoagulation, how long ago anticoagulation stopped, how long ago the clot formed, whether the initial clot was provoked or un-provoked, whether there is residual clot in the legs. Obviously, active anticoagulation with coumadin, which stops new clots from forming at surgery, precludes any surgery.

More than 50% of patients with an un-provoked clot have some blood disorder (antiphospholipid syndrome [Lupus antibodies], Hereditary thrombophilia, such as factor V Leiden mutation, prothrombin gene mutation, antithrombin deficiency, protein C deficiency, protein S deficiency, high levels of factor VIII and XI, or hyperhomocysteinemia). These patients need lifetime blood thinning.

So what does one do if they have or have had a blood clot in their leg and they want cosmetic surgery? For provoked clots you have to first solve the provoking factor and then take the blood thinners for up to 3 months. Then the patient has to be reevaluated for residual clot in those veins. If significant clot remains in those veins the placement of a filter in the large vein below the heart may be required. This filter prevents clot migration into the hearts and lungs. If a filter is not required cosmetic surgery is possible with the daily injection of low molecular weight heparin or taking the factor Xa oral anticoagulant Rivaroxaban starting about a week before the cosmetic surgery. These medications dissolve older clots but do not prevent new clots from forming at the site of surgery.

For patients with unprovoked clot formation the problem is more difficult because they can form clots anywhere including above where the vein filters are usually placed. In most cases these patients should not have cosmetic surgery on only have such surgery in a hospital where tranfusable blood products are readily available.

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