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Individualized approach to vascular surgery patients
1. Individualized approach to vascular
surgery patients
Irena Šnajdar , Damir Halužan , Andrea
Crkvenac Gregorek, Ivan Škorak, Ivan Brižić,
Josip Figl, Tomislav Meštrović, Davorin Mitar,
Zlatko Fiolić, Mladen Petrunić, Predrag Pavić
Zavod za vaskularnu kirurgiju, Klinika za
kirurgiju, Klinički bolnički centar Zagreb
2.
3. D.K., 64 years
• juvenile hepatic cirrhosis and hepatitis B
• 1970. splenectomy and portocaval
anastomosis
• 2013. liver transplantation
( immunosuppressive therapy since then )
• 2013. DVT left leg
• MTHFR heterozygote
• permanent anticoagulant therapy
(warfarin)
4. WARFARIN
• interferes with hepatic synthesis of
vitamin K-dependent clotting factors II, VII,
IX, and X, as well as proteins C and S
• depletes functional vitamin K reserves,
which in turn reduces synthesis of active
clotting factors, by competitively inhibiting
subunit 1 of the multi-unit vitamin K
epoxide reductase complex 1 (VKOR1)
5. Perioperative management recommendations
• hold warfarin therapy approximately 5 days before
surgery
• resume warfarin 12-24 hrs. after surgery
• bridge anticoagulation during interruption in
patients at high thromboembolism risk
6. • since 2014. left crural ulcer
( compression therapy,antibiotics,barotherapy )
Doppler
• on left sever sapheno-femoral insufficiency,
• on right without sapheno-femoral
insufficiency
7. • Without discontinuation of anticoagulant therapy
( PV 0.27 INR 2.31 )
• In tumescent anesthesia
• Seldinger technique for positioning of laser sonde
• endovenous laser ablation of left VSM
( Biolitec laser Leonardo dual )
• sclerotherapy of varices
8.
9. • immediately after procedure continuation
of anticoagulant and immunosuppressive
therapy
• minimal hematoma , no adverse reaction
10. V.B., 64 years
• 2015. pulmonary embolism
• 2016. paroxysmal FA with medicament
conversion
• FV Leiden R506Q normal
• F II prothrombin normal
• permanent anticoagulant therapy (dabigatran)
11. DABIGATRAN
• prevents thrombus development through
direct, competitive inhibition of thrombin
(thrombin enables fibrinogen conversion to
fibrin during the coagulation cascade)
• inhibits free and clot-bound thrombin and
thrombin-induced platelet aggregation
12. Perioperative management recommendations
• if possible, discontinue dabigatran 1 to 2 days
(CrCl ≥50 mL/min) or 3 to 5 days (CrCl <50 mL/min)
before invasive or surgical procedures because of
the increased risk of bleeding
• consider longer times for patients undergoing
major surgery, spinal puncture, or placement of a
spinal or epidural catheter or port, in whom
complete hemostasis may be required
• restart dabigatran promptly following surgery
13. • right crural ulcer and varicose veins
Doppler
• on right sever sapheno-femoral
insufficiency,
• on left without sapheno-femoral
insufficiency
14. • without discontinuation of anticoagulant therapy
• one day- surgery
• in tumescent anesthesia
• Seldinger technique for positioning of laser
sonde
• endovenous laser ablation of left VSM
( Biolitec laser Leonardo dual )
• sclerotherapy of varices
• discharged home 6 hours after procedure
15.
16. • immediately after procedure continuation
of anticoagulant therapy
• minimal hematoma , no adverse reaction
