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VTE DIAGNOSIS

Postoperative venous thromboembolic disease (VTE) accounts for approximately 25% of all VTE despite prophylaxis.1 Most postoperative patients will have an intermediate or high pretest probability of VTE. D-dimer testing in the postoperative patient has limited utility because of the high frequency of elevated results, and the American Society of Hematology guidelines recommend against the use of D-dimer alone to diagnose VTE.2 Computed tomographic pulmonary angiography and duplex ultrasound are suggested as initial studies of pulmonary embolism (PE) and deep vein thrombosis (DVT), respectively, and serial duplex ultrasound should be used in patients with high suspicion of DVT and an initial negative study.2

VTE TREATMENT

Key aspects to treatment include choice of anticoagulants, use of IVC filters, and length of treatment. If hemostasis is unclear or not secured, an anticoagulant that can be titrated and easily reversed, like unfractionated heparin, or placement of a temporary inferior vena cava (IVC) filter should be used until the bleeding risk has abated (Figure 39-1).

FIGURE 39-1

Postoperative venous thromboembolism treatment based on hemostasis.

aDOAC = direct oral anticoagulant

Choice of Anticoagulants

The American College of Chest Physicians (ACCP) guidelines suggest direct oral anticoagulants (DOACs) over vitamin K antagonists like warfarin for the treatment of VTE.3 Oral apixaban and rivaroxaban are initiated at higher doses for 1 and 3 weeks, respectively, whereas dabigatran and edoxaban need at least 5 days of parenteral anticoagulant lead-in (not overlap) (Table 39-1). Common concerns with DOACs include use in renal failure, obesity, and the ability to reverse their effect.

TABLE 39-1Standard Treatment Dosing and Renal Adjustment for Direct Oral Anticoagulants

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