Vascular surgeon's recommendation

[Marty]

I asked one of my buddies who is a fine vascular surgeon how he would prep me for removal of a large lipoma from back(hypothetical). This is his answer.

Hi Marty,

Sorry to be late responding to your query ... I am only in the office Tues -
Wed -Thur ...operate Mon & Fri.
In this litigious climate, I rely on the physician who put the patient on
long term warfarin to be in control of the anticoagulation regimen. Usually
I would suggest that we place a heparin lock in the patient's forearm and
the patient or a relative can administer the heparin in lieu of the
warfarin, which I suggest be discontinued about 5-7 days pre-op.
The heparin is a lot easier to reverse if need be.
Smaller doses of heparin can be continued post-op so that the patient does
not develop a hematoma ( this concern varies with the size of the lesion
excised ). About a week post-op the patient can then be started back on
warfarin.
Hope this helps you ...Basically the patients should work closely with their
internist and surgeon, and their physicians will recommend a protocol that
works well for them ... there are different ways to handle the situation ..
what works best for each doc in his/her experience is what should be
followed.

Best to you and Alice ..

Joe

 

[Rich]

Marty,
Does that mean you can do the Heparin at home and not lay around for days in the hospital ?

 

[LUVMyBirman]

Hi Marty,

Yes, like Rick would like to find out more about the 3-5 days off. Are you already hospitalized and waiting for surgery at that point? Someone like myself. One day off and I am down in the ones.

It did ask my GP about injectable Heparin and she stated it is available. Not sure if that is a viable option for us valves. My next thought would be home health care with the IV Heparin. Though, from my trials with the IV in the hospital your levels can turn on a dime and become very high fast.They can turn it off for an hour then back on. Not sure a visiting nurse could handle that. You need a lab to test levels.

Would be a heck of a lot easier using the Lovenox. Out of the question for most of us. I cringe at the thought of coming of my Coumadin now. It will be a major hassle. Forgetting about anything elective

 

[Nancy]

Joe has a small growth on his face that might have to be removed. It looks to be comprised mostly of capillary growth, like a hemangioma. So it will be subject to bleeding.

He sees the skin doctor in June. For this he'll probably have to be hospitalized. Plus he's on a lot of new, very tricky medication for his pulmonary hypertension which do things to his blood vessels. Regulation of this situation is going to be a nightmare. What a total pain. I never thought I would be nervous about something so minor, but I am. He's all nice and stable now, and any medication changes could rock the boat again.

With most people, you could probably just zip it off in the office.

 

[Marty]

Old fashioned IV Heparin

Old fashioned IV Heparin

My friend Joe,arguably the best vascular surgeon in our area works with the PCP's but as you see likes the heparin lock with which the patient can take heparin at home and stay out of the hospital. Most of the surgery done now in this area is done in outpatient "surgicenters". Yes Rich you can administer this heparin yourself or ask your wife to do it. Joe may be a little old fashioned (he's in his upper 60's) but I personally like his heparin lock regime. I myself would not like to get my INR down to 1.0 for 3 or 4 days for a colonoscopy or skin tumor without some type of other anticoagulation.I think unfractionated IV heparin works to keep mechanical valves clot free. This therapy is at least thirty years old but it is proven to work.You probably could get away without it but there is still a slight risk. Gina I think the heparin lock could work at home till day of admission for hysterectomy but I'm not sure.I think you would need frequent tests which monitor the heparin, Activated Partial Thromboplastin Time.Your gyn and cardiologist need to work together on this and if they do not have a protocol satisfactory to you, get another opinion from a vascular surgeon or a hematologist. Nancy I agree your Joe needs special care but it sounds like you have it up there.

 

[JimL]

Marty, thanks for keeping this issue alive. I'm still looking for a surgeon who will remove my cysts while I stay on coumadin. If I can't find one, I'll have to spend a week hospitalized later this summer or in the fall.

 

[Rich]

Thanks for the info Marty,
All of us Coumadin patients may face some kind of other surgery in our lifetime and need to understand our options.
Pesonally they had me stop my Coumadin for three days on three different occasions but reading all this tells me maybe I was just lucky nothing happened.
If there is a next time I will be a lot better armed to talk to these doctors before I submit to have anything done.

 

[Marty]

A cardiology opinion

A cardiology opinion

This is a reply to my query in regard to prep for colonoscopy from my cardiologist. Tony says,

Hi Marty,
This falls more in the realm of clinical practice and good judgement rather than an approach written in stone. The vast majority of patients who have not had a thrombotic event, and have normal LV function, are usually stopped for 3 days. Pts with valves in the Mitral position are at slightly higher risk because it is a "low flow/pressure" valve so cases are typically considered individually. Lovenox has not been approved as a bridge and is actually falling out of favor in this use because of reports of strokes in a series of pregnant women. Essentially there would be no medical-legal leg to stand on given these reports. When in doubt, they get admitted for heparin, but this is quite rare. In summary though, I am not aware of any published risk using the 3 day approach of stopping then starting coumadin.
Let me know what you do, Tony