Preoperative management of thrombotic disease

As the growing population needs to receive antithrombotic therapy, perioperative management of antithrombotic therapy, with anticoagulation and/or antiplatelet has become a major concern to physicians taking care of surgical patients. Balancing the risk of bleeding with continuation and thrombosis with discontinuation requires consideration of each patient's risks for thrombotic complications and probability of bleeding in surgical procedures. Warfarin has been a mainstay of chronic anticoagulation therapy, and patients receiving warfarin need interruption of warfarin prior to the surgery and a preoperative bridge therapy with an alternative anticoagulant typically unfractionated or low molecular weight heparin. The novel oral anticoagulants including dabigatran, rivaroxaban, edoxaban and apixaban have shorter halflives and may not need the preoperative bridge therapy. However they raised other concerns for perioperative management including prolonged elimination halflife in patients with compromised kidney, poor correlation between routine laboratory tests and clinical effectiveness of anticoagulation or lack of a specific antidote.