PIG Meeting: 18th March 2021

70s year female presents for resection of floor of mouth SCC and neck dissection + tracheostomy.

Background

• Hypertension and Asthma
• Had attempt at same surgery in December 2020. Unfortunately complicated by vascular injury during tracheostomy. This required sternotomy and repair.

Discussion

• HITTS – diagnosis via HITTS antibody, although low specificity (high false positive rate), with definitive diagnosis with serotonin release assay (usually takes 2 weeks).
• Absolute contra-indication to heparin and clexane
• IVC filter – data generally does not support use in perioperative period. May be suitable for patients with high thrombus burden in lower limbs and contra-indications to anticoagulation for extended period. Major issue is failure to remove and loss to follow up. They are difficult to remove once in long period of time due to fibrosis in vessel.
• See attached European guidelines (summary below)

Plan

• Patient reviewed by haematologist and discussed with colleagues. Noted that there was an even split on for and against IVC filter preoperatively!
• Following a discussion between surgeon and haematologist and interventional radiology a decision was made to cease NOAC 72 hours preoperatively and place IVC filter 24 hours preoperatively.
• Note that heparin was contra-indicated intra-operatively for use during vascular flap resection. Post op plan for fondaparinux for thromboprophylaxis.

Postscript – procedure successful and patient now on ward.