Open Journal of Anesthesiology, 2011, 1, 1-4
doi:10.4236/ojanes.2011.11001 Published Online October 2011 (
Copyright © 2011 SciRes. OJAnes
Perioperative Management of Case of
Gynecological Malignancy with Bilateral Deep
Venous Thrombosis of Lower Limbs Along with
Pulmonary Embolism
Mahesh K umar Ar o ra 1, Rakesh Garg2
1Department of Anaesthesiology and Intensive Care, All India Institute of Medical Sciences, New Delhi, India; 2Department of An-
aesthesio logy and Int ensive Care, All Ind i a Institute of Medi cal Sciences, New Delh i , India.
Received S eptember 5th, 2011; revised October 10th, 2011; accepted Oct ober 18th, 20 11.
We describe the anaesthetic management of 45 year female patient with pre-existing deep venous thrombosis (DVT)
and pulmonary embolism (PE) who was subsequently scheduled for a laparotomy. Before planning the surgical proce-
dures, adequate anticoagulation must be achieved to prevent further complications of DVT, thromboembolism, and
pulmonary embolism in particular. The risk of stopping the anticoagulation prior to surgery must be considered and
adequately discussed with the patient and surgeons. The anaesthetic plan must be selected keeping in mind the coagula-
tion status and the need of anticoagulation in the postoperative period.
Keywords: Deep Venous Thrombosis, Pulmonary Embolism, Anaesthesia, Oncology Surgery
1. Introduction
Venous thromboembolism (VTE), in the form of deep
vein thrombosis (DVT) or pulmonary embolus (PE) is
one of the concerns mostly in the postoperative period
[1]. The presence of preexisting DVT and PE in patient
scheduled for oncologic surgery carries a challenge for
anaesthesiologist. As many as 50% of patients who have
a proximal DVT develop a PE, and among those who
have a clinically significant PE, 70% have evidence of
DVT [1]. The underlying etiology for prothrombotic
tendency of malignancies is the impact that malignant
disease has on the Virchow’s triad of stasis, intimal
injury, and hypercoagulability [1]. Patients who have
mali gnancy have a si x fold i ncrease d risk o f VTE, and it
is estimated that the incidence of VTE in the cancer
population is 1 in 200 patients [1-4]. Patients who have
brain tumors and adenocarcinoma of the ovaries,
pancreas, stomach, colon, lung, prostate, and kidney have
a higher risk of VTE than those who have other
mali gnanc ie s [4-6 ]. With o ther r isk fac tor s equa l, sur ger y
for malignant disease results in a 2- to 3-fold increase in
thromboembolism compared with surgery for nonmali-
gnant conditions [1,5]. Among the all malignancies, the
gynecologic oncology patients have the highest risk of
venous thromboembolism [6]. Though postoperative
DVT and PE usually remains a concern and various
measures are mentioned in literature for its prevention
but the presence of DVT and PE preoperatively in a
patient scheduled for oncology surgery and its periopera-
tive management has not been much described in litera-
We present a case of bilateral lower limb DVT with
pulmonary embolus scheduled for laparotomy for gynae-
cology malignancy.
2. Case History
A 45-year-old female weighing 72 kg was scheduled for
laparotomy for the excision of abdominoplevic mass and
carcinoma ovary. On reviewing the history, patient had
fever for last 3 weeks, pain and swelling in both lower
limbs since last 10 days. The swelling appeared in the
foot and gradually involved the whole of the both lower
limbs in 3 - 4 days. Doppler examination of lower limb
revealed bilateral deep venous thrombosis (DVT). She
was started on inj enoxaparin 0.6 mL once daily since 4
days. Two days back she complained of breathlessness.
Perioperative Management of Case of Gynecological Malignancy with Bilateral Deep Venous Thrombosis of Lower
2 Limbs Along with Pulmonary Embolism
She was referred to our institute. On examination, her
pulse rate was 92 beats per min, blood pressure of 108/82
mmHg and respiratory rate was 22/min. Investigations
revealed haemoglobin 8.4 g/dL. Her D-Dimer by quanti-
tative Immunoturbidimetry method was >20 µgFibEq/mL
(normal < 0.5). Computed tomographic angiogram revea-
led thrombus in left descending pulmonary artery with
extension into left lower lobe, infrarenal inferior vena
cavae (IVC), bilateral common iliac vein, external iliac
vein, common femoral vein, saphenofemoral vein, popli-
teal veins along with hepatomegaly and abdominopelvic
mass encasing IVC. Haematologists opinion was taken
and dose of inj enoxaparin was increased to 80 mg sc
twice a day. The risk associated with the surgery and
written infor med conse nt was t aken. I VC filt er was p laced
in the infrarenal IVC via right transjugular approach.
The dose of enoxaparin was omitted on the morning of
surgery and patient was premedicated with oral diazepam
(10 mg) and pantaprazole (40 mg). Her platelet co unts were
180 × 103/mm3, prothrombin time—13:17 (control:test),
aPTT—2 8:30 (c ontrol:test) . In the opera ting roo m, routi ne
monitors were attached. Anaesthesia was induced with
intravenous fentanyl (150 µg), propofol (140 mg) and
lungs ventilated with oxygen in isoflurane (2%). After
achieving neuromuscular blockade with atracurium (40
mg), trachea was intubated with endotracheal tube. Left
radial artery was cannulated. Ultrasound guided right IJV
was cannulated using triple lumen central venous
catheter (CVC). Anaesthesia was maintained with isoflu-
rane in oxygen and air along with infusions of fentanyl
(50 µg/hr) and atracurium (20 mg/hr). Intraoperatively
tumor mass was excised and blood loss was 1500 mL,
which was replaced with 1500 mL of voluven initially
and then with 4 units of packed RBC (after removal of
tumor mass) . Pa tient re maine d hae modyna micall y stab le.
After completion of surgery, residual neuromuscular
blockade was reversed and trachea was extubated. She
was shifter to ICU for observation. Inj enoxaparin was
restarted 6 hours later. Analgesia was provided with
intravenous morphine infusion (1 mg/hr). She remained
stable and shifted to ward on 2nd day and discharged
home on the 8th day uneventfully.
3. Discussion
A number of issues related to pre-existing DVT prior to
gynecologic surgery deserve further clarification, the
optimal duration of pharmacological treatment, and the
optimal duration/modality of prophylaxis to prevent
thromboembolism in these high-risk cancer patients. The
other concern was bleeding during the perioperative
period due to anticoagulation for treatment of DVT and
pro-coagulation associated with the malignancy. The
pathogenesis of perioperative PE is assumed to be based
on a hypercoagulable state that may occur during major
surgery and that may extend into the postoperative period
[7]. Massive PE is associated with haemodynamic
instability and high mortality (30%). So, the treatment
options include anticoagulation, thrombolysis, placement
of a vena caval filter and pulmonary embolectomy [8].
Further the thrombus extension occurs during the im-
mobility in the perioperative period. This chance of
thrombus extension and risk of further pulmonary
embolus in our patient having bilateral DVT prompted us
to insert IVC filter prophylactically. Placement of IVC
filter prior to urgent surgery in a patie nt with a DVT has
also been described earlier [5,9]. The use of vena caval
filters has expanded to include primary venous throm-
boembolism (VTE) prophylaxis in special patient popu-
lations such as major trauma patients, major surgery
patients, advanced malignancy, and neurological or neu-
rosurgical patients with paralysis or prolonged immo-
bilization. We were apprehensive about the dislodgement
of IVC filter intraoperatively as site of its placement was
as same as surgical site. Surgeons were careful enough to
avoid compression or distortion of the IVC.
We started the low molecular weig ht heparin (LMWH)
—enoxaparin in our patient as LMWH like enoxaparin,
dalteparin, tinzaparin are considered the initial treatment
of choice, and may be preferable for patients with cancer
[1,5,10,11]. LMWHs are as effective as unfractionated
heparin (UFH) for reducing DVT recurrence, thrombus
extension and risk of death due to PE. For acute VTE
treatment, limitations of UFH include an unpredictable
anticoagulant response with the need for frequent
monitoring, a relatively narrow therapeutic window, and
the potential for severe toxicity, especially heparin-
induced thrombocytopenia (HIT) [12]. Importantly, trials
of UFH in PE show that many patients are subtherapeutic
or supratherapeutic while receiving UFH. In contrast,
LMWHs provide a more targeted approach to procoag-
ulant complex inhibition, predictable pharmacokinetic
and pharmacodynamic characteristics, and no need for
anticoagulant monitoring [12]. LMWH is the preferred
approach for the initial 5 to 10 days of anticoagulant
treatment of the cancer patient with established VTE
[2,13]. LMWHs are typically given subcutaneous in a
standard weight-based dose (eg, enoxaparin 1.5 mg/kg sc
once/day or 1 mg/kg sc twice a day or dalteparin 200
units/kg sc once a day). LMWH is considered to be
effective for DVT management in patients with cancer.
Thrombolytic therapy of DVT is generally reserved for
patients who have limb-threatening thrombosis, symp-
toms for less than a week and low risk of bleeding. Abso-
lute indications for thrombolytic therapy are a massive
Copyright © 2011 SciRes. OJAnes
Perioperative Management of Case of Gynecological Malignancy with Bilateral Deep Venous Thrombosis of Lower 3
Limbs Along with Pulmonary Embolism
iliofemoral DVT, especially in the case of phlegmasia
cerulea dolens, and a pulmonary embolism that is accom-
panied by hemodynamic instability. Our patient had a
history of DVT for 3 weeks and was stable hemody-
namically, so we avoided thrombolysis when the patient
presented to us and started her on enpxaparin. Never-
theless, thrombolytics have not been shown to decrease
mor t a l i t y in t hese pat ients.
The quantitative rapid ELISA, with a sensitivity of
95%, in general has shown the most clinically useful
values among the various D-dimer assays [13]. An
abnormal D-dimer indicates the need for further testing if
PE is suspected. The imaging modalities includes con-
trast enhanced multidetector computerized tomography
pulmonary angiography (CT angiography) and CT
venous phase imaging of the proximal leg veins (CT
venography). The gold standard for the diagnosis of PE
is Contrast pulmonary arteriography. In the presence of
breathlessness, we suspected PE and since D-Dimers
were raised, we confirmed the presence of PE with CT
The patients with PE, the gas-exchange abnormalities
related to various variables including the size and
character of the embolic material, the extent of the
occlusion, the underlying cardiopulmonary status and the
length of time since embolization [13]. Hypoxemia has
been attributed to an increase in alveolar dead space,
right-to-left shunting, ventilation/perfusion inequality, and
a low mixed venous oxygen level. Classic triad of PE
dyspnea, chest pain and hemoptysis is seen in 20% of
patients. Our patient had only breathlessness and preope-
rative ABG was within normal limits. This may probably
be because of thromb osis only in one segment of l ung.
So, we conclude, great vigilance is required in the
management of a patient with bilateral lower limb deep
venous thrombosis with pulmonary embolism. Measures
for prevention of further pulmonary embolism should be
undertaken prior to urgent oncology surgery. Before
planning the surgical procedures, adequate anticoagula-
tion must be achieved to prevent further complication of
DVT, thromboembolism, and pulmonary embolism. The
risk of stopping the anticoagulation prior to surgery must
be considered and adequately discussed with the patient
and surgeons. The anaesthetic plan must be selected
keeping in mind the coagulation status and the need of
anticoagulation in the postoperative period.
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Perioperative Management of Case of Gynecological Malignancy with Bilateral Deep Venous Thrombosis of Lower
Limbs Along with Pulmonary Embolism
Copyright © 2011 SciRes. OJAnes
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