Case 93 – update 3

Our patient has his d-dimer checked which is positive and has an ultrasound scan of the left leg which has confirmed a clot. On review of the images the clot is more extensive that previously. This combined with the clinical history is strongly suggestive of recurrent thrombosis.

When someone has a recurrent thrombosis it is important to think about:

  • Are levels required to assess compliance and efficacy?
  • Check compliance with patient
  • Check correct dose, weight, taking with food (if needed), timings
  • Check no medications that may reduce effect
  • On other medications e.g. chemotherapy or hormones that may increase hypercoagulability?
  • Consider
    • Looking for malignancy
    • Looking for pro-thrombotic state e.g. heparin-induced thrombocytopenia (if on heparin), paroxysmal nocturnal haemoglobinuria, myeloproliferative neoplasm and anti-phospholipid syndrome
    • Looking for anatomical abnormality e.g. May Thurner


Our patient now reports some upper abdominal discomfort and a CT scan reveals a mass at the head of the pancreas. Following a MDT discussion this is very likely to be a  pancreatic malignancy and surgery is indicated. His surgeon recommends surgery as soon as possible and does not want to wait for more than three weeks. The surgery planned would be a Whipple’s procedure.



  • How do you manage anticoagulation around elective but urgent surgery?
  • What anticoagulant do you recommend?
  • Any other interventions need considering?
  • What about post-operatively?


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