Navigating Perioperative Anticoagulation Challenges in a Cancer Patient With Deep Vein Thrombosis: A Case Report

Deep vein thrombosis (DVT) in cancer patients presents unique challenges, especially in the perioperative period, where anticoagulation must be carefully balanced to minimize both thrombotic and bleeding risks. This case highlights the complexity of managing DVT in an elderly patient with metastatic urothelial carcinoma of the bladder in the setting of a pathological femur fracture. An 80-year-old woman with metastatic urothelial carcinoma of the bladder presented with a pathological left femur fracture after trivial trauma. Multimodal imaging confirmed the fracture and incidentally revealed a right common femoral vein DVT along with disease progression, including early metastatic spread to the neural canal. Given the need for urgent surgery, full anticoagulation posed a bleeding risk, while withholding it increased the risk of embolism. To balance this, an inferior vena cava (IVC) filter was placed, and enoxaparin was initiated with a personalized perioperative regimen. Surgical fixation was delayed due to unforeseen circumstances, requiring further anticoagulation modifications. Postoperatively, wound concerns and hemoglobin drop necessitated transfusions and anticoagulation adjustments. Anemia workup identified low folate as one among many contributing factors, prompting supplementation. The patient was stabilized and transitioned to lifelong apixaban before discharge. This case underscores the complexities of anticoagulation in oncologic orthopedic patients, highlighting the individualized approach and real-time adjustments in anticoagulation management to balance thrombotic and bleeding risks, especially in light of unforeseen clinical developments.