A 49-year-old woman presented with acute coronary syndrome for which she received aspirin, clopidogrel, atorvastatin, enoxaparin, and tenecteplase at another facility. She was then transferred to our institute for further management. She underwent coronary angiography which was suggestive of triple vessel disease. As the patient was in acute congestive heart failure (Killip IV) with pulmonary edema, she was intubated and mechanically ventilated. She underwent coronary artery bypass grafting surgery the following day where she received 20,000U of unfractionated heparin.\nOn postoperative day (POD) 6, the patient developed right pedal edema with cyanosis. Bilateral lower limbs Arterial Doppler was normal. Venous Doppler of the right lower limb was suggestive of thrombosis of the right Common Femoral, Superficial Femoral, Popliteal, and Great Saphenous Veins. She also had progressively worsening thrombocytopenia in which the platelet count dropped from 297 × 109/L on day 1 of postenoxaparin exposure to a nadir of 20 × 109/L on day 8. With a suspicion of HIT and thrombosis (HITT), enoxaparin was replaced with fondaparinux on POD 7. She tested positive for HIT type 2 antibodies on day 10. Her platelets started improving by POD 11 [].\nOn POD 13, two-dimensional echocardiography done was suggestive of a left ventricular thrombus (with an ejection fraction of 25%) which resolved completely by POD 44 with anticoagulation. Fondaparinux was bridged with oral Vitamin K Antagonist-Acenocoumarol for HITT and PCD. Once there was a line of demarcation for gangrene, she underwent a right forefoot amputation on POD 34.\nThe patient was discharged on POD 47 with medications for cardiac failure along with acenocoumarol.
The patient is a 78-year-old woman who presented to emergency department with 2 days of gradually worsening right lower extremity (RLE) swelling, pain, and paresthesia that was limiting mobility. She was independent with a clinical frailty score of 2. Her past medical history was significant for diabetes mellitus with Hgb a1c 10.5 and a provoked left lower extremity DVT 30 years earlier treated with a course of warfarin and permanent IVC filter placement. She denied prior hypercoagulability workup and reported that her first episode of thrombosis followed a prolonged airplane ride. She was not anticoagulated at the time of presentation. She denied a history of dysrhythmias, prior embolic events, recent travel, injury, surgery, illness, or known exposure to COVID-19. She denied a family history of blood clots or hypercoagulability.\nPhysical examination revealed an RLE that was severely taut with cyanosis with nonpalpable peripheral pulses and multiphasic signaling on Doppler and tenderness to the mid-thigh. The contralateral limb was soft, nontender with color appropriate of ethnicity and palpable peripheral pulses. An RLE venous duplex ultrasound scan was performed with noncompressible veins and loss of spontaneous flow from the right popliteal vein extending to the right common femoral vein consistent with DVT. On presentation, she did not display hemodynamic instability nor complained of cardiopulmonary symptoms.\nBecause of progressive symptoms concerning for PCD and imminent development of venous gangrene in a patient with good functional status, she was admitted directly to the angiography suite for CDT and pharmacomechanical thrombectomy with tissue plasminogen activator (tPA) and heparin. Angiogram revealed thrombus extending proximal to the IVC filter in the mid-IVC (). She was transferred to the intensive care unit for continued CDT with tPA (1 mg/h) and heparin (500 u/h) through a Uni∗Fuse catheter. tPA was discontinued overnight for a fibrinogen of 82 mg/dL. The next morning, she reported subjective improvement of symptoms and return of palpable peripheral pulses with resolution of pain. She returned to the angiography suite for catheter removal and completion venogram that revealed persistent thrombus burden, and the decision to remove the remainder of the clot was made to decrease the risk of recurrence. Using the Penumbra Indigo CAT8 system (Penumbra, Alameda, Calif), mechanical suction thrombectomy, and balloon venoplasty were performed with successful recanalization (). She was transferred to the floor, heparin was discontinued, and rivaroxaban initiated.\nOn postoperative day 2, she was noted to have expressive aphasia and left-sided hemiplegia. A noncontrast computed tomography and computed tomography angiogram of the head and neck were performed without evidence of a hemorrhage or significant carotid or aortic arch atherosclerotic disease. International normalized ratio was therapeutic at 2.0. Given the concern for stroke, a diffusion-weighted magnetic resonance imaging of the brain was obtained () and was notable for the focal area of restricted diffusion within the right thalamus. Because of recent anticoagulation and thrombolysis, she was not a candidate for systemic tPA. Heparin was not reinitiated because of therapeutic international normalized ratio on rivaroxaban. She was transferred to a tertiary center with neurological and neurosurgical capabilities where she underwent a transesophageal echocardiogram with bubble study that revealed a PFO with an atrial septal aneurysm and left-to-right flow noted with color Doppler and a moderate right-to-left shunt during bubble study but no left atrial mass or thrombus. Rivaroxaban was continued and her neurological status improved. She was discharged to a rehabilitation facility with improved left-sided weakness on postoperative day 3. After 2 weeks of rehabilitation, the patient was discharged with a modified Rankin score of 1. Patency of the RLE veins was unknown at the time of discharge, but a repeat duplex ultrasound scan at 8 months after initial presentation showed chronic thrombus in the right common femoral vein, but the RLE venous system remained patent.\nBecause of multiple episodes of thrombosis, she was placed on lifelong anticoagulation with apixaban. Hypercoagulable disorder was suspected but was deferred by her hematologist as diagnosis would not change plan for management.