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.
A 66-year-old female presented to the emergency department with three days of acute LLE swelling, pain, cyanosis, inability to bear weight, dyspnea, and hypoxemia (Figure ). She denied recent travel, hormone replacement, or a history of DVT/pulmonary embolism (PE). Her medical history was notable for systemic lupus erythematosus, CREST (calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) syndrome, Sjogren’s syndrome, and local invasive anal squamous cell carcinoma. Doppler ultrasound revealed LLE thrombus extending from the greater saphenous vein to the popliteal vein. She was admitted to the intensive care unit (ICU) and started on an unfractionated heparin drip.\nThe vascular surgery team was consulted for surgical intervention. After further review of her case, the vascular surgery team elected for an endovascular approach with CDT of LLE. Initial venogram demonstrated extensive clotting of the tibial, popliteal, and femoral venous systems extending into the iliac system (Figures , ). From a tibial approach, a guidewire was advanced up to the common iliac, but a chronic occlusion of the left common iliac vein was found, which could not be crossed. A venous collateral circulation system in communication with the right iliac venous system was identified. In order to decrease the overall clot burden, two 50-cm EKOS endovascular catheters were placed in the left external iliac vein and collateral system. Repeat venogram at 24 hours post-CDT showed significant improvement of the overall clot burden with almost complete resolution of the clot in the LLE; however, the chronic occlusion remained (Figure ). A 20 x 80 mm Boston Scientific Wallstent™ (endoprosthesis stent) was advanced across the total chronic total occlusion and deployed. Post-operative venogram demonstrated significant improvement in flow in the system, with all flow going through the iliac system, and no flow further through the previously seen collaterals. Intravascular ultrasound was advanced through the area, which showed severe compression of the stent. A 12x 40 mm Atlas® dilatation catheter (Bard Peripheral Vascular Inc., Tempe, AZ, USA) was used for angioplasty. Repeat intravascular ultrasound showed persistent compression of the area. A 8 x 40 mm Boston Scientific Mustang™ dilatation catheter (high-pressure balloon) was used to re-attempt angioplasty; however, compression was still noted (Figure ). Regardless, outflow improved throughout the left common iliac system, and no further interventions were performed. The patient returned to the ICU and transitioned to direct oral anticoagulation without any further complications. She was subsequently transferred to a medicine ward for further care.