A 21-year-old female college student presented to the emergency department (ED) with severe pain in her left hip, thigh, and calf. The pain started suddenly when she was playing basketball a few hours earlier. She twisted her torso to shoot the ball and heard a “pop” in her left hip with immediate onset of pain, and she subsequently fell to her knees. She was initially able to ambulate but had worsening pain and rapid progression of swelling and mottling in the left leg from her hip to her ankle. She denied any pain or swelling in that extremity prior to the injury during the basketball game. With the exception of oral contraceptive use, she had no significant medical or family history.\nOn examination her left extremity was mottled, dusky, and cool to the touch from the hip to the toes and she had decreased dorsalis pedis and posterior tibial pulses when compared with the right extremity. The leg was markedly tender to palpation and sensation to light touch was diminished. Passive range of motion of the hip, knee, and ankle elicited severe pain.\nPOCUS was performed at the bedside to evaluate for arterial blood flow and deep venous thrombosis. This demonstrated normal color flow in the femoral and popliteal arteries (), but echogenic material was noted within the left common femoral vein extending distally to the popliteal vein and the veins were non-compressible (). Vascular surgery was immediately consulted, and while awaiting their arrival to the ED the patient was sent for an emergent computed tomography (CT) angiogram, which confirmed arterial patency and extensive deep venous thrombosis in the left popliteal, femoral, and iliac veins (). A heparin bolus was given and the patient was then taken to interventional radiology where she underwent partial thrombectomy, catheter-directed tissue plasminogen activator (tPA) treatment, and placement of an inferior vena cava (IVC) filter. By the next morning her leg was noted to be well-perfused, non-tender, and without swelling, and her pain had resolved. A workup for hypercoagulable states revealed heterozygosity for the Factor V Leiden mutation. She was discharged one week later on warfarin after bridging from enoxaparin.
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.