Antithrombin III as a Factor in Recurrent Thromboembolism

Abstract

A 43-year-old man with recurrent pulmonary emboli associated with antithrombin III deficiency is presented. After laparotomy for penetrating abdominal trauma, thrombophlebitis and emboli were treated with heparin. Subsequent failure of therapy resulted in application of an inferior vena cava clip. Recurrent emboli from the site of the clip were managed by vena cava division and reconstruction. The primary problem was antithrombin III deficiency with levels less than 40% of normal. The first recorded case of ligation of the inferior vena cava (IVC) for pulmonary embolus was by Trendelenburg in 1911.12 Homans2 suggested prevention of pulmonary embolus with ligation of the IVC in 1944. Since then, treatment of deep vein thrombosis with or without pulmonary embolus has focused on anticoagulant therapy. Recent studies have demonstrated a lower morbidity and mortality with anticoagulation than with any surgical procedure.3 The primary indications for IVC interruption are contraindica tion to anticoagulation or failure of anticoagulation to prevent pulmonary embolus. Partial interruption of the IVC with extraluminal plication or clip, or intraluminal device, is the usual surgical approach. We present a case of recurrent pulmonary embolus managed by IVC ligation with difficulties in anticoagulation due to an antithrombin III defi ciency and subsequent clot propogation above an IVC clip. This case illus trates the management of thrombus above a vena cava interuption as well as underlining Virchow's lessons of hypercoagulability and stasis as predisposing factors of deep vein thrombosis.