Extensive Deep Venous Thrombosis Research Articles

The Venous Thrombectomy Armamentarium: An Expanding World.

Acute deep venous thrombosis (DVT) is a common and important public health problem. It affects more than 350,000 people in the United States annually and has a substantial economic impact. Without adequate treatment, there is significant risk of development of post-thrombotic syndrome (PTS) resulting in patient morbidity, worse quality of life, and costly long-term medical care. Over the past decade, the treatment algorithm for patients with acute DVT has significantly changed. Prior to 2008, the treatment recommendation for patients with acute DVT was limited to anticoagulation and conservative management. In 2008, national clinical practice guidelines were updated to include interventional strategies such as surgical- and catheter-based techniques for the treatment of acute DVT. Early strategies for debulking of extensive acute DVT primarily consisted of open surgical thrombectomy and administration of thrombolytics. In the intervening period, a plethora of advanced endovascular techniques and technologies have been developed which reduced the morbidity of operative intervention and risks of hemorrhage associated with thrombolysis. This review will focus on the novel technologies commercially available for management of acute DVT, denoting unique features inherent to each device. This expanded armamentarium gives vascular surgeons and proceduralists the opportunity to individualize their treatment approach to the specific patient's anatomy, lesion, and history.

Metastatic duodenal carcinoma presenting as severe anaemia and extensive bilateral lower limb deep venous thrombosis

No abstract available

Rare diagnosis of coexistent antiphospholipid syndrome and systemic lupus erythematosus in a male patient with successful management: a case report.

A 28-year-old male, referred to our hospital for the assessment of chest pain. Past medical history was significant for extensive deep venous thrombosis despite the appropriate management with a therapeutic dose of direct-acting oral anticoagulant. Prolonged partial thromboplastin time was not corrected by mixing study along with positive lupus anticoagulant, anticardiolipin, and B-2 glycoprotein antibodies. In addition, antinuclear antibodies, anti-DNA antibodies, and direct Coombs were positive with decreased levels of C3. The patient was diagnosed with SLE with brain, heart, and kidney involvement in the setting of antiphospholipid antibody syndrome. He was treated successfully with full recovery. SLE and APS both have sneaky ways of manifestation. Ineffective diagnosis and therapy could cause irreversible organ damage. Clinicians should have a high index of suspicion for APS, particularly in young patients who approach with spontaneous or unprovoked thromboses or unexplained recurrent early or late pregnancy loss. Anticoagulation, modifying cardiovascular risk factors, and identifying and treating any underlying inflammatory diseases are all part of the multidisciplinary care that is needed for management. Although male affection is rare, SLE and APS should be considered in male patients as these conditions tend to be more aggressive than in the female.

Man with leg pain.

A 66-year-old-male with a history of type 2 diabetes and hypertension presented as a transfer for rapid progression of lower extremity pain, swelling, and blue-purple discoloration of the entire limb (Figure 1) with concern for a possible necrotizing infection. His symptoms began earlier in the day and progressed over just a few hours. He had no known thromboembolic risk factors. Initial vital signs were notable only for a heart rate of 115. Point-of-care ultrasound revealed extensive deep venous thrombosis burden confirmed by formal duplex sonography. The patient was admitted on a heparin infusion and underwent EKOSTM catheter directed tissue plasminogen therapy with stent placement. He was admitted for 5 days and successfully discharged on oral anticoagulation back to his baseline level of function. Phlegmasia cerulea dolens Phlegmasia cerulea dolens (PCD) is a rare ischemic complication of massive venous thromboembolism with high rates of morbidity and mortality. Patients present with limb edema, pain, and cyanosis that can quickly develop into compartment syndrome, limb ischemia, and venous gangrene with amputation and death rates as high as 50% and 40%, respectively.1 PCD tends to affect the iliofemoral segment of the lower extremities.2 Non-traumatic cases of PCD are most commonly associated with malignancy.3 The preferred imaging modality is Doppler ultrasound and use of point-of-care ultrasound by physicians can expedite treatment of PCD.4 Management includes limb elevation, intravenous fluids, and either systemic anticoagulation, catheter-directed thrombolysis, thrombectomy, or a combination of these definitive therapies.5

1264: EXTRACORPOREAL MEMBRANE OXYGENATION IN MASSIVE PULMONARY EMBOLISM: THE CHALLENGES OF DIAGNOSIS OF PE

Introduction: Pulmonary embolism (PE) is the third most common cause of death after myocardial infarction & stroke. Diagnosis is challenging without a computed tomographic pulmonary angiography (CTPA), & advanced management techniques are difficult to implement without confirmation. We present a patient who was unable to undergo a CTPA, but through a multidisciplinary approach was progressed to veno-arterial extracorporeal membrane oxygenation (VA ECMO). Description: A 245-kg 30-year-old male was admitted for Ludwig’s angina, fiber-optically intubated, taken for incision & drainage, & later successfully extubated. Two days later, he became increasingly hypoxic, leading to reintubation and initiation of a heparin infusion for suspected massive PE. Point of care ultrasound was non-diagnostic due to poor acoustic windows & CTPA unobtainable due to the patient’s body habitus. He progressed to obstructive shock & refractory hypoxia. Lower extremity (LE) dopplers were positive for extensive deep venous thrombosis. A multidisciplinary team including critical care, interventional cardiology & cardiothoracic surgery, opted to proceed to the catheterization lab for a transesophageal echocardiogram (TEE) & pulmonary angiography for diagnosis & attempted thrombectomy with VA ECMO as backup. TEE showed a severely dilated right ventricle (RV) with strain. Angiography confirmed extensive PE, but catheter advancement induced ventricular fibrillation & thrombectomy was aborted. Patient was then cannulated for VA ECMO. Discussion: CTPA is the first line diagnostic technique in patients with PE. Unfortunately, our patient’s body habitus limited the ability for this modality. Catheter pulmonary angiography has been considered too invasive solely for diagnosis but has been favored over CTPA when endo-vascular intervention is intended. Angiography has its limitations, including ease of availability, risk of hemodynamic compromise in severe RV failure & interpretation of imaging. Although this is a concern, it should not deter from making a diagnosis given the case-fatality of an undiagnosed PE. We aim to recognize the challenges in PE diagnosis and to reiterate the importance of a multidisciplinary approach in massive PE to broaden therapeutic options and improve mortality.

Abstract 15381: Phlegmasia Cerulea Dolens and Concurrent Gastrointestinal Bleeding: A Dangerous Combination With Challenging Management

Introduction: Phlegmasia cerulea dolens (PCD) is a rare and life-threatening complication related to extensive deep venous thrombosis (DVT) resulting in acute limb ischemia. Treatment options include anticoagulation, thrombolysis and thrombectomy. Case: A 31-year-old female with a history of ulcerative colitis (UC) on chronic steroids presented with acute dyspnea and tachycardia. She was hemodynamically stable. The initial workup included a lower extremity (LE) Doppler ultrasound (US) which showed an acute occlusive thrombus involving the left posterior tibial and popliteal veins, and a computerized tomography angiography (CTA) of her chest which showed bilateral pulmonary emboli. She was placed on heparin drip for 48 hours but due to an episode of acute gastrointestinal (GI) bleeding due to severe UC, anticoagulation was discontinued after an inferior vena cava filter placement and she was discharged from the hospital. After 1 month, she presented with severe diarrhea, hypotension and tachycardia. A chest CTA showed reduced clot burden compared to prior. On hospital day 2, the patient experienced acute onset of severe left LE pain, bluish skin discoloration and rapidly progressing edema. A repeat US showed progression of DVT to the left common femoral vein. The findings were consistent acute limb ischemia in the setting of PCD. She was managed with emergent thrombectomy, with significant amount of thrombus retrieved. Gastroenterology was consulted and GI bleeding did not recur. Discussion: Due to its rarity, there are limited data available to guide PCD management in the setting of elevated bleeding risk such as severe UC. However, after a risk-benefit assessment, we determined that this young patient should be treated with anticoagulation and undergo emergent thrombectomy, which resulted in significant improvement of her symptoms. We highlight the importance of multidisciplinary approach, early diagnosis and prompt treatment in these complex patients.

INTRACEREBRAL HEMORRHAGE POSTPHARMACOMECHANICAL CATHETER-DIRECTED THROMBOLYSIS: CAN WE PREVENT IT?

INTRACEREBRAL HEMORRHAGE POSTPHARMACOMECHANICAL CATHETER-DIRECTED THROMBOLYSIS: CAN WE PREVENT IT?

Evaluation of the Predictive Role of Standard Laboratory Tests for Disease Severity in Patients with Deep Venous Thrombosis

Introduction: Deep venous thrombosis (DVT) can result in fatal outcomes if it is not timely diagnosed and sufficiently treated. Some laboratory markers were identified in previous reports for predicting the disease with low sensitivity or specificity. We aimed to evaluate the predictive value of serum albumin levels and compare them with conventional laboratory parameters. Material and Methods: Fifty patients with acute lower-extremity DVT who has no previous history of malignancy or hematologic disorder were included in the study. The demographical variables and standard biomarkers of the DVT group were compared with the normal population (n:50). Thereafter patients were divided into two groups as extensive DVT (thrombosis involves popliteal, femoral, and iliac veins together) and localized DVT (thrombosis involves popliteal vein and below) and biomarkers were compared in patient groups. Results: The demographical variables and white blood cell count (WBC) found as similar between healthy groups and DVT groups. However, mean platelet volume (MPV), D-Dimer, neutrophil to lymphocyte ratio (NLR), and fibrinogen to albumin ratio (FAR) were found markedly higher in DVT patients. Moreover, statistically incremental FAR and NLR levels were detected (p < 0.05) in patients with extensive DVT (involved iliac and femoral veins). Conclusion: Serum NLR and FAR levels seem to be significant predictors for the extensive thrombotic event in patients with DVT.

Deep venous thrombosis in an individual with statin-exposed anti-SRP myopathy: case report and review of literature

BackgroundImmune-mediated necrotizing myopathy (IMNM) is characterized by proximal muscle weakness, elvated serum muscle enzyme levels, myopathic electromyography findings, and necrotic muscle fiber with few inflammatory cell infiltration in muscle biopsies. Statins, the first line drug to lower triglyceride and cholesterol level in blood, have been reported to be associated with statins-induced necrotizing autoimmune myopathy (SINAM). Although anti-3-hydroxy-3-methylglutarylcoenzyme-A reductase (anti-HMGCR) myopathy is considered as the leading myopathy related to the statins medication, anti-signal recognition particle (SRP) myopathy were also identified in several cases with statin exposure. The risk of deep venous thrombosis (DVT) is substantially high in individuals with autoimmune inflammatory diseases. But few studies have reported the occurrence and recommendation for treatment of DVT in patients with anti-SRP myopathy. Here, we reported a statin-exposed anti-SRP myopathy individual developed DVT who was successfully treated with catheter-directed thrombolysis (CDT) and systemic anticoagulants therapy.Case presentationA 56-year-old Chinese female came to the outpatient room with gradually progressive bilateral lower-extremity weakness. Magnetic resonance imaging revealed myopathy in bilateral thighs. Serum anti-SRP antibody was positive. She was diagnosed with anti-SRP myopathy. When treated with corticosteroids and immunosuppressants, the patient developed mild edema and pain of left lower extremity. Angiography and ultrasound revealed diffuse venous thrombosis of left lower extremity. Therapy was initiated with CDT and lower molecular weight heparin, then switched to once daily oral rivaroxaban. Meanwhile, steroids combined with tacrolimus were also carried on while simvastatin was discontinued. One month later, patient’s symptoms were resolved and only partial thrombosis in left femoral vein was remained.ConclusionThe prevalence of DVT in patient with anti-SRP myopathy was rare. No well-established treatment strategy is available to manage the IMNM and DVT at the same time. The systemic anticoagulants therapy combined CDT can be an effective therapeutic approach to address extensive DVT in patient with anti-SRP myopathy.

Spontaneous Heparin-Induced Thrombocytopenia and COVID-19 Infection

Background and Objective: Heparin-induced thrombocytopenia (HIT) can develop if immune responses to infections become pathologic in the presence of heparins. Low molecular weight heparin or unfractionated heparin are recommended for prophylaxis and treatment of venous thromboembolic disease in hospitalized patients with Covid-19 infection but may trigger HIT. Our aim is to alert clinicians that HIT occurs in association with Covid-19 infections even in the absence of prior exposure and may not be easily recognized without a high index of suspicion. Case Summary: A 33-year-old previously healthy male was initially evaluated for low grade fever, dyspnea without hypoxia and cough. A Covid-19 PCR swab was negative despite a recent exposure. He was treated with azithromycin. However, his symptoms did not improve, he then developed right leg swelling and hypoxia, so he was re-evaluated. CTA of the chest showed bilateral pulmonary emboli and ground-glass opacities at the lung bases. Venous Duplex Ultrasound showed non-occlusive thrombus in the deep veins of right lower extremity. He was hospitalized and placed on oxygen and heparin. Covid-19 swab was negative again. Laboratory tests before heparin showed a decreased platelet count of 64,000 k/ul, elevated prothrombin time of 16.4 seconds, normal aPTT at 30.8 seconds, decreased serum fibrinogen at 120 mg/dl and markedly elevated D-dimer at 59,966 ng/ml. Lupus anticoagulant and anti-phospholipid antibody tests were negative. On heparin at the desired therapeutic aPTT target range, the right leg became significantly swollen and painful by day five. Platelet count had decreased further to 39,000 k/ul. Repeat doppler examination of the right leg now showed more severe and extensive deep venous thrombosis. D-dimer had increased to 125,133 ng/ml. The HIT 4T score was 4, suggesting intermediate probability. Rapid HIT immunoassays on 2 separate samples were positive. Heparin was discontinued and he was placed on argatroban. Serotonin release assays on 2 separate samples came back positive. Suspicion for Covid-19 infection remained high and so a Covid-19 serology sample was obtained which was positive for IgG. A repeat nasopharyngeal swab at this time turned positive. He did not receive any COVID specific treatments. As viability of his leg appeared threatened, he underwent right iliofemoral vein thrombectomy with arteriovenous fistula creation. He improved on argatroban and was transitioned to apixaban with gradual normalization of hemostasis laboratory parameters, improvement in hypoxemia and fading clinical symptoms, he was discharged home on day 15. Conclusion: Current consensus guidelines for thromboprophylaxis and treatment of thromboembolism in hospitalized patients with Covid-19 infection recommend heparins as primary therapy to reduce morbidity and mortality. However, our report in addition to the two previous reports of HIT in Covid-19 patients illustrate that HIT can be a complication in the setting of Covid-19 infection. Further, our report also highlights that HIT with thrombosis can occur in a spontaneous manner in the absence of prior heparin exposure, which has been so far studied only in bacterial infection with the hypothesis that Platelet factor 4 (PF4) can bind to negatively charged polysaccharides on the surface of bacteria, triggering an immune response. DisclosuresNo relevant conflicts of interest to declare.

Impact of Compliance on Elastic Compression Stockings Efficacy to Prevent Post-Thrombotic Syndrome: A Prespecified Analysis of the Celest Double-Blind Study

Introduction: Elastic compression stockings (ECS) are commonly used for the prevention of post-thrombotic syndrome (PTS) after deep venous thrombosis (DVT). However, their efficacy is controversial. While two open-label studies reported a 50% risk reduction of PTS in the ECS vs. no-ECS groups, a large double-blind study didn't find any benefit of ECS vs. placebo-ECS to prevent PTS. These opposite results could be explained either by a placebo effect in the open-label studies or to a lack of compliance to study ECS in the double-blind study. Additional data on the impact of compliance on ECS efficacy, obtained in a double-blind way, are therefore needed.Methods: We analyzed data from the French, CELEST, multicentre double-blind trial comparing 25mmHg ECS vs. 35mmHg ECS to prevent PTS at 2 years after a first symptomatic ipsilateral proximal DVT (NCT01578122). All CELEST patients who had complete data for primary outcome (i.e. PTS, defined as a Villalta score ≥5 on the DVT affected leg at the one- or 2-year follow up visit) were included. The objectives of this predefined analysis were to: i) compare the incidences of PTS at 2 years according to compliance to ECS (irrespective of allocated treatment group) during the first 3 months of treatment and during the 2-year follow-up; ii) assess independent predictors of PTS using a stepwise multivariable model including all of the following variables (baseline patients' and DVT characteristics, anticoagulant treatment and compliance to ECS) if they achieved a p value of 0.2 or less in univariate analysis as well as ECS strength allocation group; iii) build an induction tree algorithm to measure the impact in terms of incidence of PTS of each of the independent predictor of PTS. Compliance to ECS was defined as reasonable and optimal if the patient had worn the study ECS more than 50% and more than 80% of the time respectively and had a modified GIRERD score of 0-2.Results: 249 patients were eligible for this analysis. Mean baseline age was 57 years, 70% (n=174) were men, 20% (n=50) were obese, 21% (n=52) had previous VTE event, 7% (n=18) had a baseline Villalta score ≥5 and the most proximal extent of DVT was the iliac vein in 15% (n=37) of cases. In 80% (n=179) of cases patients were treated with anticoagulation for more than 6 months after DVT and a direct oral anticoagulant (DOAC) was used in 69% (n=164) of cases. 32 % (n=80) of patients developed PTS at 2 years. When patients wore study ECS>80% of the time (i.e optimal compliance), incidence of PTS over 2 years was 26.1% (n=31). Incidence of PTS was 25.0% (n=10) and 40.5% (n=34) in those patients who wore ECS 50-80% and <50% of the time, p=0.06. When comparing patients who never wore study ECS (compliance<50% during the whole study follow-up) to those who were reasonably compliant during the whole study follow-up, incidence of PTS was respectively 46.4% (n=13) vs. 25.3% (n=38), p=0.02. Results of the univariate and multivariate analyses are presented in Table 1 and induction tree algorithm is provided in Figure 1.Conclusions: In our double bling study assessing 25mmHg vs. 35mmHg ECS to prevent PTS, compliance to ECS was a significant independent predictor of PTS in our multivariable model. Impact of ECS use became apparent when patient used ECS at least 50% of the time without any strong benefit beyond. Wearing study ECS>50% of the time was associated with 2-fold decreased risk of developing PTS, which is consistent with the results from previous ‘positive’ open-label studies. It suggests that use of ECS influences the risk of developing PTS. Our induction tree algorithm evidences that being compliant with ECS seems particularly beneficial in - non-obese - patients with extensive DVT. [Display omitted] DisclosuresVerriere: Laboratoires Innothera: Current Employment.

MULTIDISCIPLINARY APPROACH USING CATHETER DIRECTED MECHANICAL THROMBECTOMY IN TREATMENT OF A PULMONARY EMBOLISM WITH CLOT IN TRANSIT

TOPIC: Pulmonary Vascular Disease TYPE: Fellow Case Reports INTRODUCTION: Clot in transit (CIT) is a term associated with pulmonary embolism (PE) used to describe thrombus found in the right atrium or ventricle on echocardiography. We present a case of CIT treated in a multidisciplinary approach with catheter-directed mechanical thrombectomy. CASE PRESENTATION: A 60 year old male with a history of unprovoked PE off anticoagulation presented with dyspnea and syncope. At presentation, he was tachycardic to 130 but normotensive and not hypoxemic. Troponin-I was elevated at 0.06 ng/mL and B type-NP at 96 pg/mL. SARS-CoV-2 PCR was negative. CT angiography revealed extensive acute bilateral PE with increased RV/LV ratio of 1.9. A stat transthoracic echocardiography (TTE) found a dilated right ventricle with severely reduced systolic function, positive McConnell sign, a tricuspid annular plane systolic excursion (TAPSE) < 1cm, and a serpiginous mobile echodensity in the right atrium consistent with a CIT. A stat ultrasound of the legs also revealed extensive deep venous thrombosis in the proximal left femoral vein extending to the popliteal vein. After a multidisciplinary PE response team discussion, the patient was taken emergently to the catheterization lab. Prior to transport, VA ECMO safety lines were preemptively placed to facilitate ECMO initiation in case of decompensation. With the ECMO circuit primed and the ECMO team, cardiac anesthesiologist, and cardiothoracic surgery on standby, the patient underwent percutaneous mechanical thrombectomy utilizing the Inari Flowtriever® system. With adjunctive TTE guidance, the right atrial clot was first extracted in its entirety with no hemodynamic deterioration. This was followed by aspiration of clot from the right and left pulmonary arteries. Pulmonary artery pressures and cardiac index improved, and the procedure ended with placement of an IVC filter. The patient was transferred to the ICU and was started on enoxaparin at 1mg/kg twice a day. He was discharged on day 4 with rivaroxaban. DISCUSSION: CIT is a rare phenomenon with a prevalence rate of around 4% and is considered a medical emergency given its high mortality rate of 25-40%. While treatment guidelines are limited, anticoagulation alone has shown to be insufficient to treat CIT effectively. While there is data supporting the use of catheter directed therapies for PE, data on its use for CIT is scarce but growing. Furthermore, the preparation of advanced support prior in conjunction with the use of catheter directed therapy may be beneficial in case of life-threatening decompensation. CONCLUSIONS: Catheter-directed mechanical thrombectomy may be effective and safe as shown in this case, but requires a team capable of advanced therapies like ECMO and urgent surgical intervention if needed. REFERENCE #1: Otoupalova E, Dalal B, Renard B. Right heart thrombus in transit: a series of two cases. Crit Ultrasound J. 2017;9(1):14. doi:10.1186/s13089-017-0069-9. REFERENCE #2: Garvey S, Dudzinski DM, Giordano N, Torrey J, Zheng H, Kabrhel C. Pulmonary embolism with clot in transit: An analysis of risk factors and outcomes. Thromb Res. 2020 Mar;187:139-147. doi: 10.1016/j.thromres.2020.01.006. Epub 2020 Jan 10. PMID: 31991381. REFERENCE #3: Dhulipala V R, Fayoda B O, Kyaw H, et al. (August 04, 2020) Thrombus in Transit: Extract or Dissolve?. Cureus 12(8): e9550. doi:10.7759/cureus.9550. DISCLOSURES: No relevant relationships by Mara Caroline, source=Web Response No relevant relationships by Eliot Friedman, source=Web Response No relevant relationships by Eric Gnall, source=Web Responseresearch relationship with Inari Please note: April,2021 to presen Added 04/29/2021 by Lee Greenspon, source=Web Response, value=Grant/Research Support No relevant relationships by Patrick Ho, source=Web Response

57-Year-Old Woman With Weakness and Word-Finding Difficulties

57-Year-Old Woman With Weakness and Word-Finding Difficulties

An Eminent Absence: Agenesis of Inferior Vena Cava Underlying Bilateral Iliac Vein Thrombosis

Agenesis of the inferior vena cava is a rare risk factor for deep venous thrombosis.Agenesis of the inferior vena cava requires lifetime follow-up and treatment.Idiopathic deep venous thrombosis, especially in young patients, requires additional diagnostic investigation that considers congenital anomalies.

LARGE DVT BURDEN? CONSIDER IVC ATRESIA

Agenesis and atresia of the inferior vena cava (IVCA) is a rare vascular anomaly, estimated to occur in 0.07%-8.7% of the general population. Diagnosis is often incidental as disease can be asymptomatic given extensive collateral vein development. However, extensive deep venous thrombosis (DVT) can

PULMONARY EMBOLISM WITH THROMBUS IN TRANSIT ACROSS A PATENT FORAMEN OVALE

Thromboembolism-in-transit is a rare complication of deep venous thrombosis (DVT) in patients with a patent foramen ovale (PFO). A healthy 51-year-old male presented with shortness of breath. He was diagnosed with a pulmonary artery saddle embolus and extensive lower extremity DVT. Bedside

Recurrence of Paget-Schroetter Syndrome: A Rare Case Report and Review of Literature

Paget-Schroetter syndrome (PSS) is a primary upper extremity deep vein thrombosis (DVT) that occurs with no significant risk factors, mostly in a young and healthy patient. Treatment of this disease is discussed heavily in the literature and the optimal treatment method is still being debated. Here, we present a patient with PSS treated with balloon angioplasty, thrombolysis and treatment with an oral thrombin inhibitor (apixaban) who developed recurrence of PSS. A 38-year-old white male with no past medical history, presented to an urgent care center with sudden onset axillary pain and an axillary lump that was treated with outpatient antibiotics. Extensive deep venous thrombosis was diagnosed with computed tomography (CT) and ultrasound. He underwent percutaneous pharmacomechanical thrombectomy. Postprocedural angiogram showed significant improvement in the caliber of the axillary and subclavian veins where they crossed the first rib. He was discharged on apixaban and underwent removal of his first rib 1 month later. He returned 3 weeks later with recurrence of right arm pain and swelling. Repeat ultrasound showed thrombus in the right arm and venogram confirmed 80% stenosis at the subclavian vein as it enters the innominate vein. He was again treated with placement of a thrombolytic catheter and overnight thrombolysis of the central venous circulation on the right-side upper extremity balloon angioplasty of the subclavian vein, axillary vein, and basilic vein. He is disease-free for 6 months. Recurrence of PSS after surgical removal of rib, thrombectomy, thrombolysis while using apixaban is very rare. This is the first case to our knowledge presented with recurrent PSS treated with apixaban, early rib resection, balloon angioplasty and thrombectomy. J Med Cases. 2020;11(1):22-25 doi: https://doi.org/10.14740/jmc3416

Massive Uterine Fibroid Resulting in Extensive Deep Venous Thrombosis, Compartment Syndrome and Rhabdomyolysis

The patient is a 48-year-old woman who presented with menorrhagia due to a massive uterine fibroid requiring multiple blood transfusions. Her case was complicated with extensive deep venous thrombosis (DVT) of the left LE with subsequent limb threatening compartment syndrome that resulted in severe hyperkalemia due to rhabdomyolysis and the need for renal replacement therapy.

Deep Vein Thrombosis Revealing Prostate Cancer about a Case in the Cardiology Department of the Ignace Deen National Hospital in Conakry

Introduction: Deep vein thrombosis is a frequent disease, its origin is most often multifactorial. Venous thromboembolic disease (MVTE) and cancer are two frequently entangled pathologies. Here we report the diagnosis of deep vein thrombosis that discovered prostate cancer in an 88-year-old Guinean man. On clinical examination, there was a painful and hot swelling of the right leg, an absence of sloshing of the calf, a positive sign of Homans. The digital rectal examination revealed an enlarged prostate with an irregular surface. Cardiopulmonary auscultation was normal. The electrocardiogram showed a regular sinus rhythm at 65 cycles/min, with no sign of enlarged cavities or conduction disturbance. Venous Doppler ultrasound of the lower limbs showed the presence of an extensive acute deep venous thrombosis of the right sural vein extended to the popliteal and to the homolateral deep femoral. The reino-vesico-prostatic ultrasound concluded in a heterogeneous prostatic hypertrophy with projection of a median lobe associated with a bladder of fight with an important post voiding residue evaluated at 170 ml; the rate of specific antigen of the prostate PSA was at 84.87 ng/ml. The pathology analysis made after a prostate biopsy puncture concluded with an adenocarcinoma with a Gleason score of 3. Conclusion: The association of venous thromboembolic disease (MVTE) and neoplasia is frequent. The existence of active cancer in a patient is a known risk factor for MVTE and, conversely, the discovery of a first episode of deep vein thrombosis (DVT) or pulmonary embolism (PE) may be the mode of revelation of cancer.

Facing Deep Venous Thrombosis (DVT) in University Tertiary Hospital: Role of Conventional Thrombophilia Testing in Idiopathic DVT Treatment

INTRODUCTION: Deep venous thrombosis (DVT) is a frequent cause or morbidity and mortality, and multiple genetic and environmental factors are involved in its etiopathogenesis. According to it, besides investigating about personal and familiar DVT history, thrombophilia testing is often asked by physicians in order to diagnose patients, even if current validated markers can't predict the risk of recurrence of the disease. METHODS: We developed an observational and prospective study between January 2017 and December 2017, in order to register the patients with DVT that were treated in our DVT unit. As secondary objectives, we wanted to know how many had an idiopathic DVT, if we tested all of them for thrombophilia, which of them stopped treatment and the results after one year of follow up. RESULTS: We included 172 patients with DVT, 56.9% were men, and the average age was 66.4 years old with an increased incidence above the 50 years old. In our study group we found 43.6% (75) of patients without major risk factors for DVT, classified as idiopathic DVT and we will refer to them in this abstract from now on. Just 36.7% of them had a positive personal history of DVT and 36.7% had familiar history. Almost all were localized in the lower limbs (98.7%) and 17.3% presented in association with pulmonary embolism (PE) at diagnosis. All of them started treatment with LMWH, and after the first clinical visit, 26.7% continued with it, while 51.2% changed to VKA and 22.1% to DOACs. Only 45 (60%) of idiopathic DTVs were tested for thrombophilia (patients younger than 60 years old, with extensive DVT, or personal or familiar history of DVT): 31 had a negative study, 11 had a positive study for hereditary thrombophilia (4 S protein deficiency, 3 C protein deficiency, 2 V Leiden factor mutation + prothrombin mutation, 1 V Leiden factor mutation, 1 prothrombin mutation), and 3 were diagnosed of antiphospholipid syndrome. All these patients with positive study or antiphospholipid syndrome received indefinite anticoagulation. From all the patients with idiopathic DVT, 77.3% received indefinite anticoagulation, 17.3% were treated for 3-6 months, 4% for &gt;6-12 months and 1,3% for 15 months. Only one patient who stopped treatment after 3 months had a recurrent DVT and had to restart it. CONCLUSIONS: DVT is the most frequent indication for thrombophilia testing and regarding its multifactorial etiology, it must be performed specially in incidental cases. In our incidental DVT study group (with PE associated or not), we found a 31.1% of positive studies, consistent with what is expected in general DVT population, but in contrast with it is described in the literature, we found more cases of S and C deficiency than V Leiden factor and prothrombin mutations. We also had only one patient with recurrence DVT after few months of stopping anticoagulation, no thrombophilia was found. This low rate of recurrence that differs from the latest data published, might be explained by the short time of follow up that we have, so it would be interesting to increase it, as well as the number of patients in the cohort studied. There is a need for investigating new clinical and genetic scores in order to improve the poor predictive role in recurrent disease with the current thrombophilia markers. Disclosures Bosch: F. Hoffmann-La Roche Ltd/Genentech, Inc.: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Takeda: Honoraria, Research Funding; AstraZeneca: Honoraria, Research Funding; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; AbbVie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Celgene: Honoraria, Research Funding; Acerta: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Kyte: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau.