ABSTRACT Damned If I Do, Damned If I Don't! Nihar Pandit Introduction: An elderly lady with a no past history was admitted to hospital for a two week history of left lower limb swelling. Investigations revealed femoral vein thrombosis, for which she was initiated on anticoagulation, with Rivaroxaban. Progress: The patient had no past personal or family history of thrombosis and no active medical issues predisposing to venous thrombo- embolism (VTE). Her haemoglobin was 11.1 gm%, renal and liver function, normal. Two weeks after starting Rivaroxaban, ar the clinic visit, she had no new symptoms and laboratory tests were unremarkable. One week later, she presented to the emergency department for lethargy and breathlessness. She was found to have hematochezia on digital rectal examination, haemoglobin 3.9 gm%. She underwent treatment with packed red cell’s, prothrombin complex concentrate and cryoprecipitate. A oesophago -gastroduodenoscopy was normal, mesenteric angio computerised tomography showed hyperdense material in the colon, suggestive of a recent bleed. Rivaroxaban was discontinued at admission and a decision was made not to restart anticoagulation till a definitive plan was made for the bleeding. However, in view of the recent proximal deep vein thrombosis (DVT), she was deemed to be a high risk for subsequentVTE. A duplex ultrasound, requested to look for the progression of proximal DVT did not reveal any thrombosis! Discussion: At this juncture, what is the next mode of action? The 2014 American College of Chest Physician guidelines advocate insertion of inferior vena cava filter for a patient with proximal VTE and contra-indications for anticoagulation. However, despite the recent VTE, our patients’ clot had disappeared after three weeks of Rivaroxaban. Should we insert an IVC filter and endure the risk for VTE or sit tight and do watchful expectancy, since there is no clot to prevent embolism?. |