Successful Treatment of Paraplegia Caused by Venous Hypertension Secondary to Extensive Iliocaval Deep Venous Thrombosis in the Absence of Phlegmasia Cerulea Dolens

Objectives: Paraplegia is known to complicate extensive iliocaval and lower extremity deep vein thrombosis (DVT) in rare instances. The most common pathophysiology is ischemia from severe venous hypertension in phlegmasia cerulea dolens. Less understood, however, is paresis or paraplegia in the absence of ischemia. We present a case of paraplegia in extensive iliocaval and lower extremity DVT without ischemia, which was successfully treated by percutaneous pharmacomechanical therapy. Methods: A 46-year-old African American woman with a history of hypertension, insulin-dependent diabetes mellitus, indwelling inferior vena cava filter since 2005, and recent coronavirus disease 2019 diagnosis, presented with acute abdominal pain with severe bilateral lower extremity edema, pain, and paresis. She was found to have bilateral iliocaval to tibial DVT (Fig 1). The patient was noted to have multiphasic arterial waveforms on ankle-brachial index and duplex ultrasound examination. Paresis quickly progressed to flaccid bilateral lower extremity paralysis. Neurologic workup was unrevealing. Despite her symptoms, thrombolytic therapy was delayed due to severe menstrual bleeding requiring a blood transfusion. Therapeutic anticoagulation was initiated. Results: On hospital day 10, the patient underwent 24-hour catheter-directed thrombolysis via bilateral popliteal vein access. Bilateral mechanical thrombectomy was then performed, achieving recanalization of the bilateral lower extremities, iliac veins, and inferior vena cava with minimal residual thrombus (Fig 2). The patient's edema and sensorimotor function immediately improved and never incurred lower extremity tissue ischemia. She was discharged on lifelong rivaroxaban. With physical therapy, the patient ambulated independently at 1 month postoperatively. Venous duplex ultrasound examination revealed continued iliocaval and lower extremity patency at 6 months postoperatively. Conclusions: We postulate that this patient suffered lower extremity paralysis secondary to cauda equina syndrome. Pharmacomechanical thrombectomy is a pragmatic means that reestablishes venous patency and relieves venous hypertension. This pathophysiology and its treatment should be considered in extensive iliocaval DVT and lower extremity neurologic compromise despite duration of paralysis. [Formula presented] [Formula presented]

An audit of therapeutic anticoagulation with Anti-Xa monitoring during pregnancy

The risk of venous thromboembolism (VTE) increases by 10% in pregnancy to around 1/1000 and is a leading cause of death in pregnant women. Low molecular weight heparins (LMWHs) are the anticoagulant of choice for treatment of acute VTE during pregnancy. The initial dose of LMWH is weight based but currently there is lack of evidence supporting routine Anti-Xa monitoring during pregnancy and LMWH dose adjustments based on Anti-Xa levels. We conducted a retrospective audit of pregnant patients receiving therapeutic dose LMWH between October 2020 and October 2021 in a tertiary referral centre. The aim of this audit was to review LMWH dosages required in pregnancy to achieve peak Anti-Xa levels relative to weight-based and report maternal thrombotic or bleeding outcomes based on dose adjustments. A total of 21 pregnant patients were included who required therapeutic LMWH (Tinzaparin) during pregnancy. Of these, 10 (48%) had an acute VTE in the index pregnancy;one (4%) had recurrence of DVT despite weight adjusted LMWH. Ten (48%) were on long-term anticoagulation for a prior VTE including two with antithrombin deficiency and one with JAK 2 positive myeloproliferative disorder. They were all changed to LMWH during pregnancy. The site of acute VTE in index pregnancy (11) included: five (45%) deep vein thrombosis (DVT), three (28%) pulmonary emboli (PE), two (18%) had thromboses at an unusual site, and one patient (9%) had a superficial thrombophlebitis with gestational age range 7-40 weeks. Majority of pregnant patients (18/21;86%) had at least one peak Anti-Xa measured, and 12 (67%) patients had dose of LMWH increased at least once to achieve a target peak Anti-Xa level of 0.5-0.7 IU/ml. Five required two dose adjustments, and one required three dose adjustments. Nineteen patients have delivered and two have ongoing pregnancy. Twelve patients had spontaneous vaginal delivery, three assisted vaginal delivery and four had caesarean section for obstetric reasons. No patients had a recurrent thrombosis while on therapeutic dose LMWH and with dose adjustments as per peak anti-Xa level. One patient who presented with an acute DVT at 40 weeks of gestational age (GA) was managed with twice daily therapeutic dose Tinzaparin and insertion of an inferior vena cava (IVC) filter for anticoagulation interruption around delivery. The last dose Tinzaparin was 12 h prior to emergency Caesarean Section. She had postpartum haemorrhage with an estimated blood loss of 1800 ml but did not require blood product support and there was no evidence of progression of her symptoms of VTE or bleeding postoperatively when anticoagulation was resumed. Of note, six patients (29%) had a BMI >30 with five (83%) needing at least one adjustment of LMWH dose based on Anti-Xa levels and two (33%) needing > 2 dose increments with LMWH based on Anti-Xa monitoring. One patient had recurrence of PE on weight based LMWH dose with no recurrence of symptoms when the LMWH dose was adjusted to peak Anti-Xa level. None of the patients developed SARS-CoV-2 infection in the reported cohort. Fourteen (67%) pf pregnant had received their COVID-19 vaccination during this period . None of the thrombotic episodes were associated with COVID-19 vaccination. Although this audit study has limitations due to small patient numbers there was no evidence of increase in bleeding or thrombotic risk with ongoing anticoagulation with Anti-Xa monitoring during pregnancy..

Unexplained pulmonary embolism post SARS-CoV2 pneumonia in a patient with MYH9-related disease: a case report

This report describes the case of a man affected by Myosin Heavy Chain 9 (MYH9)-related platelet disorder, with a recent history of SARS-CoV-2 pneumonia, who developed pulmonary embolism (PE). At the admittance the patient presented a marked thrombocytopenia. The rotational thromboelastometry (ROTEM) showed a reduction in maximum clot firmness. The CT scan showed a lobar PE while and no sign of superficial or deep venous thrombosis was found. Given the contraindication of anticoagulant therapy due to severe thrombocytopenia, after collegial evaluation of the case, an inferior vena cava filter was applied. The patient was discharged after 5 days of hospitalization, and fondaparinux 2.5 mg subcutaneously was prescribed for two months. Could MYH9 mutation contribute to thrombotic predisposition? Or rather the endothelial dysfunction induced by SARS-CoV-2 infection? The report presents a dissertation on the possible causes for the PE and describes the therapeutic strategy adopted. (www.actabiomedica.it).

Current Controversies in Inferior Vena Cava Filter Placement: AJR Expert Panel Narrative Review.

Despite inferior vena cava (IVC) filter practice spanning over 50 years, interventionalists face many controversies in proper utilization and management. This article reviews recent literature and offers opinions on filter practices. IVC filtration is most likely to benefit patients at high risk of iatrogenic pulmonary embolus during endovenous intervention. Filters should be used selectively in patients with acute trauma or who are undergoing bariatric surgery. Retrieval should be attempted for perforating filter and fractured filter fragments when imaging suggests feasibility and favorable risk-to-benefit ratio. Antibiotic prophylaxis should be considered when removing filters with confirmed gastrointestinal penetration. Anticoagulation solely because of filter presence is not recommended except in patients with active malignancy. Anticoagulation while filters remain in place may decrease long-term filter complications in these patients. Patients with a filter and symptomatic IVC occlusion should be offered filter removal and IVC reconstruction. Physicians implanting filters may maximize retrieval by maintaining physician-patient relationships and scheduling follow-up at time of placement. Annual follow-up allows continued evaluation for removal or replacement as appropriate. Advanced retrieval techniques increase retrieval rates but require caution. Certain cases may require referral to experienced centers with additional retrieval resources. The views expressed should help guide clinical practice, future innovation, and research.