PO16 - A comprehensive clinical case of recurrent venous thrombolism under therapeutic anticoagulation

Background: Patients with symptomatic venous thromboembolism (VTE), especially unprovoked episodes, are at high risk for recurrence. Despite therapeutic anticoagulation progressive thrombosis is not uncommon, sometimes within the first few weeks of treatment.

Aims: To present a difficult-to-manage case of recurrent VTE under therapeutic anticoagulation.

Methods: Collected data was obtained through patient record.

Results: A 48-year-old woman with superficial venous thrombosis of the left lower extremity was treated with low molecular weight heparin (LMWH) 1mg/kg bid. Four weeks later, at the end of treatment, she presented with extensive pulmonary embolism (PE) requiring intensive care.
Initial study of thrombophilia was negative and anticoagulant therapy was changed from LMWH (1mg/kg bid) to apixaban (5mg bid). Four days after, she developed swelling of the right lower extremity (RLE) and made a new switch to rivaroxaban (15mg bid 21 days followed by 20 mg 1id).
Two weeks later, the patient presented a deep vein thrombosis in the RLE with occlusion of the right iliac vein, extension to the inferior vena cava, requiring mechanical aspiration and inferior vena cava filter placement. She also showed evidence of intermediate-high risk PE with extensive pulmonary infarction. The patient was discharged on edoxaban (60mg 2id). Less than a month later, anticoagulation was switched to LMWH (1.5mg/kg 2id) due to progressive symptoms of RLE.
The diagnostic protocol for occult oncologic disease (OOD) revealed a lung adenocarcinoma. The remaining thrombophilia study, including Next-Generation Sequencing was negative.
After 6 months, an unsuccessful attempt was made to remove the vena cava filter due to the presence of a partial thrombus. The patient remains on LMWH (1.5mg/kg bid) by multidisciplinary decision without recurrence and undergoing therapy for the oncological disease.

Conclusion(s): In young patients with recurrent TVE, without precipitating factor, exhaustive screening for OOD seems increasingly pertinent. Careful monitoring of anticoagulation with a multidisciplinary approach are crucial to optimal results.