July 14th, 2011
Recurrent Arterial Thrombosis plus GI Bleeding in an Elderly Woman
Faiza Hashmi, MD and James Fang, MD
An 85-year-old woman with a history of hypertension and Crohn’s disease presented with severe pain in the left hand and was admitted to the hospital. Examination revealed a diminished left-radial pulse; arterial Doppler imaging showed a thrombus in the radial artery. The patient underwent surgical thrombectomy. The workup, including a hypercoagulability profile, was negative. Transthoracic and transesophageal echocardiograms did not reveal any intracardiac thrombi or valvular lesions.
After surgery, the patient was started on a heparin drip, with a plan to transition to warfarin for long-term anticoagulation. However, her primary care physician started her on dabigatran (75 mg twice daily) instead of warfarin, for ease of monitoring in an elderly patient.
Ten days after discharge, the patient presented to the ED complaining of dark bowel movements that had started the previous day. Blood was found in her stool. She was admitted to the ICU, and dabigatran was discontinued. She received 2 units of packed red blood cells and 4 units of fresh frozen plasma to reverse the coagulopathy — and underwent colonoscopy with clipping of the bleeding vessel.
Three days later, the patient again complained of left-hand pain and numbness. Her skin was cold, mottled, and bluish in appearance. Repeat arterial Doppler imaging revealed a thrombus in the left radial artery, and the patient was quickly taken to the operating room for another thrombectomy.
Questions:
1. How should anticoagulation proceed, given the patient’s recurrent arterial thrombosis and recent gastrointestinal bleeding?
2. Did the off-label use of dabigatran, rather than use of warfarin, to treat an arterial thrombosis contribute in any way to the patient’s complications?
3. What other causes of the arterial thrombosis should be considered? What additional tests, if any, should be performed?
Response:
1. The standard of care in this situation would still be heparin anticoagulation with transition to warfarin, given that the GI bleeding was due to a specific treatable cause. My concern is that the underlying cause of the arterial thrombosis has yet to be clearly identified. In fact, the arterial thrombosis is recurrent in the same place (namely, the radial artery) and is suggestive of a vascular abnormality rather than an embolic phenomenon and/or pure thrombophilia.
Although malignancy is classically associated with migratory superficial venous thrombosis, it has been found with DVTs and arterial thromboses. In such cases, a high-dose low-molecular-weight heparin may be more effective. Some might add an antiplatelet agent such as aspirin or clopidogrel to warfarin, but this strategy would complicate a GI bleed (if another were to occur), given that the effects of the antiplatelet agents are not easily reversible. The sole use of an antiplatelet agent could be considered, but in most experiences recurrence rates are high.
2. Warfarin would likely have been associated with the same issue of GI bleeding but may have been more effective an anticoagulant in this setting. Extrapolating dabigatran data to the treatment of an arterial thrombosis, particularly in an older patient like this with unclear renal function, is probably not prudent without more published evidence of its efficacy in this clinical context.
3. The recurrent nature of the arterial thrombosis in the same territory suggests a vascular abnormality such as atherosclerosis, thoracic outlet syndrome, or a large-vessel aneurysm. Such a vascular abnormality could also be complicated by a thrombophilia or medium- to large-vessel vasculitis (e.g. Takayasu’s or giant cell arteritis), particularly in light of the Crohn’s disease. I’d consider a magnetic resonance or CT angiography of the thorax to look for abnormal vascular structures. Vasospastic disease is also possible but a difficult diagnosis to make. It would be interesting to know what the “hypercoagulable” workup consisted of. An embolic process is more likely to occur from a localized arterial aneurysm or the aortic arch rather than the heart, in light of the recurrent location of the thrombosis. Heparin-induced thrombocytopenia is unlikely.
9 Responses to “Recurrent Arterial Thrombosis plus GI Bleeding in an Elderly Woman”
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I assume that the TEE did not show severe or mobile aortic atheroma or PFO. If creat clearance was less than 30, the off label albeit lower dose dabi may have contributed to the bleed (a very high PTT would support this). The second thrombotic episode was likely a local phenomenon, as it apparently involved the exact same area. Is there a malignancy? But for some reason cancer is usually a venous thrombosis issue. Is there an anatomic radial arterial abnormality? Is there HIT causing the recurrent thrombosis, temporarily treated with dabi?
The decision re next therapy depends on above and GI situation…what” bleeding vessel” on colonoscopy presenting with melana? Can we try aspirin initially? Interesting case.
I would use low-weight heparine. Just one dose a day. Easy to use and easy to suspend if needed.
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The melena was not related to the blood loosing in the colon, so there is something else that has to be investigated.
I also will give her haeparine.
Dabigatran sure contribute to the bleeding, but by the moment i will not give Warfarine
Some local defect in the radial artery should be investigate
Prudencio Monasterio-
I think the risk of bleeding is greater than ASA or LMWH single prophylactic dose with this age,so ASA as 1st line 2ry prevention may be more worth it than Pradaxa low dose, as regard recurrent arterial thrombosis i think we should to investigate the presense of showering vulnarable atheromatous calcified plaque starting from origin of Aorta by MSCT angiography , and also to investigates what about her natural anticoagulants ?? it is very interesting case,,please up date us about it.
Iatrogenic cannulation of the radial artery could cause a thrombus. Did the patient have a LHC via radial approach in the days before the thrombus? I would think the cause is related to some type of trauma since this appears only in the arterial circulation and not the venous. The thrombus also occurred in the same location, so I would think there is some intimal damage in this particular area. I also wonder if this could be a complication of her Crohn Disease, or maybe a vasculitis. Interesting case.
Thank you all for your valuable input regarding this case.I will try to answer all the queries .
@ Dr.Powell: Yes the TEE did not show any intracrdiac (atrial or ventricular )thrombus.It also did not show a PFO.The patient had a past history of ovarian cancer for which she had had Hysterectomy and bilateral oophorectomy.I agree with you that thrombosis due to underlying malignanacy is usually venous.The patint initially presented with arterial thrombosis and underwent thrombectomy on her first hospital admission.Before that there was no history of exposure to Heparin to suspect HIT leading to thrombosis.
@Dr.Shoukry : She did have a CT angiogram on her first admission which did show that there was a mural thrombus in Left subclavian artery. It was not extending all the way to axiallra nd brachial artery.However the radial and ulnar arteries were not opacified by the contrast so they had occlusion due to thromboembolism.
@Dr.Earles: there was no iatrogenic cannulation or LHC via radial artery before this presentation in the history.
I also wonder if she had hypercoagulability due to Crohn’s disease.
Dr. Hashmi, I think you have eliminated all the other possiblities. This is an interesting case. What is most interesting is the fact she had the thrombus in the exact same area. Thanks for the reply!
Why not remove the subclavian thrombus. Is there anything crimping the subclavian Artery?
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pt should have a formal angio of the subclavian artery If LARGE ulcerated plaque is seen, stenting perhaps with a covered stent may be helpful. If the thrombus extends to the thoracic outet, an angio with the arm hyperabductted would would be in order. Very intersting case.i WORRY THAT THE NEXT EMBOLUS MAY BE TO THE VERTBRAL.