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CASE REPORT
Year : 2017  |  Volume : 27  |  Issue : 1  |  Page : 26-28

Thrombotic risk after a major bleeding during anticoagulation: A clinical case


1 Division of Cardiology-UTIC-Cardiovascular Rehabilitation, Spoleto Hospital, USL Umbria 2, Spoleto, Italy
2 Department of Radiology, Spoleto Hospital, USL Umbria 2, Spoleto, Italy
3 Department of Medicine, Internal and Cardiovascular Medicine and Stroke Unit, University of Perugia, Perugia, Italy

Date of Web Publication25-Jan-2017

Correspondence Address:
Serenella Conti
Serenella Conti, Hospital San Matteo Degli Infermi, Via Loreto 3, 06049 Spoleto
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2211-4122.199065

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  Abstract 

We report on a 81-year-old female admitted to the emergency department for the occurrence of abdominal pain after a minor trauma. She was on treatment with warfarin for atrial fibrillation. The abdominal computed tomography (CT) angiography revealed a retroperitoneal hematoma (RH) of the left iliopsoas muscle with no evidence of active bleeding. The international normalized ratio exceeded the upper recommended anticoagulation limit. Prothrombin complex concentrates (PCCs) were used for anticoagulation reversal. Two days later, the patient presented acute dyspnea and a pulmonary CT angiography showed an embolus in the right pulmonary artery. Enoxaparin was started. Thoracic symptoms improved and a second abdominal CT angiography revealed a reduction in RH. Apixaban was started from day 11. No further bleedings occurred and clinical conditions improved. Anticoagulation reversal with PCCs rapidly restores hemostasis, but, on the other side, the thrombotic risk due to their procoagulant effect should be considered.

Keywords: Prothrombin complex concentrates, pulmonary embolism, retroperitoneal hematoma, Vitamin K antagonists


How to cite this article:
Conti S, Ciuffetti M, Vedovati MC. Thrombotic risk after a major bleeding during anticoagulation: A clinical case. J Cardiovasc Echography 2017;27:26-8

How to cite this URL:
Conti S, Ciuffetti M, Vedovati MC. Thrombotic risk after a major bleeding during anticoagulation: A clinical case. J Cardiovasc Echography [serial online] 2017 [cited 2020 Jun 6];27:26-8. Available from: http://www.jcecho.org/text.asp?2017/27/1/26/199065


  Introduction Top


According to the International Society on Thrombosis and Haemostasis definition,[1] 2.4%–4% of patients treated with oral anticoagulant therapy with Vitamin K antagonists (VKAs) experience a major bleeding. Management of a bleeding event in patients treated with VKAs is based on therapy withdrawal, administration of Vitamin K, hemodynamic support (volume resuscitation with fluids or red blood cell transfusion), and in life-threatening cases, on the use of reversal agents.[2] Surgery or radiologic intervention should be considered in case of continuous active bleeding. Although fresh frozen plasma can be given in this situation, the use of prothrombin complex concentrates (PCCs) in a small infusion volume gives a rapid full recovery of coagulation parameters.[3] When PCCs are used as reversal, the thrombotic risk related to both the intrinsic effect of the agent and to the prothrombotic predisposition of the patient should be considered.


  Case Report Top


We report on a 81-year-old female admitted to the emergency department for the occurrence of abdominal pain after a minor trauma. She was on treatment with warfarin for atrial fibrillation and a previous cardioembolic stroke event. The computed tomography (CT) angiography of the abdomen revealed a retroperitoneal hematoma (RH) of the left iliopsoas muscle sized 12 cm × 10 cm with no evidence of active bleeding. The iliac venous system was compressed by the RH with no evidence of thrombosis [Figure 1]. The international normalized ratio (INR) at admission was 6.6, and hemoglobin value was normal (13.7 g/dl). Reversal with 3-factor PCC at the dosage of 25 U/Kg was administered, and a normal value of INR was achieved soon after. Hemoglobin level was 12 g/dl at 24 h. However, 2 days later, the patient developed dyspnea and tachypnea (respiratory rate over 30 breaths for minute); arterial oxyhemoglobin saturation was 78% in room air with severe hypoxia (40 mmHg) and normocapnia (45 mmHg). Systolic blood pressure and heart rate were normal. A pulmonary CT angiography revealed a thrombus in the right pulmonary artery with the involvement of the superior, medium, and inferior lobar branches and a mild pleural effusion [Figure 2]. At echocardiography, no signs of right ventricular failure due to pressure overload were found [Figure 3]. There was a mild increase in troponin I level (0.26 ng/ml, normal value. <0.04 ng/ml) with normal levels of N-terminal pro-B-type natriuretic peptide. The hemoglobin value was stable (12 g/dl) without renal impairment (creatinine clearance according to Cockcroft-Gault = 77 ml/min); therefore, treatment with enoxaparin at the dosage of 0.75 mg/Kg every 12 h was started and continued for 4 days. Enoxaparin dose was increased at 1 mg/Kg every 12 h at day 5 and continued until day 10. Thoracic symptoms improved and a second CT angiography of the abdomen revealed a mild reduction in RH volume. At this point, the oral anticoagulation with a direct inhibitor of factor Xa apixaban (5 mg every 12 h) was introduced. No further bleedings occurred, and clinical conditions subsequently improved.
Figure 1: Computed tomography angiography of abdomen (coronal view): Retroperitoneal hematoma (marked by white arrow) of left iliopsoas muscle sized 12 cm × 10 cm with no evidence of active bleeding. The retroperitoneal hematoma compressed iliac venous system without evidence of venous thrombosis.

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Figure 2: Pulmonary computed tomography angiography (sagittal view): Thrombus of right pulmonary artery with the involvement of superior, medium, and inferior lobar branches.

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Figure 3: Two-dimensional echocardiography in apical view: Early diastolic pulmonary regurgitation velocity <2.4 m/s.

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  Discussion Top


In patients receiving VKAs experiencing a major bleeding the use of a reversal agent is recommended. Treatment options include the use of Vitamin K and PCCs. The intrinsic hypercoagulable state of patients candidate to receive VKAs may be exacerbated by the infusion of PCCs. The use of PCCs is associated with an increased risk of both venous and arterial thrombosis during the recovery period.[4] In this patient, the use of PCCs together with the compression of the venous iliac vessels acted as triggers for the occurrence of intermediate-low risk pulmonary embolism.[5] Since the stability of hemoglobin values and of RH size, parental anticoagulation with enoxaparin was started. Phase 3 trials on the use of non-VKAs oral anticoagulants (NOACs) in patients with venous thromboembolism showed similar efficacy compared to heparin/VKA.[6] However, because of their better safety profile compared to standard anticoagulation (as showed in trials on atrial fibrillation and in subgroup analyses on pulmonary embolism), the use of a NOAC was preferred.[7],[8]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Schulman S, Angerås U, Bergqvist D, Eriksson B, Lassen MR, Fisher W, et al. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in nonsurgical patients. J Thromb Haemost 2005;3:692-4.  Back to cited text no. 1
    
2.
Dentali F, Marchesi C, Giorgi Pierfranceschi M, Crowther M, Garcia D, Hylek E, et al. Safety of prothrombin complex concentrates for rapid anticoagulation reversal of Vitamin K antagonists. A meta-analysis. Thromb Haemost 2011;106:429-38.  Back to cited text no. 2
    
3.
Chai-Adisaksopha C, Hillis C, Siegal DM, Movilla R, Heddle N, Iorio A, et al. Prothrombin complex concentrates versus fresh frozen plasma for warfarin reversal. A systematic review and meta-analysis. Thromb Haemost 2016;116:879-890.  Back to cited text no. 3
    
4.
Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, et al. The European Guideline on management of major bleeding and coagulopathy following trauma: Fourth edition. Crit Care 2016;20:100.  Back to cited text no. 4
    
5.
Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014;35:3145-6.  Back to cited text no. 5
    
6.
van der Hulle T, Kooiman J, den Exter PL, Dekkers OM, Klok FA, Huisman MV. Effectiveness and safety of novel oral anticoagulants as compared with Vitamin K antagonists in the treatment of acute symptomatic venous thromboembolism: A systematic review and meta-analysis. J Thromb Haemost 2014;12:320-8.  Back to cited text no. 6
    
7.
Vedovati MC, Becattini C, Germini F, Agnelli G. Efficacy and safety of direct oral anticoagulants after pulmonary embolism: A meta-analysis. Int J Cardiol 2014;177:601-3.  Back to cited text no. 7
    
8.
Ruff CT, Giugliano RP, Braunwald E, Hoffman EB, Deenadayalu N, Ezekowitz MD, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: A meta-analysis of randomised trials. Lancet 2014;383:955-62.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]


This article has been cited by
1 Prothrombin complex concentrate/warfarin
Reactions Weekly. 2017; 1642(1): 256
[Pubmed] | [DOI]



 

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