Title

A unique case of inferior vena cava compression secondary to abdominal aortic aneurism complicated by deep veins thrombosis and heparin-induced thrombocytopenia type two

Authors

Marko Kozyk MD, First Year Internal Medicine Resident Doctor, Beaumont Hospital, 3601 W 13 Mile Rd, Royal Oak, MI 48073, USA marko.kozyk@beaumont.org Kateryna Strubchevska MD, First Year Internal Medicine Resident Doctor, Beaumont Hospital, 3601 W 13 Mile Rd, Royal Oak, MI 48073, USA kateryna.strubchevska@beaumont.org Pokharel Rajesh MD, Internal Medicine Beaumont Hospital, 3601 W 13 Mile Rd, Royal Oak, MI 48073, USA rajesh.pokharel@beaumont.org

Introduction

We present a unique case of a patient who had 11.6 cm abdominal aortic aneurism compressing the inferior vena cava. Decreased blood flow from the lower extremities contributed to the progression of deep vein thrombosis. In addition, his hospital course was complicated by heparin-induced thrombocytopenia type two and hematochezia.

Case Presentation

A 64-year-old male with a past medical history of coronary artery disease, abdominal aortic aneurysm complicated by rupture with subsequent endovascular repair and stenting, left leg deep vein thrombosis presented after an episode of hypotension with blood pressure of 70/30 mmHg and near syncope. He was immediately given a bolus of normal saline intravenously. His blood pressure subsequently improved to 100/50 mmHg. Of note, the patient was admitted for abdominal aortic aneurism rupture and endovascular repair two months ago. His hospital course was complicated by acute deep vein thrombosis of distal ileac, femoral, popliteal, soleal, posterior tibial, and great saphenous veins. He was discharged home on apixaban 5 mg twice daily; however, the patient did not take his medications as prescribed. One month ago, he was admitted for gastrointestinal bleeding. His esophagogastroduodenoscopy showed gastritis with no active bleeding. His colonoscopy revealed grade two internal hemorrhoids. Review of systems during the current admission was positive for lightheadedness and fatigue. Physical exam was remarkable for left lower extremity edema. Pertinent positive laboratory test results included hemoglobin of 7.4 g/dL (baseline 7.5 g/dL), lactic acid of 3.2 mmol/L, and creatinine of 2.16 mg/dL (baseline of 1.9mg/dL). Computed tomography angiography of the abdomen and pelvis with intravenous contrast was negative for abdominal aortic aneurism endoleak but showed extension of known left iliac thrombus. The diameter of abdominal aortic aneurism was 11.6 cm causing almost complete compression of the inferior vena cava. Interventional radiology and vascular surgery decided to postpone the inferior vena cava filter placement because the aneurism was causing auto-filtration in the inferior vena cava. Gastroenterology team evaluated the patient and cleared him for intravenous heparin. On the next day his platelets dropped from 191 bil/L to 54 bil/L. The heparin was stopped and the patient was started on argatroban. Platelet factor four antibodies and serotonin release assay were ordered due to a high suspicion for heparin-induced thrombocytopenia type two. On the next day, platelet factor four antibodies came positive, therefore, the patient was continued on argatroban for four more days. The patient was discharged on apixaban 5 mg twice daily with platelets of 87 bil/L.

Discussion

We report a unique case of inferior vena cava compression secondary to abdominal aortic aneurism contributing to progression of deep veins thrombosis.

References

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