{"id":9322,"date":"2011-07-14T10:30:50","date_gmt":"2011-07-14T14:30:50","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?p=9322"},"modified":"2011-10-04T18:08:45","modified_gmt":"2011-10-04T22:08:45","slug":"recurrent-arterial-thrombosis-plus-gi-bleeding-in-an-elderly-woman","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2011\/07\/14\/recurrent-arterial-thrombosis-plus-gi-bleeding-in-an-elderly-woman\/","title":{"rendered":"Recurrent Arterial Thrombosis plus GI Bleeding in an Elderly Woman"},"content":{"rendered":"

An 85-year-old woman with a history of hypertension and Crohn\u2019s 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.<\/p>\n

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.<\/p>\n

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 \u2014 and underwent colonoscopy with clipping of the bleeding vessel.<\/p>\n

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.<\/p>\n

Questions:<\/strong><\/p>\n

1. How should anticoagulation proceed, given the patient\u2019s recurrent arterial thrombosis and recent gastrointestinal bleeding?<\/p>\n

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\u2019s complications?<\/p>\n

3. What other causes of the arterial thrombosis should be considered? What additional tests, if any, should be performed?<\/p>\n

\u00a0Response:<\/strong><\/p>\n

James Fang, MD<\/a><\/p>\n

1.\u00a0The 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.<\/p>\n

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. <\/strong>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.<\/p>\n

2.\u00a0Warfarin 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.<\/p>\n

3.\u00a0The 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.\u00a0 Such a vascular abnormality could also be complicated by a thrombophilia or medium- to large-vessel vasculitis (e.g. Takayasu\u2019s or giant cell arteritis), particularly in light of the Crohn\u2019s disease. I\u2019d 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 \u201chypercoagulable\u201d workup consisted of.\u00a0 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.<\/p>\n","protected":false},"excerpt":{"rendered":"

An 85-year-old woman with a history of hypertension and Crohn\u2019s 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 […]<\/p>\n","protected":false},"author":367,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[495],"tags":[492,339,368],"class_list":["post-9322","post","type-post","status-publish","format-standard","hentry","category-anticoagulation-2","tag-anticoagulation","tag-dabigatran","tag-warfarin"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/9322","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/367"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=9322"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/9322\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=9322"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=9322"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=9322"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}