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Remarkable regression of massive deep vein thrombosis in response to intensive oral rivaroxaban treatment.

Koitabashi N, Niwamae N, Taguchi T, Ohyama Y, Takama N, Kurabayashi M - Thromb J (2015)

Bottom Line: Intensive high-dose anticoagulation is recommended during the initial 3 weeks of DVT treatment.The present report describes a case of a 77-year-old male showing a remarkable regression of DVT in response to rivaroxaban treatment within the initial 3 weeks of therapy and who did not experience any adverse events.Rivaroxaban, especially in intensive high-dose treatment, might be a safe and effective therapeutic choice for massive DVT.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine and Biological Sciences, Gunma University Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511 Japan.

ABSTRACT
Deep vein thrombosis (DVT) is a common disease and is associated with pulmonary embolism (PE). Proximal iliofemoral DVT may lead to severe PE and chronic venous insufficiency. The standard therapy for DVT is anticoagulant therapy using heparin and a vitamin K antagonist, but a recent clinical study showed that rivaroxaban, an oral Xa inhibitor, was comparable to standard therapy and had less bleeding complications. Intensive high-dose anticoagulation is recommended during the initial 3 weeks of DVT treatment. The present report describes a case of a 77-year-old male showing a remarkable regression of DVT in response to rivaroxaban treatment within the initial 3 weeks of therapy and who did not experience any adverse events. His DVT was massive and was accompanied by proximal iliofemoral vein thrombus and iliac vein compression syndrome. Rivaroxaban, especially in intensive high-dose treatment, might be a safe and effective therapeutic choice for massive DVT.

No MeSH data available.


Related in: MedlinePlus

Multi-detector computed tomography (MDCT) on admission. A and B. Transverse plane (A) and coronal plane (B) at the ilio-cava junction level. Left external iliac vein (lt EIV) branches off directly from the inferior vena cava. The left EIA is compressed by the abdominal aorta (*) with thrombus; C to E. Transverse plane (C and E) and coronal plane (D and F) at the iliofemoral vein level. Lt EIV, right common iliac vein (rt CIV), left internal iliac vein (lt IIV) and left femoral vein (let FV) have thrombi; G. left popliteal vein thrombus (white arrow); H. thrombi of left lower leg veins/soleal veins (white arrows).
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Fig1: Multi-detector computed tomography (MDCT) on admission. A and B. Transverse plane (A) and coronal plane (B) at the ilio-cava junction level. Left external iliac vein (lt EIV) branches off directly from the inferior vena cava. The left EIA is compressed by the abdominal aorta (*) with thrombus; C to E. Transverse plane (C and E) and coronal plane (D and F) at the iliofemoral vein level. Lt EIV, right common iliac vein (rt CIV), left internal iliac vein (lt IIV) and left femoral vein (let FV) have thrombi; G. left popliteal vein thrombus (white arrow); H. thrombi of left lower leg veins/soleal veins (white arrows).

Mentions: A 77-year-old male was admitted to our hospital due to left lower limb swelling with heat sensation and redness. These symptoms had appeared 2 days prior to hospital admission. Five months before admission, he was diagnosed with polymyalgia rheumatica syndrome and started treatment with prednisolone 10 mg per day. He had no previous history of thrombosis and no family history suggestive of inherited thrombophilia. His major risk for VTE was advanced age, but he did not have any other risks, such as obesity, cancer, surgery, immobilization or recent long travel. At the time of arrival to our Emergency Department, his entire left leg was swollen and showed pitting edema with mild pain. Blood pressure was 164/78 mmHg, and pulse of 102 bpm. Respiratory rate was 12/min, and arterial oxyhemoglobin saturation was 96% at room air. Plasma D-dimer level was high (45.0 μg/mL) while serum protein level, renal function and liver function were normal. Multi-detector computed tomography (MDCT) showed massive deep vein thrombosis from the lower edge of inferior vena cava to the lower leg veins (Figure 1). This patient had a congenital anomaly of the iliac vein in which the left external iliac vein (EIV) and left internal iliac vein (IIV) separately branched off from the inferior vena cava without a left common iliac vein (Figure 1A). The left EIV was compressed by the abdominal aorta and the fifth lumbar vertebra (Figure 1A and B). The thrombosis extended from the calf veins to the compressed site, suggesting a variant of iliac vein compression syndrome (May-Thurner syndrome) [11,12]. The left IIV also had a large thrombus (Figure 1C and D). The patient did not have any symptom related with PE and his lung MDCT did not show any embolism in the pulmonary arteries. Compression venous ultrasonography also showed massive DVT from the left iliofemoral level to the lower leg level, but slight venous flow was observed by color Doppler at the level of the left common femoral vein. A diagnosis of DVT was made, and the patient was immediately started on intravenous unfractionated heparin administration. The patient subsequently provided written informed consent to participate in the J-EINSTEIN study [10]. We screened thrombophilia including antiphospholipid syndrome, protein S/C deficiency, fibrinogen and antithrombin III abnormality, but could not find any cause of DVT except steroid administration. Then, prednisolone dose was reduced to 7.5 mg. Since the patient was assigned to begin rivaroxaban therapy on the second day of hospitalization, a 15-mg dose of rivaroxaban administration was given 4 hours after termination of heparin, according to the study protocol. His left leg swelling showed progressive reduction on a daily basis in response to rivaroxaban 15 mg twice-daily. After 2 weeks of treatment, the patient was discharged from our hospital, as his symptoms and leg swelling had markedly improved. We did not use any compression therapy because the symptom improvement was observed from initial several days. The circumference of the left femoral region had decreased from 50.6 cm to 45.8 cm over the 2 weeks of initial treatment, and plasma D-dimer level decreased to 3.9 μg/mL by the time of hospital discharge. Surprisingly, the massive DVT in his left leg had almost completely disappeared according to MDCT performed on day 22 of the treatment (Figure 2). Compression venous ultrasonography at day 25 only showed a small thrombus at the left popliteal vein. As per protocol, we switched the dose of rivaroxaban to 15 mg per day following 3 weeks of intensive therapy. We monitored his clinical symptom and physical examination every month and continued the study drug for 1 year. Neither bleeding nor recurrence of thrombosis occurred over the entire clinical course of the treatment.Figure 1


Remarkable regression of massive deep vein thrombosis in response to intensive oral rivaroxaban treatment.

Koitabashi N, Niwamae N, Taguchi T, Ohyama Y, Takama N, Kurabayashi M - Thromb J (2015)

Multi-detector computed tomography (MDCT) on admission. A and B. Transverse plane (A) and coronal plane (B) at the ilio-cava junction level. Left external iliac vein (lt EIV) branches off directly from the inferior vena cava. The left EIA is compressed by the abdominal aorta (*) with thrombus; C to E. Transverse plane (C and E) and coronal plane (D and F) at the iliofemoral vein level. Lt EIV, right common iliac vein (rt CIV), left internal iliac vein (lt IIV) and left femoral vein (let FV) have thrombi; G. left popliteal vein thrombus (white arrow); H. thrombi of left lower leg veins/soleal veins (white arrows).
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4364575&req=5

Fig1: Multi-detector computed tomography (MDCT) on admission. A and B. Transverse plane (A) and coronal plane (B) at the ilio-cava junction level. Left external iliac vein (lt EIV) branches off directly from the inferior vena cava. The left EIA is compressed by the abdominal aorta (*) with thrombus; C to E. Transverse plane (C and E) and coronal plane (D and F) at the iliofemoral vein level. Lt EIV, right common iliac vein (rt CIV), left internal iliac vein (lt IIV) and left femoral vein (let FV) have thrombi; G. left popliteal vein thrombus (white arrow); H. thrombi of left lower leg veins/soleal veins (white arrows).
Mentions: A 77-year-old male was admitted to our hospital due to left lower limb swelling with heat sensation and redness. These symptoms had appeared 2 days prior to hospital admission. Five months before admission, he was diagnosed with polymyalgia rheumatica syndrome and started treatment with prednisolone 10 mg per day. He had no previous history of thrombosis and no family history suggestive of inherited thrombophilia. His major risk for VTE was advanced age, but he did not have any other risks, such as obesity, cancer, surgery, immobilization or recent long travel. At the time of arrival to our Emergency Department, his entire left leg was swollen and showed pitting edema with mild pain. Blood pressure was 164/78 mmHg, and pulse of 102 bpm. Respiratory rate was 12/min, and arterial oxyhemoglobin saturation was 96% at room air. Plasma D-dimer level was high (45.0 μg/mL) while serum protein level, renal function and liver function were normal. Multi-detector computed tomography (MDCT) showed massive deep vein thrombosis from the lower edge of inferior vena cava to the lower leg veins (Figure 1). This patient had a congenital anomaly of the iliac vein in which the left external iliac vein (EIV) and left internal iliac vein (IIV) separately branched off from the inferior vena cava without a left common iliac vein (Figure 1A). The left EIV was compressed by the abdominal aorta and the fifth lumbar vertebra (Figure 1A and B). The thrombosis extended from the calf veins to the compressed site, suggesting a variant of iliac vein compression syndrome (May-Thurner syndrome) [11,12]. The left IIV also had a large thrombus (Figure 1C and D). The patient did not have any symptom related with PE and his lung MDCT did not show any embolism in the pulmonary arteries. Compression venous ultrasonography also showed massive DVT from the left iliofemoral level to the lower leg level, but slight venous flow was observed by color Doppler at the level of the left common femoral vein. A diagnosis of DVT was made, and the patient was immediately started on intravenous unfractionated heparin administration. The patient subsequently provided written informed consent to participate in the J-EINSTEIN study [10]. We screened thrombophilia including antiphospholipid syndrome, protein S/C deficiency, fibrinogen and antithrombin III abnormality, but could not find any cause of DVT except steroid administration. Then, prednisolone dose was reduced to 7.5 mg. Since the patient was assigned to begin rivaroxaban therapy on the second day of hospitalization, a 15-mg dose of rivaroxaban administration was given 4 hours after termination of heparin, according to the study protocol. His left leg swelling showed progressive reduction on a daily basis in response to rivaroxaban 15 mg twice-daily. After 2 weeks of treatment, the patient was discharged from our hospital, as his symptoms and leg swelling had markedly improved. We did not use any compression therapy because the symptom improvement was observed from initial several days. The circumference of the left femoral region had decreased from 50.6 cm to 45.8 cm over the 2 weeks of initial treatment, and plasma D-dimer level decreased to 3.9 μg/mL by the time of hospital discharge. Surprisingly, the massive DVT in his left leg had almost completely disappeared according to MDCT performed on day 22 of the treatment (Figure 2). Compression venous ultrasonography at day 25 only showed a small thrombus at the left popliteal vein. As per protocol, we switched the dose of rivaroxaban to 15 mg per day following 3 weeks of intensive therapy. We monitored his clinical symptom and physical examination every month and continued the study drug for 1 year. Neither bleeding nor recurrence of thrombosis occurred over the entire clinical course of the treatment.Figure 1

Bottom Line: Intensive high-dose anticoagulation is recommended during the initial 3 weeks of DVT treatment.The present report describes a case of a 77-year-old male showing a remarkable regression of DVT in response to rivaroxaban treatment within the initial 3 weeks of therapy and who did not experience any adverse events.Rivaroxaban, especially in intensive high-dose treatment, might be a safe and effective therapeutic choice for massive DVT.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine and Biological Sciences, Gunma University Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511 Japan.

ABSTRACT
Deep vein thrombosis (DVT) is a common disease and is associated with pulmonary embolism (PE). Proximal iliofemoral DVT may lead to severe PE and chronic venous insufficiency. The standard therapy for DVT is anticoagulant therapy using heparin and a vitamin K antagonist, but a recent clinical study showed that rivaroxaban, an oral Xa inhibitor, was comparable to standard therapy and had less bleeding complications. Intensive high-dose anticoagulation is recommended during the initial 3 weeks of DVT treatment. The present report describes a case of a 77-year-old male showing a remarkable regression of DVT in response to rivaroxaban treatment within the initial 3 weeks of therapy and who did not experience any adverse events. His DVT was massive and was accompanied by proximal iliofemoral vein thrombus and iliac vein compression syndrome. Rivaroxaban, especially in intensive high-dose treatment, might be a safe and effective therapeutic choice for massive DVT.

No MeSH data available.


Related in: MedlinePlus