Do you have an Asymptomatic Surgical Patient with a Massive Venous Thromboembolism? Keep Calm, “don’t touch” and Start Aggressive Anticoagulation!

Case Report

Austin J Emergency & Crit Care Med. 2015;2(1): 1013.

Do you have an Asymptomatic Surgical Patient with a Massive Venous Thromboembolism? Keep Calm, “don’t touch” and Start Aggressive Anticoagulation!

Colombo J1*, Arena A2, Gamba A3, Codazzi D2 and Langer M1,2

1Department of Pathophysiology and Transplantation, University of Milan, Italy

2Department of Anesthesia, Intensive Care and Palliative Care – Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.

3Cardiovascular Department, Manzoni Hospital, Lecco, Italy

*Corresponding author: Jacopo Colombo, Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 3, Milan, Italy

Received: December 30, 2014; Accepted: February 16,, 2015 Published: February 18, 2015


Here we present a case of a 49-year-old man affected by Pseudomyxoma peritonei who experienced extended venous thromboembolism (VTE) 15 days after cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC).

Despite the large sizes of thrombi, the involvement of superior vena cava, right atrium and pulmonary artery, patient was asymptomatic and hemodynamically stable. He had just been subjected to a radical surgery so that we decided to avoid thromboembolectomy on cardio-pulmonary-bypass and to start anticoagulation (continuous intravenous infusion of unfractioned heparin to maintain the APTT in a range of 46-90 seconds).

We monitored sonographically the intracardiac portion of the thrombus: we noticed change in shape and a progressive dimensionality reduction. These findings were confirmed by CT scan, which, on the 14th day of anticoagulant therapy, showed only small residues of the known thrombus. We switched anticoagulant therapy to low-molecular-weight heparins (LMWH) and the patient was moved to his surgical ward.

Pre-demission CT scan showed no more evidence of VTE.

We can conclude that medical treatment was the right choice because aggressive anticoagulant therapy allowed regression and disappearance of thrombus without any complication.

Keywords: Venous thromboembolism; Anticoagulant therapy; Thromboembolectomy; Pseudomyxoma peritonei; Citoreduction; HIPEC

Case Presentation

A 49-year-old man, affected by Pseudomyxoma peritonei, was scheduled for cytoreductive surgery (CRS), involving peritonectomy and multivisceral resections with intra-operative hyperthermic intraperitoneal chemotherapy (HIPEC).

The patient was in excellent conditions; routine preoperative investigations showed no abnormalities. Postoperative monitoring in intensive care unit was planned for length and invasiveness of surgery.

Balanced anaesthesia was performed without complication. A central venous catheter (CVC) was placed to allow perioperative drug administration.

After uncomplicated surgery (CRS and HIPEC with cisplatin 150 mg plus mitomycin 25 mg, perfusion time 60 minutes at 42,5oC) and anaesthesia, the patient was admitted to the intensive care unit (ICU). He was discharged from the ICU on postoperative day 1 pain-free and following an uneventful stay.

No abnormalities in the routine postoperative blood tests were observed.

For the following two weeks he kept to the department protocol for VTE prophylaxis (one-daily-dose of subcutaneous Nadroparin Calcium 0,4 mL) and post-surgical rehabilitation without any complications.

On the 15th postoperative day, the patient became pyretic, shivered and inflammatory markers rose (C-reactive protein 271 mg × L-1 and leukocyte count 15.310 × 109 × L-1). No variations in hemodinamic and respiratory parameters were noted. Blood culture samples were taken and the patient was started at broad-spectrum antibiotics (piperacillin- tazobactam, teicoplanin, fluconazole).

Surgeons required an abdomen CT scan with iv contrast for suspected abdominal abscess. No intrabdominal problem was noted but cranial slices revealed thromboembolism in right pulmonary artery. CT scan of thorax with iv contrast was done to see the extent of the thrombus and showed thromboembolism in right pulmonary artery and a large thrombus in superior vena cava extending into the right atrium.

Lower limbs’ ecocolordoppler didn’t show any sign of deep venous thrombosis (DVT).

Surgeons involved intensivists for case management: we consulted three cardiac surgeons; two of them laid the indication for surgical embolectomy on cardio-pulmonary-bypass (CPB).

Patient was asymptomatic, hemodynamically stable and he had just been subjected to a radical surgery so that we decided to avoid thromboembolectomy and to embrace the more conservative policy given by the third cardiac surgeon, the medical therapy.

The patient was moved to ICU to start continuous intravenous infusion of unfractioned heparin (UFH). Treatment was initiated with a bolus injection of 80IU/Kg, followed by continuous infusion of 18IU/kg/hr.

Serial blood samples were planned to monitor anticoagulation (activated Partial Thromboplastin Time (APTT) and antithrombin III values) and continuous infusion was adjusted to maintain aPTT in a range of 46-90 seconds (Figure 1). Few days later blood-cultures became positive for Staphylococcus Epidermidis so that a targeted antibiotic therapy with Daptomycin was started.