(1701) PE and DVT With Clot Progression After Bilateral Lung Transplant Despite Anticoagulation

Introduction: Post-surgical patients are at high risk for developing deep vein thrombosis (DVT) and pulmonary emboli (PE), thus prophylactic anticoagulation is the standard of care. When clot progression occurs despite the use of anticoagulants, treatment failure must be examined. We present a case of massive clot burden and progression in a high-risk patient after bilateral lung transplantation (LT).

Description: A 64-year-old man with rheumatoid arthritis, interstitial lung disease, pulmonary hypertension (WHO group 3), and a history of DVT and PE underwent successful bilateral LT after undergoing a complete evaluation. The patient was heterozygous for factor V Leiden, thus, systemic anticoagulation was to be initiated as soon as it was safe after surgery. The patient had a difficult intraoperative chest dissection and blood loss, necessitating perioperative blood transfusions. Subcutaneous heparin was initiated for prophylaxis at around 12 hours after surgery when bleeding had settled. Two days after LT, he developed left arm pain and swelling; upper and lower extremity ultrasounds revealed extensive left upper extremity DVT and a right upper extremity nonexclusive DVT of the right brachial vein. The patient was started on heparin GTT with transition to a therapeutic dose of enoxaparin sodium. A few days later, he developed ongoing shortness of breath, and further work-up revealed right lower lobe segmental PE and lingular subsegmental PE without evidence of right heart strain on CTA. The patient underwent left upper extremity thrombectomy with a moderate amount of acute and chronic thrombus removed and angioplasty of the left axillary, subclavian, and superior vena cava with remarkable stenosis improvement. He was started on therapeutic enoxaparin sodium with eventual transition to lifelong apixaban. Follow-up imaging confirmed clot dissolution.

Discussion: This case prompts discussion of DVT prophylaxis for patients who are undergoing LT evaluation with a history of DVT and PE and known factor V Leiden mutation. The risk of postoperative bleeding after high-risk LT versus the risk of clot formation must be weighed. Patients with factor V Leiden mutation and known chronic thrombus burden have a high propensity for recurring thrombosis and clot progression, necessitating aggressive management.