Limb loss following the use of Heparin: A lesson to be remembered

Abstract

The optimal method of prophylaxis against venous thromboembolism after total hip replacement (THR) remains uncertain. Most surgeons use some form of pharmacological prophylaxis, most commonly heparin. The precise balance of the benefits and risks is unclear, and serious complications can occur. We describe a case of heparin-induced thrombocytopenia and thrombosis syndrome in a 62-year-old woman after THR.

Catastrophic heparin-induced thrombocytopenia/thrombosis syndrome related to the use of a Port-A-Cath in a breast cancer patient receiving chemotherapy

“…It is usually caused by IgG antibodies directed against complexes of heparin and platelet factor 4 (PF4) that bind to the platelet surface receptor Fcg, inducing platelet aggregation and resulting in multifocal venous or arterial thrombosis [1,5]. Accelerated platelet consumption (50% reduction of platelet count) and clinical thrombosis can occur upon repeated heparin infusion, and catastrophic thromboembolism can ensue if left un- diagnosed [6]. Our patient had been exposed twice to heparin, once after PAC implantation and a second time after completion of the first course of chemotherapy.…”

Current Concepts Review: Heparin-Induced Thrombocytopenia

“…21, 67, 93, 94, 106 Although HIT and its associated risk for paradoxical thrombotic disease, limb amputation, and death, represents an example of one of the most severe complications of VTED chemoprophylaxsis, only 15 papers have been published in the English orthopedic literature focusing on this disease. These case reports discuss less than a total of 30 cases, and do not differentiate between Type I and Type II disease, 4,6,7,9,17,20–22,31,40,42,47,56,57,63–68,70,74a,75,76,93,94,106,108,111,114 Collectively, these clinical accounts provide at best for only Level IV evidence on this issue. A meta-analysis of these scattered orthopaedic publications identified an estimated 22% amputation rate, 11% mortality rate, and 33% major complication rate with HIT.…”

“…A meta-analysis of these scattered orthopaedic publications identified an estimated 22% amputation rate, 11% mortality rate, and 33% major complication rate with HIT. 6,7,9,17,42,47,56,64,65,68,70,74a,75,76,93,94 Although there are no known published reports of immune-mediated HIT in an orthopedic patient after a singular exposure to heparin or its derivatives, this author has observed a patient die of systemic complications related to HIT approximately one month after a single perioperative injection with a LMWH as prophylaxsis for a foot and ankle procedure. 50,67,106,109…”

“…These include antiplatelet agents such as aspirin, Arvin, dextran, plasmapheresis, thrombolytic therapy, thromboembolectomy, and intravenous IgG. 47,50 Platelet transfusions are contraindicated because they may augment the consumptive process and propogate thrombosis.…”