Thrombectomy and Catheter-Directed Thrombolysis Combined With Antithrombin Concentrate for Treatment of Antithrombin Deficiency Complicated by Acute Deep Vein Thrombosis That Is Refractory to Anticoagulation

Abstract

SummaryA 22-year-old male was admitted to our hospital with deep vein thrombosis that was complicated by antithrombin deficiency. This deficiency was refractory to anticoagulation therapy. Although catheter-directed thrombolysis could not reperfuse the total occlusion in the left deep vein, a combination of thrombectomy, catheter-directed thrombolysis, and antithrombin concentrate treatment was able to dissolve the clots and ameliorate the blood flow into the left deep vein. Antithrombin concentrate administration would be effective in the treatment of antithrombin deficiency with medical refractory deep vein thrombosis. (Int Heart J 2016; 57: 649-653) Key words: Medical refractory DVT, Antithrombin concentrate A ntithrombin deficiency is an inherited thrombophilia with a genetic tendency to cause venous thromboembolism. 1) Deep vein thrombosis is a frequent serious complication in patients with antithrombin deficiency.2) We report here a case of antithrombin deficiency that was complicated by acute deep vein thrombosis and refractory to anticoagulation. The patient was successfully treated by thrombectomy and catheter-directed thrombolysis (CDT) combined with antithrombin concentrate. Case ReportIn June 2012, a 22-year-old male with syncope while walking was admitted to our department. He had been sitting in a chair for a long time to study for his school examinations. He had no past medical history and no past history of limb swelling. He was a smoker. His grandmother had a past history of pulmonary embolism. He was conscious on admission. Physical examination showed swelling of the left lower limb. His heart rate was 141 beats/min and regular, and his arterial blood pressure was 139/87 mmHg. Auscultation of the lungs and heart revealed no inspiratory rales. A 12-lead electrocardiogram showed S waves in lead I, and flat T waves in III and aVF. Echocardiography demonstrated a dilated and hypokinetic right ventricle (RV) with moderate tricuspid regurgitation. The maximum tricuspid regurgitation velocity was 3.5 m/s indicating pulmonary hypertension. A conventional chest CT was performed. A CT image at the pulmonary artery level with intravenous contrast revealed thrombus in the bilateral pulmonary (Figure 1) arteries and the left lower limb (Figure 2). Pulmonary perfusion scanning showed scattered defects in the bilateral pulmonary perfusion (Figure 3), and lower limb perfusion scanning showed severe perfusion defect and development of collateral circulation (Figure 4).The patient was diagnosed with acute pulmonary artery thromboembolism (PTE) due to acute deep vein thrombosis (DVT). The plasma levels of protein C and protein S activities were within normal limits. Lupus anticoagulant and anticardiolipin antibody were not detected. Conventionally, we had the patient put on an elastic stocking on admission to mitigate the pain and edema of the left lower limb. Conventional anticoagulant treatment using heparin and oral anticoagulation were indicated, and an intravenous filter was initiated on admission. Hepari...

An Exceedingly Rare Case of Antithrombin III Deficiency and Catastrophic Antiphospholipid-Like Disease

“…AT III deficiency and APS are both typically managed with vitamin K antagonists [ 3 , 8 ]. Although our patient did not meet the criteria for a definitive diagnosis of APS or CAPS, we managed her similarly to patients diagnosed with said conditions.…”

“…Various acquired causes may include decreased production and increased consumption, such as in liver disease, nephrotic kidney disease, or enteropathic protein loss. Most commonly, AT III deficiency leads to venous thromboemboli (VTE) of the deep veins and pulmonary vessels, leading to a seven-fold increased risk of VTE [ 2 , 3 ]. As with most inherited thrombophilia syndromes, warfarin is an acceptable anticoagulant for VTE prevention; however, strict anticoagulation is required, which makes the treatment difficult for some patients.…”