A 68-year-old man is brought to the emergency department with 2 days of bright red blood per rectum. He complains of feeling dizzy and extremely fatigued. Six months ago, he had a diverticular bleed that required hospitalization. The patient has moderate chronic obstructive pulmonary disease (COPD) and uses his inhalers regularly. Three weeks ago, he was hospitalized for a COPD exacerbation and was also found to have a right femoral and popliteal vein thrombosis; he was discharged on warfarin. His mobility is significantly impaired by right hip osteoarthritis and back pain. Blood pressure is 80/60 mm Hg and pulse is 115/min and regular. Mucous membranes are pale. The abdomen is soft and nontender. There is swelling of the right ankle and calf. Laboratory results are as follows: Warfarin is stopped. He is volume resuscitated and given a blood transfusion and fresh frozen plasma. Lower endoscopy reveals a diverticular bleed. Which of the following is the best management for this patient's deep venous thrombosis?

Question

A 68-year-old man is brought to the emergency department with 2 days of bright red blood per rectum.  He complains of feeling dizzy and extremely fatigued.  Six months ago, he had a diverticular bleed that required hospitalization.  The patient has moderate chronic obstructive pulmonary disease (COPD) and uses his inhalers regularly.  Three weeks ago, he was hospitalized for a COPD exacerbation and was also found to have a right femoral and popliteal vein thrombosis; he was discharged on warfarin.  His mobility is significantly impaired by right hip osteoarthritis and back pain.  Blood pressure is 80/60 mm Hg and pulse is 115/min and regular.  Mucous membranes are pale.  The abdomen is soft and nontender.  There is swelling of the right ankle and calf.  Laboratory results are as follows:  Warfarin is stopped.  He is volume resuscitated and given a blood transfusion and fresh frozen plasma.  Lower endoscopy reveals a diverticular bleed.  Which of the following is the best management for this patient's deep venous thrombosis?

Quizplus · Accepted Answer

11ec25c8_d91a_294a_bc81_857d40a4ba2e_MD0003_00 This patient with a life-threatening bleeding episode (ie, hypotension, tachycardia, significant anemia) also has a proximal deep venous thrombosis (DVT) with a high risk of embolizing to the lungs and causing a pulmonary embolus (PE). Patients with a DVT/PE who have a contraindication to or complication from anticoagulation (eg, significant active bleeding, recent surgery, acute hemorrhagic stroke) should have an inferior vena cava (IVC) filter placed. Another indication for IVC filter placement includes if anticoagulation fails (eg, the patient develops a new or recurrent proximal DVT while on therapeutic anticoagulation). IVC filters are placed via a transvenous approach and inhibit large thrombi in the lower extremities from embolizing to the lungs. Generally, it is preferable to place a retrievable filter and remove it after the patient has stabilized and the filter is no longer necessary. Short-term complications of IVC filters include bleeding, infection, and thrombus at the puncture site. Long-term complications include filter migration or erosion into surrounding structures and recurrent thrombus (including one that extends into the IVC and surrounds the filter). (Choices A, B, C, and D) For patients with a DVT/PE and on warfarin, the warfarin dose is typically adjusted to achieve a therapeutic INR value between 2 and 3. In this patient with a life-threatening gastrointestinal bleed (with a therapeutic INR and a normal platelet count), therapeutic anticoagulation (ie, warfarin, heparins, rivaroxaban) is contraindicated. (Choice F) Compression stockings are used for postthrombotic syndrome, which can lead to pain, swelling, and venous ulcers from chronic venous insufficiency following a DVT. However, they are not effective in preventing DVT. (Choice G) Treating only the symptoms would be incorrect as the patient has a large, proximal DVT, which is at high risk for embolizing to the lungs. This could be life threatening, especially in a patient with low lung reserve due to chronic obstructive pulmonary disease with recent exacerbation. Educational objective: Inferior vena cava filters are placed to prevent clinically significant pulmonary emboli in patients with contraindications to or complications from anticoagulation (eg, active bleeding) and those who have recurrent proximal deep venous thrombosis who failed anticoagulation. References: Indications, complications, and management of inferior vena cava filters: the experience in 952 patients at an academic hospital with a level I trauma center. (http://www.ncbi.nlm.nih.gov/pubmed/23552968) The effectiveness of prophylactic inferior vena cava filters in trauma patients: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/24195920)

A 68-Year-Old Man Is Brought to the Emergency Department with 2