Avoiding the Surgery! Conservative Management of Extensive BilateralDVT in a Case of Complex Hypercoagulability

Abstract

Background: Venous thromboembolism (VTE) can often be triggered by the convergence of multiple predisposing factors, making it challenging to identify the primary trigger in complex cases. Based on the clinical profile, management ranges from medical to surgical interventions. This case highlights the successful conservative management of extensive bilateral deep vein thrombosis (DVT) spanning from the IVC filter down to the lower extremity veins in a patient with multiple coexisting risk factors and hypercoagulable states.

Case Presentation: An 88-year-old male presented with acute swelling of the right lower extremity. His past medical history is significant for type 2 diabetes mellitus, hypertension (HTN), chronic kidney disease (CKD), prostate cancer, monoclonal gammopathy of undetermined significance (MGUS), and prior thrombotic events, including a saddle pulmonary embolism (PE) managed with Inferior vena cava (IVC) filter placement. There was a recent hospitalization for a urinary tract infection (UTI) with sepsis, which further compounded his thrombotic risk. Imaging confirmed extensive bilateral DVT below the IVC filter, and laboratory tests revealed hypercoagulability associated with antiphospholipid syndrome (APS).

Management: Considering the patient’s age, CKD, and extensive thrombosis, a multidisciplinary approach was adopted. The patient was managed conservatively with heparin followed by warfarin, achieving a therapeutic INR of 2-3. Surgical intervention was avoided as the vascular surgery team deemed anticoagulation sufficient to address the extensive DVT. The patient was discharged on warfarin and remained asymptomatic at a four-week follow-up, with no recurrence of thrombotic events.

Discussion: This case illustrates the challenges of managing VTE in patients with multiple overlapping risk factors, such as advanced age, chronic illness, recent infections, and hypercoagulable conditions like APS. It emphasizes the role of individualized, conservative management in extensive and potentially fatal DVTs. We showcase a successful non-surgical approach that highlights the efficacy of anticoagulation therapy and the importance of multidisciplinary collaboration in achieving favourable outcomes in high-risk patients.