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Dislodged Endovascular Heat-induced Thrombus Resulting In Pulmonary Embolus Following Postoperative Ultrasound Compression
Aghilas Belkadi, DO, MS, Danielle Park, DO, Mallika Mendu, Holly Graves, MD.
Inspira Health Network, Vineland, NJ, USA.
DEMOGRAPHICS: 48-year-old male with painful varicose veins
HISTORY: The patient underwent an elective greater saphenous vein radiofrequency ablation (RFA) of 48.5 cm over 10 cycles. On post-operative day 3, routine post-procedure venous duplex identified a thrombus at the right sapheno-femoral junction (SFJ). Compression was applied and upon release, the thrombus dislodged and embolized upstream toward the common femoral vein.
PLAN: The patient was admitted for observation. Heparin drip was initiated. His only complaint was mild post-operative pain. Chest computed tomography angiography (CTA) showed an acute pulmonary thromboembolism in the right lower subsegmental branch without right heart strain. Computed tomography venogram was negative for ilio-caval thrombus. The patient remained asymptomatic throughout admission and was discharged on apixaban therapy. He remained asymptomatic at 1-month and 2-month follow-up. Repeat chest CTA at 4 months post-op demonstrated interval resolution of the pulmonary embolus.
DISCUSSION: Endovascular heat-induced thrombosis (EHIT) is a rare complication of RFA. It occurs secondary to induced vascular injury with the formation of deep vein thrombus originating from the ablated superficial vein. A meta-analysis by Healy et al (2018) noted that EHIT occurred in 1.4% of study participants. Further sequelae of EHIT have rarely been reported in the literature. A case report published by Sufian et al (2012) previously described DVT dislodgement during routine post-operative ultrasound causing pulmonary embolism. Risk factors contributing to EHIT have not been well elucidated. Several studies suggest that a large diameter of the GSV near the SFJ may contribute to thrombus formation and extension. Other factors identified in small-scale studies include demographics and CEAP score. However, these studies have not been fully validated. Current management guidelines recommend a graded approach based on the EHIT classification by the American Venous Forum and the Society for Vascular Surgery. This ranges from observation to anticoagulation, depending on the extent of the thrombus. The management of pulmonary thromboembolism related to EHIT formation has not been well studied, and whether long-term anticoagulation is indicated for these patients remains unclear. Our case describes a unique clinical entity that clinicians should be aware of. Further studies are required to standardize management.
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