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Acute Pulmonary Embolism With Inferior Vena Caval Thrombus Following Radiofrequency Ablation Of The Great Saphenous Vein Despite Early Ultrasound Surveillance
Mitali Doshi, MD, Juan Carlos Jimenez, MD, MBA.
University of California, Los Angeles, Los Angeles, CA, USA.
DEMOGRAPHICS: We present the case of a 69-year-old female with multiple risk factors for development of venous thromboembolism who developed bilateral pulmonary emboli despite early postprocedural ultrasound screening after radiofrequency ablation (RFA) of her great saphenous vein (GSV).
HISTORY: The patient's medical history was significant for invasive ductal carcinoma of the right breast (Stage III, T1a, N0, ER Positive) treated with lumpectomy and radiation 7 years prior. Medications included an etonogestrel/ethinyl estradiol secreting vaginal ring (0.120mg/0.015 mg per day) changed monthly prescribed by per primary care physician. She had no prior history of phlebitis or DVT. Her family history was negative for any known hypercoagulable disorders. She had a 30 pack-year smoking history, but quit 20 years prior. A preprocedural duplex ultrasound demonstrated an incompetent right SFJ with 3 seconds of reflux. Her GSV diameter measured 20 mm immediately caudal to the SFJ and upper thigh and 10 mm in the mid-thigh. Right common femoral vein (CFV) reflux was also present.
PLAN: She underwent RFA of the right GSV and post-procedural ultrasound two days later demonstrated successful closure of the right GSV from the SFJ to the distal thigh and a patent CFV with no evidence of ARTE or DVT. She was asymptomatic at this time. Five days later, she presented to our clinic with shortness of breath and cough. Computed tomography angiography (CTA) demonstrated acute multifocal bilateral pulmonary emboli and thrombus burden in the inferior vena cava extending into the right atrium.
DISCUSSION: The reported incidence of pulmonary embolism in the published literature after radiofrequency ablation of the GSV is exceedingly rare. Recent societal clinical practice guidelines recommend against routine postprocedural ultrasound screening for ablation-related thrombus extension in asymptomatic average-risk patients. However, screening is recommended for asymptomatic high-risk patients. Despite compliance to surveillance per societal guidelines, postprocedural duplex ultrasound will not always be able to prevent acute DVT and PE after saphenous vein RFA. Patients should be counseled appropriately that, although rare, life-threatening risks associated with elective thermal ablation of the saphenous vein can occur.
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