Suspected DVT - To Treat or Not to Treat?

Author: V. Dimov, M.D., Cleveland Clinic

69 yo CM with PMH of DM 2, Afib on Coumadin, HTN is admitted to the hospital with CC: left leg pain. Cellulitis is diagnosed and Unasyn is started. During the hospital stay patient is found to have anemia with Hgb 8 and guaiac positive stools.
Colonoscopy showed diverticulosis and a benign polyp which was removed. Coumadin was held for 10 days. He was on Heparin 5000 U SQ BID.

Why are we presenting this case?
Read on... it will become interesting.
X-ray of the left heel showed osteomyelitis and patient was scheduled for surgery. At the same time left calf swelling was not subsiding although patient was afebrile and WBC was WNL. D-dimer was 2117, INR 1.10.

Is it DVT?
D-dimer may be elevated due to a lot of different reasons and is not specific for DVT.
Left calf DVT was suspected and confirmed by the preliminary Duplex report. Full dose Lovenox was started - 1 mg/kg q 12 hrs.

During the second day of LMWH therapy patient developed rectal bleeding passing clots.

How to treat bleeding caused by LMWH?
FFP is not helpful and Protamine is effective in only 5070% of cases. This is one of the drawbacks of LMWH therapy.

What happened?
Lovenox was stopped and bleeding gradually resolved. Hgb was stable around 8-9 and he did not need PRBC transfusion. A tagged RBC scan did not show any evidence of acute bleeding.


NM GI Bleeding scan

Final Duplex report was not convincing.


Venous Duplex Report-LLE

What to do now?
Nuclear medicine venous thrombosis scan with TC 99 Accutect, i.e. Accutect scan.
Accutect did not show an acute DVT.


NM Accutect scan for DVT

Follow-up
Patient had a persistent AFib and the rate was controlled.
For now he will be on Plavix and ASA. His anticoagulation with Coumadin (very risky given the history) will be discussed with the GI and Cardiology consultants.

What did we learn from this case?
Anticoagulation is risky.
Starting Coumadin for somebody with DVT opens a whole new bag of worms and changes their life for at least 6 months.
It is not an easy decision to make and that's why we have to be sure.
If the Duplex is not conclusive you have to do an Accutect scan.

References:
Phlegmasia Cerulea Dolens. NEJM, Volume 356:e3, January 18, 2007, Number 3.

Further reading:
Cheney treated for blood clot in his leg. CNN, March 5, 2007.


Created: 04/2005
Updated: 03/05/2007