An Unusual Source of Systemic Thromboembolism
American Journal of Internal Medicine
Volume 3, Issue 3, May 2015, Pages: 141-145
Received: Nov. 15, 2014; Accepted: Apr. 12, 2015; Published: May 6, 2015
Views 5118      Downloads 143
Olusegun Sheyin, Department of Medicine, Harlem Hospital Center, Columbia University, College of Physicians and Surgeons, New York, USA
Bredy Pierre-Louis, Division of Cardiology, Department of Medicine, Harlem Hospital Center, Columbia University, College of Physicians and Surgeons, New York, USA
Article Tools
Follow on us
Pulmonary vein thrombosis (PVT) is a rare but potentially life threatening condition. This is a case of pulmonary vein thrombosis presenting with systemic thromboembolism despite treatment with anticoagulation. A 73-year-old woman, with past medical history of hypertension, peripheral arterial disease (PAD), and treated endometrial and breast cancer, presented with complaint of pain in her right foot of one-day-duration. She had a history of PVT diagnosed on chest CT angiogram one month prior to presentation, which was done to exclude pulmonary embolism when she presented with progressively worsening dyspnea. Physical examination was notable for an elderly woman in painful distress, with a cold, pulseless right foot with bluish discoloration of the skin of the forefoot and a clear line of demarcation from the proximal foot. The angiogram revealed occlusion of the right popliteal artery just above the knee with no appreciable blood flow within the distal vessels. Contrast CT of the abdomen and pelvis revealed multiple hypo-enhancing ill-defined hepatic masses, bilateral adrenal masses and mediastinal adenopathy. Echocardiogram revealed a large left ventricular thrombus and hyper-dynamic left ventricular systolic function. She was admitted for acute right foot ischemia and underwent popliteal exploration, open thrombectomy and embolectomy with restoration of pedal flow. However, she had repeat right popliteal exploration two days later due to further ischemic changes in the foot. Post-operatively, she developed multi-organ dysfunction including respiratory failure requiring endotracheal intubation and mechanical ventilation. She was terminally weaned from mechanical ventilation on request by her family and she died on the sixth day of admission. This case describes the occurrence of systemic embolization despite anticoagulation for pulmonary vein thrombosis. The large thrombus found in the left ventricle most likely represents a thrombus in transit from the superior left pulmonary vein en-route systemic embolization with consequent multi-organ dysfunction.
Pulmonary Vein Thrombosis, Peripheral Arterial Disease, Acute Ischemia, Thrombectomy, Embolectomy
To cite this article
Olusegun Sheyin, Bredy Pierre-Louis, An Unusual Source of Systemic Thromboembolism, American Journal of Internal Medicine. Vol. 3, No. 3, 2015, pp. 141-145. doi: 10.11648/j.ajim.20150303.18
Dye TE, Saab SB, Almond CH, Watson L.Sclerosing mediastinitis with occlusion of pulmonary veins: manifestation and management. J Thorac Cardiovasc Surg 1977, 74:137-141.
Stevens LH, Hormuth DA, Schmidt PE, Atkins S, Fehrenbacher JW. Left atrial myxoma: pulmonary infarction caused by pulmonary venous occlusion. Ann Thorac Surg 1987, 43:215-217.
Mario JG, Leonardo R, Pieter V. Pulmonary vein thrombosis and peripheral embolization. Chest 1996, 109:846-847.
Sarsam MA, Yonan NA, Beton D, McMaster D, Deiraniya AK. Early pulmonary vein thrombosis after single lung transplantation. J Heart Lung Transplant 1993, 12:17-19.
McIlroy DR, Sesto AC, Buckland MR. Pulmonary vein thrombosis, lung transplantation and intraoperative transesophageal echocardiography. J Cardiothorac Vasc Anesth 2006, 20(5):712-715
Dore R, Alerci M, D'Andrea F, Di Giulio G, De Agostini A, Volpato G. Intracardiac extension of lung cancer via pulmonary veins: CT diagnosis. J Comput Assist Tomogr 1988, 12:565-568.
Cavaco R, Kaul S, Chapman T, Casaretti R, Philips B, Rhodes A, Grounds MR. Idiopathic pulmonary fibrosis associated with pulmonary vein thrombosis: a case report. Cases Journal 2009, 2:9156
Goldenberg N, Kahn SR, Solymoss S. Markers of coagulation and angiogenesis in cancer-associated venous thromboembolism. J Clin Oncol 2003; 21:4194-4199.
Maraveyas A, Johnson M. Does clinical method mask significant VTE-related mortality and morbidity in malignant disease? Br J Cancer 2009; 100:1837-1841.
Timp JF, Braekkan SK, Versteeg HH, Cannegieter SC. Epidemiology of cancer-associated venous thrombosis. Blood 2013; 122:1712-1723.
Pabinger I, Thaler J, Ay C. Biomarkers for prediction of venous thromboembolism in cancer. Blood 2013; 122:2011-2018.
Barsam SJ, Patel R, Arya R. Anticoagulation for prevention and treatment of cancer-related venous thromboembolism. Br J Haematol 2013; 161:764-777.
Falanga A, Marchetti M, Vignoli A. Coagulation and cancer: biological and clinical aspects. J Thromb Haemost 2013; 11:223-233.
Wyatt PJ, Burke RD, Hanlon RC. Morphologic study of canine lungs after ligation of the pulmonary veins. Am J Pathol 1953; 29: 291-303
Trujillo-Santos J, Nieto JA, Tiberio G, et al. Predicting recurrences or major bleeding in cancer patients with venous thromboembolism. Findings from the RIETE Registry.J Thromb Haemost 2008; 100:435-439.
Lyman GH, Khorana AA, Kuderer NM, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2013; 31:2189-2204.
Carrier M, Le Gal G, Cho R, et al. Dose escalation of low molecular weight heparin to manage recurrent venous thromboembolic events despite systemic anticoagulation in cancer patients. J Thromb Haemost 2009; 7:760-765.
Lo GK, Juhl D, Warkentin TE, et al. Evaluation of pretest clinical score (4 T's) for the diagnosis of heparin-induced thrombocytopenia in two clinical settings. J Thromb Haemost 2006; 4:759-765.
Science Publishing Group
1 Rockefeller Plaza,
10th and 11th Floors,
New York, NY 10020
Tel: (001)347-983-5186