Figure 1
By counseling the cardiac surgery team, we decided that surgical
thrombectomy would not benefit the patient. Therefore, the patient was
transferred to the intensive care unit. After consulting with vascular
surgery and cardiology teams, we started alteplase (100 mg continuous
intravenous infusion over two hours) with caution. The patient went
under close observation, including abdominopelvic sonography (for early
detection of intraabdominal leakage or bleeding), echocardiography,
neurologic examinations, and laboratory follow-ups. One hour after
alteplase, her JP drain started to discharge blood (about 2 liters in
the first 24 hours) along with bloody vaginal discharge, needing 3 bags
of packed cells and 3 bags of fresh frozen plasma to be transfused.
Although she initially was actively bleeding, it significantly decreased
over the next four days. On Post-Operative Day (POD) 4, she became
hemodynamically stable with a normal abdominal exam and tolerated the
diet. Thereafter, we started therapeutic heparin (800 IU/hour continuous
intravenous infusion) for three days. On the 7th POD, the bleeding
stopped, and she was transferred to the surgery ward, where we switched
from heparin to rivaroxaban (15 mg twice daily). Then, she was observed
for a day and discharged from the hospital.
The medical team followed her after discharge until the submission of
this paper (8 months). She experienced an uneventful post-operative
period while losing 40 kg of her weight. On follow-ups, she developed
iron deficiency anemia, which is being treated with intravenous iron
supplements. Hematologic evaluations for thrombotic tendencies,
including factor V Leiden, protein C, and protein S were all
unremarkable.