Recurrent thrombosis after carotid endarterectomy secondary to activated protein C resistance and essential thrombocytosis

Abstract

Rationale:Thrombosis is a major cause of morbidity in the perioperative period. Although many risk factors are known, activated protein C resistance is a prominent risk for thrombosis. Activated protein C resistance frequently occurs with recurrent thromboembolism.Patient concerns:A 59-year-old Korean woman patient with hypertension was admitted due to dysarthria and left side motor weakness.Diagnosis and interventions:Magnetic resonance imaging showed subacute cerebral infarction with right frontoparietal lobe and stenosis at the right internal carotid artery. She underwent right carotid endarterectomy under general anesthesia. However, recurrent thrombosis on postoperative day 1 was noted at patient's right carotid artery, which prompted emergency surgery. Additional preoperative laboratory review revealed findings for activated protein C resistance, low protein S activity, antinuclear antibody (>1:160), anti-cardiolipin IgM antibody (16.6), and thrombocytosis, Janus kinase and factor V Leiden mutations. At the intensive care unit, heparin was continually infused until postoperative day 12 and was then switched to warfarin.Outcomes:Patient was discharged at postoperative day 21 without any event. Patient had no signs of recurrence within the 3-year follow-up period, and she is still on oral warfarin and clopidogrel.Lessons:Screening test for hypercoagulability can be used to identify patients at higher risk of postoperative complications. If hypercoagulability state is confirmed by laboratory testing, a suitable anticoagulant treatment plan should be made within the perioperative period.

A Case of Symptomatic Intraluminal Internal Carotid Artery Thrombus in a Patient with Essential Thrombocythemia Surgically Treated by CEA

“…As far as we have found, fve cases of intraluminal extradural ICA thrombus in patients with ET have been reported in the literature so far (summarized in Table 1) [6][7][8][9][10]. Including the present case, fve of the six cases were located in the cervical ICA near the bifurcation where carotid plaque often develops, and the other case was located in the petrous portion of the ICA [9].…”

“…Taken together, the evidence suggests anticoagulant therapy is important for preventing thrombi developing. Another important point from the case reported by Huh et al was the possibility that the thrombus of patients with ET would be exacerbated by the wound caused by direct operation on the carotid artery [6]. Fortunately, the recurrence of the thrombus in our patient has not been recognized, even in the latest examination one and a half year after the operation.…”

“…Four of the six cases were treated conservatively with medical treatment, and thrombi disappeared without causing additional infarction in three of the four. In the fourth case, the thrombus grew, and the ICA was totally [6]. In that case, intraarterial thrombus occurred 1 POD after emergent CEA, and ET was diagnosed by subsequent workup.…”

“…Regarding the relationship between ET and intraluminal ICA thrombosis, as far as we know, only fve cases of intraluminal ICA thrombus in patients with ET have been reported so far, and only one out of fve cases was surgically treated [6][7][8][9][10].…”

Recurrent arterial thrombosis of the lower extremity with secondary thrombocythemia due to reperfusion injury: a case report

“…Although advanced age, pregnancy, surgery, immobilization, malignancy, anticoagulation resistance, and oral contraceptive use are considered to be important clinical risk factors, the cause of many venous thrombotic events remains unknown (16). However, due to the rarity of arterial thromboembolism (aTE) and the inherent limitations imposed by the Taiwan registry data (17), few studies have explored the recurrence of arterial thrombosis. It has been reported that BMI >23 kg/m 2 , hypertension, cerebrovascular disease, atrial fibrillation, stage IV disease, and AST level are risk factors of aTE.…”