Description

A woman in her 70s presented to the emergency department with concern for pulmonary embolism (PE). For months, she had pain and swelling of her lower extremities at the end of the day with varicose veins, for which she had an endovenous radiofrequency ablation (EVRFA) of her right great saphenous vein a day prior to the presentation. She also had a history of atrial fibrillation on rivaroxaban and at baseline, she used a cane to walk and was cognitively intact. Rivaroxaban was held for 1 day prior to the procedure. Ablation was done ultrasound guided, confirming the absence of thrombus on completion of the procedure. On the day of presentation, she had a follow-up visit to obtain duplex ultrasound of her right lower extremity (RLE) as part of the postprocedural protocol, which revealed a non-compressible femoral vein, indicating deep venous thrombosis (DVT). While the ultrasound technician was performing a thorough ultrasound compression test on the proximal femoral vein, common femoral vein and superficial femoral vein, the technician noticed a dislodge of the DVT from the femoral vein, followed by recovery of compressibility of all venous systems (figure 1). The patient was referred to the emergency department for further evaluation. On arrival, patient was asymptomatic, vital signs were unremarkable and physical examination was unrevealing except for varicose veins and a taped postprocedural site seen on the RLE (figure 2A). CT of the chest with contrast revealed a thrombus involving the right middle lobe pulmonary artery (figure 2B,C). Transthoracic echocardiogram did not reveal any right ventricular strain. However, brain natriuretic peptide was elevated to 640 pg/mL and high-sensitivity troponin I was mildly elevated to 21 ng/L, indicating submassive PE. Patient was compliant with medication and denied previous history of thrombosis nor family history of hypercoagulation. Initial hypercoagulation work-up was also unrevealing. She was treated with heparin inpatient and was transitioned to apixaban on discharge.

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Figure 1

Recovery of ultrasound compressibility seen after dislodge of the thrombus in the proximal femoral vein (A). Ultrasound compressibility seen on common femoral vein (B) and superficial femoral vein (C).

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Figure 2

Varicose veins and a taped postprocedural site seen on the right lower extremity (A). CT of the chest with contrast revealed a thrombus involving the right middle lobe pulmonary artery (white arrow) (B and C).

PE is a rarely reported complication of EVRFA of the great saphenous vein, occurring in 0.1% of the total patients undergoing the procedure in a meta-analysis involving 16 398 patients.1 However, the extent of this complication in the geriatric population remains unclear. In general, age is one of the highest independent risk factors for DVT.2 In this case, it is likely that age played a large role, along with potential venous static pathology in this specific population undergoing EVRFA, inflammatory process as a nature of the procedure and immobility that comes with age and postprocedural discomfort of the leg. In addition, this case was highly alarming in developing a large proximal DVT only 1 day after the procedure, which is very early in the postprocedural course, while follow-up duplex ultrasound was commonly performed after 1 week in previous studies.1 It is important to recognise the under-reported complication of PE/DVT in elderly patients undergoing EVRFA, as mortality is high for elderly patients with PE.3 When clinicians encounter geriatric patients with varicose veins, EVRFA should be carefully discussed after individualised risk evaluation for PE/DVT.