From the Guidelines
Testing for thrombophilia, including Protein C, Protein S, and Factor V Leiden mutation, is justified in this patient with a history of recurrent deep vein thrombosis (DVT) and current findings of chronic right lower limb DVT with incomplete recanalization of the common femoral and proximal superficial femoral veins. This 39-year-old male has been on rivaroxaban 20 mg daily and presents with signs of superficial thrombophlebitis on the left side, along with a history of steroid use, which can increase thrombotic risk. The results of thrombophilia testing will help guide treatment decisions, including whether to continue indefinite anticoagulation therapy or consider alternative approaches, such as angioplasty and stenting of the affected vessels, as recommended for chronic venous hypertension with skin changes and impending ulcers 1. If a hereditary thrombophilia such as Factor V Leiden or Protein S deficiency is identified, this would strengthen the case for long-term anticoagulation given the patient's recurrent events and incomplete vessel recanalization, as suggested by guidelines for antithrombotic therapy in patients with venous thromboembolism (VTE) disease 1. Key considerations in managing this patient include:
- The risk of recurrent VTE and the potential benefits of extended anticoagulation therapy, as outlined in guidelines for antithrombotic therapy in patients with VTE disease 1.
- The role of thrombophilia testing in guiding treatment decisions, particularly in patients with recurrent VTE or a family history of thrombophilia, as discussed in the American College of Medical Genetics consensus statement on Factor V Leiden mutation testing 1.
- The importance of addressing chronic venous hypertension and preventing postthrombotic syndrome (PTS) through the use of compression stockings and other measures, as recommended in guidelines for antithrombotic therapy in patients with VTE disease 1. Given the patient's history and current findings, a comprehensive approach to management, including thrombophilia testing, anticoagulation therapy, and consideration of angioplasty and stenting, is necessary to reduce the risk of recurrent VTE and improve quality of life 1.
From the Research
Patient Evaluation
The patient presents with a history of deep vein thrombosis (DVT) and is currently experiencing signs of acute thrombophlebitis. The patient is on rivaroxaban 20 mg OD and has a history of steroid intake.
- The patient's history of recurrent DVT and current symptoms suggest a need for further investigation to determine the underlying cause of the thrombosis.
- The patient's protein S deficiency, as suggested by the signs of protein S insufficiency, may be a contributing factor to the recurrent DVT 2.
- The presence of factor V Leiden mutation also increases the risk of recurrent DVT 3.
Investigation and Treatment
The patient is currently on rivaroxaban, which is a reasonable alternative to standard therapy for the treatment of DVT and prevention of recurrent VTE 4.
- The use of non-vitamin K antagonist oral anticoagulants (NOACs) such as rivaroxaban may be effective and well-tolerated in patients with severe inherited thrombophilia, including protein S deficiency 5.
- However, the patient's history of recurrent DVT and protein S deficiency may require closer monitoring and consideration of alternative treatment options.
- The patient's current symptoms and history suggest a need for continued medical treatment and the use of compression stockings to prevent further complications.
Risk Factors and Prevention
The patient's history of recurrent DVT and protein S deficiency increases the risk of future events.