How should I evaluate and manage a 77‑year‑old patient who underwent iliac‑vein stenting and is receiving intravenous heparin and clopidogrel (Plavix) who now reports fatigue and insomnia?

Evaluation and Management of Fatigue and Insomnia After Iliac Vein Stenting

Your 77-year-old patient's fatigue and insomnia require immediate evaluation for anemia from heparin-related bleeding, followed by assessment for other medication side effects and stent complications.

Immediate Priority: Rule Out Bleeding

Check a complete blood count immediately to exclude anemia from occult bleeding, which is the most critical reversible cause of fatigue in a patient on dual antiplatelet therapy plus heparin. 1

• Obtain hemoglobin/hematocrit to detect blood loss that may not be clinically obvious
• Examine for signs of bleeding: melena, hematuria, ecchymoses, gingival bleeding, or retroperitoneal hematoma 1
• Review vital signs for tachycardia or orthostatic hypotension suggesting volume depletion 1

The combination of heparin and clopidogrel creates substantial bleeding risk—in coronary stent patients, major bleeding occurs in 0.9% with dual therapy versus 0.4% with aspirin alone. 2 A drop in hemoglobin to 8.5 g/dL, as seen in similar cases, can cause profound fatigue and requires transfusion. 1

Assess for Stent Thrombosis

Evaluate for early stent thrombosis, which occurs in 3.6% of iliac vein stent patients within 30 days and can present with subtle symptoms before catastrophic occlusion. 3

• Perform duplex ultrasound of the stented segment to assess patency and flow
• Ask about new or worsening leg swelling, pain, or heaviness that might indicate partial thrombosis 3
• Document adequacy of anticoagulation: check aPTT to ensure therapeutic range (1.5–2.3 times control) 4

Patients with complete venous outflow occlusion have a 25.5% early reocclusion rate, with type IV obstruction (multiple segments) carrying 4.6-fold higher odds of thrombosis. 5 Inadequate anticoagulation during the first 10 days is a major risk factor. 5

Medication-Related Causes

Clopidogrel Side Effects

Clopidogrel can cause fatigue as a direct side effect, though this is less common than rash or gastrointestinal symptoms. 6

• Review timing: symptoms starting within days of clopidogrel initiation suggest drug effect
• Consider alternative antiplatelet agents only if bleeding and thrombosis are excluded and symptoms are severe

Heparin Duration

Routine post-procedural intravenous heparin beyond 48 hours is not recommended after uncomplicated venous intervention and may be contributing to fatigue through subclinical bleeding. 4

• If the stent procedure was uncomplicated and >48 hours ago, transition from IV heparin to oral anticoagulation (low-molecular-weight heparin or direct oral anticoagulant if renal function permits) 4
• Low-molecular-weight heparin for >10 days reduces early reocclusion odds by 98.8% (OR 0.012) compared to shorter courses 5

Insomnia-Specific Evaluation

Insomnia in this context may reflect:

• Anxiety about the procedure or medications: common in elderly patients on multiple blood thinners
• Hospital environment disruption: if still hospitalized
• Unrecognized nocturnal dyspnea: check for volume overload or heart failure
• Pain from the access site or leg discomfort: assess femoral puncture site and lower extremity

Diagnostic Algorithm

1. Stat CBC with differential → If Hgb <10 g/dL or drop >2 g/dL from baseline, search for bleeding source and transfuse as needed 1
2. aPTT and INR → If subtherapeutic, adjust heparin; if supratherapeutic, consider dose reduction 4
3. Duplex ultrasound of stented segment → If thrombosis detected, urgent intervention may be required 3, 5
4. Metabolic panel → Check renal function (affects heparin clearance) and electrolytes
5. Review medication timing and doses → Ensure clopidogrel 75 mg daily is appropriate maintenance dose 3

Management Plan

If Anemia Is Present

• Transfuse to Hgb >8.5 g/dL to relieve fatigue 1
• Identify and treat bleeding source (endoscopy if GI suspected, imaging if retroperitoneal) 1
• Do NOT discontinue antiplatelet therapy unless life-threatening bleeding; this risks catastrophic stent thrombosis 1
• Add proton pump inhibitor if not already prescribed to reduce GI bleeding risk 1

If Stent Thrombosis Is Detected

• Urgent vascular surgery or interventional radiology consultation for possible thrombolysis or mechanical thrombectomy 3, 5
• Ensure therapeutic anticoagulation with heparin bolus and infusion 4
• Continue clopidogrel unless contraindicated by active bleeding 3

If No Bleeding or Thrombosis

• Transition from IV heparin to LMWH (e.g., enoxaparin 1 mg/kg subcutaneously twice daily) for at least 10 days total post-stent 5
• Continue clopidogrel 75 mg daily for 3 months as standard post-venous stent protocol 3
• Symptomatic management of insomnia: low-dose trazodone 25–50 mg at bedtime or melatonin 3–5 mg, avoiding benzodiazepines in elderly patients
• Reassess in 48–72 hours: if fatigue persists despite normal labs, consider other causes (hypothyroidism, depression, deconditioning)

Critical Pitfalls to Avoid

• Never discontinue clopidogrel in the first 30 days post-stent without consulting the interventionalist; early cessation dramatically increases thrombosis risk 1, 3
• Do not attribute fatigue to "old age" or "stress" without excluding anemia—this is a common and dangerous oversight 1
• Do not continue IV heparin indefinitely beyond 48 hours without clear indication (e.g., visible thrombus, hypercoagulable state); transition to LMWH reduces bleeding risk while maintaining efficacy 4, 5
• Do not use warfarin alone in the immediate post-stent period; bridging with heparin or LMWH is essential until therapeutic INR is achieved 5