Direct Oral Anticoagulant for a Right Atrial Thrombus Following Endovascular Stenting in Superior Vena Cava Syndrome
論文ID: CJ-22-0055
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論文ID: CJ-22-0055
A 69-year-old man was referred to Ehime University Hospital for recurrent facial edema. The patient was diagnosed with partial anomalous pulmonary venous return. When the patient was 63 years of age, he underwent a modified Williams’ procedure (Figure A). Two years later, the initial symptom presented as facial edema due to superior vena cava (SVC) syndrome caused by proximal graft stenosis due to compression from the ringed graft (Figure B). A self-expandable stent (S.M.A.R.T.; Cordis, Miami Lakes, FL, USA) was implanted (Figure C), but new progression of distal graft stenosis was observed with recurrence of SVC syndrome (Figure D). Subsequently, insertion of another self-expandable stent (LUMINEXX; Bard, Murray Hill, NJ, USA) improved the symptoms (Figure E). The patient was given antithrombotic therapy with aspirin after stenting. However, follow-up computed tomography revealed an intramural thrombus in the right atrium (RA) adjacent to the stent (Figure F). The patient had no inherent clotting function abnormality and good adherence to medication. According to the Japanese guideline for venous thromboembolism (https://www.j-circ.or.jp/cms/wp-content/uploads/2017/09/JCS2017_ito_h.pdf), the patient was given anticoagulant therapy with rivaroxaban 15 mg twice a day for 3 weeks and then 15 mg once a day. Because the patient was allergic to contrast agent, we decided to follow up with non-contrast magnetic resonance imaging (Figure G). The RA thrombus decreased progressively and was almost resolved at 9 months after anticoagulation without thromboembolic events and bleeding complications (Figure H–J).
(A) Modified Williams’ procedure. LA, left atrium; PV, pulmonary vein; RA right atrium; SVC, superior vena cava. (B) Contrast-enhanced computed tomography (CT) showing proximal graft stenosis after Williams’ procedure. (C) After stenting for proximal graft stenosis. (D) Contrast-enhanced CT showing distal graft stenosis. PA, pulmonary artery; RV, right ventricle. (E) Fluoroscopic image showing stent implantation for distal graft stenosis. (F) Contrast-enhanced CT showing intracardiac thrombus. (G–J) Magnetic resonance images before (G) and 1 (H), 3 (I), and 9 months (J) after the administration of a direct oral anticoagulant (DOAC) showing resolution of the thrombus (encircled area) over time.
RA thrombus following endovascular stenting in SVC syndrome is a rare but potentially serious complication. Although intracardiac thrombus resolution using a direct oral anticoagulant (DOAC) has been reported in various clinical scenarios, this strategy is still debated.1,2 Therefore, accumulating evidence of the efficacy of DOAC for intracardiac thrombi is crucial. This case illustrates the efficacy and safety of DOAC for stent-related RA thrombus resolution in an unusual clinical scenario.
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