Rivaroxaban
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Lack of efficacy: case report An approximately 35-year-old woman experienced lack of efficacy following anticoagulant therapy with rivaroxaban. The woman had heterozygous prothrombin G20210A gene mutation, recurrent pulmonary embolism, cerebral vein thrombosis (superior sagittal and transverse sinuses) and left leg deep vein thrombosis. She had been receiving warfarin; however, she was not compliant with the medical treatment. She presented to the hospital at the age of 34 years with shortness of breath and desaturation. Her face looked plethoric, but she had no central cyanosis. Chest examination revealed normal vesicular breathing with no added sounds. Cardiac examination showed normal heart sounds with no murmurs. There were dilated veins in her chest anteriorly. She had dilated superficial abdominal veins. Her lower limbs showed varicose veins, with mild bilateral oedema. Chest X-ray showed a normal lung parenchyma. She was started on enoxaparin sodium [enoxaparin]; however, her saturation remained around 80–85% room air. Because of the high likelihood of pulmonary embolism, CT angiography of the chest was done which showed complete superior vena cava occlusion with extensive collaterals. The pulmonary arteries were not opacified because of the superior vena cava occlusion. The collaterals were seen connecting the tributaries of the superior vena cava to the pulmonary veins. Her echocardiography revealed an ejection fraction of 30%. A repeat echocardiogram with bubble study showed that the agitated saline injection was filling the left side of the heart completely, with no filling of the right side. After discussion with the interventional radiology team, a procedure was done to insert a coil in the shunt connecting the superior vena cava tributaries to the pulmonary veins. She was discharged on rivaroxaban [route and dosage not stated] because of the poor compliance with warfarin. She was reassessed 6 months after the procedure, and there was no improvement in oxygen saturation. After 1 year, she was diagnosed with portal vein thrombosis while she was on rivaroxaban. As a result, the woman’s treatment with rivaroxaban was replaced by warfarin. Because of the persistent hypoxaemia despite the optimal treatment of her heart failure and the coiling of the shunt, a decision was made to insert a stent into the superior vena cava to relieve the obstruction. The rationale was that stenting the superior vena cava would result in collapse of the systemic-to-pulmonary venous shunts. An inferior vena cava cavogram was done to assess the port for extracorporeal membrane oxygenation if needed. It showed complete obstruction of the infrahepatic part of the inferior vena cava obstruction with extensive collateral vessels. The procedure was deferred because of the presence of complete inferior vena cava obstruction. She was discharged on home oxygen with requirements of 1–2 L/min and warfarin. She was under close follow-up. Ahmed AOE, et al. Complete Superior and Inferior Vena Cava Obstruction Associated with Systemic-to
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