A Case of Deep Vein Thrombosis after Coronary Angiography in a Patient Using Antidepressants and Anxiolytics
A 50-year-old woman presented with frequent retrosternal chest tightness. She also had a ten-year history of anxiety disorder. She was admitted and underwent CAG through the femoral artery approach using a 4 Fr sheath. We did not use prophylactic anticoagulation during diagnostic CAG. CAG showed no significant stenosis of the coronary artery. The femoral sheath was removed 30 minutes after the CAG, and hemostasis was achieved by manual compression for 15 minutes. After the patient had taken bed rest for 16 hours, she complained of pain and swelling in the right calf. There was no chest pain, cough, dyspnea, or shortness of breath, and the patient was stable, with a temperature 36.3℃, blood pressure of 120/80 mmHg, pulse of 80 beats/min, respiration of 18 breaths/min, and room air oxygen saturation 99%. All extremity pulses were unremarkable and the lower limbs appeared to be of equal temperature. Laboratory tests gave a white blood cell count 7300/mm3 with 53.2% neutrophils, hemoglobin 11.3 g/dL, platelet count 304×103/mm3, sodium 141 mEq/L, potassium 4.5 mEq/L, blood urea nitrogen 15 mg/dL, and creatinine 0.8 mg/dL. The plasma D-dimer level was 1140.0 ng/mL (normal range <250.0 ng/mL). Electrocardiography showed a normal sinus rhythm without focal abnormalities. Echocardiography revealed normal systolic function with good regional wall motion without right ventricle dilation with tricuspid regurgitation and elevation of pulmonary artery pressure. We performed a lower extremity CT angiography and found a thrombus extending from the right infrapopliteal vein to the anterior and posterior tibia vein, without any hematoma or pseudoaneurysm (). Based on the above results, a diagnosis of DVT regarding the right lower extremity was made.\nThe patient was further evaluated for the risk factors of DVT. She was a hairdresser, a non-smoker, and premenopausal. She had no history of hormone replacement therapy, other substance abuse, surgery, trauma or chronic systemic problems. Her anxiety disorder had been treated for ten years with fluoxetine 20 mg, diazepam 2 mg, alprazolam 0.5 mg, and tofisopam 25 mg. Her condition had been stable and there had been no change of medicine for at least six months. There was no family history of DVT. An extensive laboratory work-up was performed in search of any underlying disorders predisposed to DVT. Protein C activity 102% (70-130%), free protein S antigen 60.0% (50-150%), antithrombin III activity 86% (80-120%), antiphospholipid IgM (-), antiphospholipid IgG (-), international normalized ratio 0.85, activated prothrombin time 24 seconds (23-38 seconds), and homocysteine levels, were all in the normal range. Factor V Leiden and prothrombin 20210A mutations were also ruled out. The patient was treated with low molecular weight heparin and warfarin. Following these treatments, her symptoms improved. The patient was discharged uneventfully after ten days of hospitalization. She continued the anticoagulant therapy with oral warfarin and at a follow-up of three months the presenting leg pain had resolved and no further complications were evident.