Figure 1

By counseling the cardiac surgery team, we decided that surgical thrombectomy would not benefit the patient. Therefore, the patient was transferred to the intensive care unit. After consulting with vascular surgery and cardiology teams, we started alteplase (100 mg continuous intravenous infusion over two hours) with caution. The patient went under close observation, including abdominopelvic sonography (for early detection of intraabdominal leakage or bleeding), echocardiography, neurologic examinations, and laboratory follow-ups. One hour after alteplase, her JP drain started to discharge blood (about 2 liters in the first 24 hours) along with bloody vaginal discharge, needing 3 bags of packed cells and 3 bags of fresh frozen plasma to be transfused. Although she initially was actively bleeding, it significantly decreased over the next four days. On Post-Operative Day (POD) 4, she became hemodynamically stable with a normal abdominal exam and tolerated the diet. Thereafter, we started therapeutic heparin (800 IU/hour continuous intravenous infusion) for three days. On the 7th POD, the bleeding stopped, and she was transferred to the surgery ward, where we switched from heparin to rivaroxaban (15 mg twice daily). Then, she was observed for a day and discharged from the hospital.

The medical team followed her after discharge until the submission of this paper (8 months). She experienced an uneventful post-operative period while losing 40 kg of her weight. On follow-ups, she developed iron deficiency anemia, which is being treated with intravenous iron supplements. Hematologic evaluations for thrombotic tendencies, including factor V Leiden, protein C, and protein S were all unremarkable.