Thrombotic Risk after a Major Bleeding During Anticoagulation: A Clinical Case

We report on a 81-year-old female admitted to the emergency department for the occurrence of abdominal pain after a minor trauma. She was on treatment with warfarin for atrial fibrillation. The abdominal computed tomography (CT) angiography revealed a retroperitoneal hematoma (RH) of the left iliopsoas muscle with no evidence of active bleeding. The international normalized ratio exceeded the upper recommended anticoagulation limit. Prothrombin complex concentrates (PCCs) were used for anticoagulation reversal. Two days later, the patient presented acute dyspnea and a pulmonary CT angiography showed an embolus in the right pulmonary artery. Enoxaparin was started. Thoracic symptoms improved and a second abdominal CT angiography revealed a reduction in RH. Apixaban was started from day 11. No further bleedings occurred and clinical conditions improved. Anticoagulation reversal with PCCs rapidly restores hemostasis, but, on the other side, the thrombotic risk due to their procoagulant effect should be considered.