How long would you anticoagulate a patient with recurrent VTE who has ongoing risk factors for intracranial bleeding?

What would be your preferred anticoagulation agent? Has a history of intracranial hemorrhages in the absence of anticoagulation due to abnormal anatomy (cavernous hemangiomas), although no recent bleeding. Initial VTE was an unprovoked subsegmental PE found 3 months prior that was not treated due to bleeding risk. Now with a provoked large saddle PE after major lung surgery, with a clot remaining despite thrombectomy.

1 Answer

Mednet MemberInvited Expert

Hematology · University of Rochester School of Medicine and Dentistry

Answered on · Updated on

In general, my preferred agent outside of the inpatient setting in patients with a risk of intracranial bleeding is LMWH. In the inpatient setting, utilizing a bivalirudin or heparin gtt is most appropriate. I would monitor carefully, including potentially imaging 24 hours after the therapeutic anticoagulation, to determine that there is no evidence of ICH.

In the setting of the only unprovoked clot being a subsegmental PE, this may not warrant indefinite anticoagulation. The large thrombus requiring thrombectomy could consider doing six weeks of anticoagulation and reimaging, and if no residual clot is stopping at the six-week mark could be reasonable - although the patient will be at elevated risk of recurrence versus continuing for 3 to ...

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