I have a 41year old lady, smoked history of OCP induced cerebral venous clot years ago, 3 miscarriages, normal subsequent pregnancy on lovenox now years later with LLE pain and numbness, reduced pulses. CTA showed aortic thrombus, emboli in LLE. Had thrombolysis at time of angiogram that confirmed aortic thrombus with clinical improvement. Anti cardiolipin and B2M negative, LAC pending. She’s on hep drip and I started asa and statin. Gyn recommended to leave Morena in place (for PCOS). Where do I go from here? Update speaks about distinguishing between thromboembolism va atheroembolus which I’m still not clear on how to do. Vascular surgeon not very helpful. Should she get asa alone, asa and plavix or asa and Coumadin? How long is the heparin needed?
I would suggest getting an echocardiogram to look for a cardiac source of embolus just to be safe, but it is most likely that the thrombus started in the aorta as a result of plaque rupture then embolized to the LLE. Treatment will depend on the LAC testing. If she has evidence of antiphospholipids then she would need indefinite anticoagulation and warfarin would be the best choice. If LAC is negative and there is no cardiac source of thrombus then would continue asa/plavix for a minimum of three months in addition of statin and lifestyle modifications (weight loss, smoking cessation ect...). After three months if she has improvement in PAD on imaging (ABI or CT arteriogram) then could consider dropping back to asa alone. It would probably also be helpful to have her establish care with cardiology to help manage hyperlipidemia if she has not already done so.