Do you have an Asymptomatic Surgical Patient with a Massive Venous Thromboembolism? Keep Calm, “don’t touch” and Start Aggressive Anticoagulation!

Here we present a case of a 49-year-old man affected by Pseudomyxoma peritonei who experienced extended venous thromboembolism (VTE) 15 days after cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC). Despite the large sizes of thrombi, the involvement of superior vena cava, right atrium and pulmonary artery, patient was asymptomatic and hemodynamically stable. He had just been subjected to a radical surgery so that we decided to avoid thromboembolectomy on cardio-pulmonary-bypass and to start anticoagulation (continuous intravenous infusion of unfractioned heparin to maintain the APTT in a range of 46-90 seconds). We monitored sonographically the intracardiac portion of the thrombus: we noticed change in shape and a progressive dimensionality reduction. These findings were confirmed by CT scan, which, on the 14th day of anticoagulant therapy, showed only small residues of the known thrombus. We switched anticoagulant therapy to low-molecular-weight heparins (LMWH) and the patient was moved to his surgical ward. Pre-demission CT scan showed no more evidence of VTE. We can conclude that medical treatment was the right choice because aggressive anticoagulant therapy allowed regression and disappearance of thrombus without any complication.