Rivaroxaban-induced chest wall spontaneous expanding hematoma

Chest wall hematoma after central venous hemodialysis catheter insertion

There were few case reports discuss about iatrogenic chest wall hematoma. Although it is rare life threatening, it still can result in significant morbidity. A 68-year-old woman with histories of end-stage renal disease under regular hemodialysis and congestive heart failure was sent to our emergency department because of progression of ecchymosis over the anterior chest wall a few hours after hemodialysis. The right subclavian hemodialysis catheter was inserted for hemodialysis on the same day. She did not have a history of bleeding disorders and was not taking any antiplatelet or anticoagulant agents. Additionally, she had no recent trauma episodes. Physical examination revealed a large ecchymosis over the anterior right chest wall with swelling and tenderness. Blood examination showed no specific finding. Contrast-enhanced computed tomography of the chest revealed a hyperdense lesion with extravasation over the right chest wall, suggesting the presence of a hematoma with active bleeding. Local compression was applied. However, hematoma expansion was still noted. Therefore, we consulted a thoracic surgeon concerning surgical intervention. During the operation, active bleeding of the intramuscular arterial branch of the right pectoralis major was encountered. After surgical repair, no more bleeding was noted. It is important to confirm the possible cause of chest wall hematoma. Treating the underlying disease and discontinuing anticoagulation and antiplatelet agents should be considered. For iatrogenic chest wall hematoma, bleeding control should be the priority. Contrast-enhanced computed tomography could be arranged if there are no contraindications.

Incomplete Resolution of Deep Vein Thromboses during Rivaroxaban Therapy

We present the case of a patient with a deep vein thrombosis (DVT) who failed rivaroxaban therapy. Our patient initially presented with left lower extremity edema, erythema, and pain. He was subsequently started on rivaroxaban therapy for a combined treatment period of 12 months, during and after which he persisted to have evidence of a DVT. The patient's prescribed drug regimen was changed from rivaroxaban to warfarin, which demonstrated a rapid resolution of the DVTs as determined by ultrasound assessment of our patient's lower extremity veins. Rivaroxaban, a factor Xa inhibitor, is a well-known oral anticoagulant that is used for a variety of indications and has become a mainstay in the treatment of deep vein thrombosis. With the introduction and emergence of this medication in the clinic, postmarketing reports of efficacy or lack thereof are important to review. In conclusion, we anticipate that it is likely that there are other patients with DVTs who may not respond to rivaroxaban and for whom alternative anticoagulation therapies should be explored.