Major orthopedic procedures place patients at risk for Deep venous thrombosis (DVT) and venous thromboembolism (VTE), including pulmonary embolism (PE). Complications of DVT include postphlebitic syndrome or death from PE. Therefore, prophylaxis with anticoagulant medications, as well as the adjunctive use of mechanical devices, is essential. Deep venous thrombosis (DVT) involves a disorder of venous return caused by abnormal blood clotting in deep veins, often occurring in lower limbs due to limited mobility, prolonged bed rest, and the use of intraoperative tourniquets ^[1]. Virchow’s triad implicates three contributing factors in the formation of thrombosis: Venous stasis, vascular injury, and hypercoagulability with venous stasis being the most consequential. VTE includes DVT and PE ^[2]. When a thrombus formed of DVT is dislodged in the body, the embolus travels down the inferior vena cava (IVC) to the pulmonary artery through the blood flow, causing a serious complication like PE. Risk factors to develop VTE events include increased age and body mass index, comorbidity of diabetes mellitus, high American Society of Anesthesiologists score, surgery requiring intubation, immobility, and estrogen. Female sex, smoking, congestive heart failure, and cancer are commonly thought to be secondary risk factors. DVT is recognized sequelae of isolated lower extremity fractures, with a 10–40% incidence after isolated fractures of the tibia and distal bones of the lower extremity [3, 4]. Gao et al. ^[5] found that (28.65%) cases with tibiofibular fractures developed DVT, including popliteal vein thrombosis, accounting for 13.7% (14/102). Other studies ^[6] reported that the incidence was lower, about 2.86–11.5%. The current gold standard invasive diagnostic techniques are venography and pulmonary angiography. The non-invasive diagnostic test for DVT is venous compression ultrasonography with a sensitivity and specificity of 97% and 98%, respectively. Another safe and cost-effective way of evaluation is a D-dimer assay which is a very sensitive laboratory test, and a negative assay is useful in ruling out the presence of DVT and PE. There are currently two main types of prevention methods for VTE: Mechanical prophylaxis and chemical/pharmacological prophylaxis. Early post-operative ambulation helps in reducing the incidence of post-operative thromboembolism ^[7]. Mechanical prevention mainly includes compression stockings, external mechanical equipment, etc. which reduce the chance of DVT by reducing stasis in venous blood flow. The main drugs commonly used for pharmacological prophylaxis include heparin, factor Xa inhibitors, Vitamin K antagonists, direct coagulation inhibitors, and antiplatelets. Heparin analogs are unfractionated heparin (UFH) and low molecular weight heparin (LMWH). Factor Xa inhibitors include sodium fondaparinux and rivaroxaban. Vitamin K antagonists like warfarin [8, 9] should be started as soon as possible after the diagnosis of VTE, in combination with UFH, LMWH, or sulforaphane sodium. Direct thrombin inhibitors include dabigatran whereas antiplatelet agents are aspirin and clopidogrel. Tenecteplase, a fibrinolytic drug, is a recombinant tissue plasminogen activator which has been the drug of choice for intravenous (IV) thrombolysis. The inferior vena cava filter (IVCF) is an intravascular interceptor device that intercepts foreign bodies flowing through the IVC and prevents them from reaching the pulmonary artery and causing PE. However, the function of IVCF is to intercept thrombus and not to prevent thrombosis.

The case was treated at a corporate hospital, Navi Mumbai, India, in January 2024 and followed up to May 2024, approximately a span of 6 months. This case was of a 39-year-old female having a history of road traffic accidents, brought to ER with a right-sided compound Type 2 mid-shaft tibia fracture on January 25, 2024 (Fig. 1). There was a lacerated wound of 4 × 2 cm² with graze abrasions over the anterolateral aspect of the right upper leg.

She was taken for debridement of a wound with intramedullary nailing for tibial shaft fracture (closed, Static) immediately on January 26, 2024. A prophylactic dose of injection LMWH 0.4 was given subcutaneously post-operatively after 6 h and once daily later. Triple antimicrobials were given as a prophylaxis for wound infection. She was mobilized non-weight-bearing on the right lower limb for 2 days, but on the 3^rd day during physiotherapy and mobilization, she developed shortness of breath. She was evaluated clinically and her arterial blood gas analysis (ABGA)and chest X-ray were apparently normal. Her D-Dimer was found to be elevated >6.5. She was evaluated by a cardiologist and pulmonologist and investigations electrocardiogram (ECG), 2D echocardiogram (ECHO) and computed tomography pulmonary angiography (CTPA) were done. ECG was within normal parameters but 2D ECHO showed dilated right atrium (RA), and right ventricular (RV) with normal ejection fraction. CTPA showed saddle embolism at the junction of pulmonary artery division extending into B/L pulmonary arteries and into lobar, segmental arteries (Fig. 2). She was shifted to the intensive care unit (ICU) for monitoring and was decided upon two options for treating PE: First was to aspirate the thrombus with a catheter by doing an angiogram and second was to do IV thrombolysis with drugs. IV thrombolysis with injection tenecteplase 30 mg was given stat. In post-thrombolysis, there was no active bleeding or soakage from an operative wound or sutured lacerated wound. Later, she was started on an injection of LMWH 0.6 twice daily and the prothrombin time-international normalized ratio was monitored. After 2 days, the patient was shifted out from ICU and started on tab rivaroxaban 20 mg once daily.

Follow-up 2D ECHO showed normal RA, and RV with normal ejection fraction. A bilateral venous Doppler was done which showed DVT on the right lower limb (Fig. 3) and sluggish blood flow on the left lower limb. The patient was discharged after 1 week on February 06, 2024 with tab rivaroxaban 15 mg twice daily for 18 days. After 1 week of discharge, she complained of high-grade fever with persistent swelling over the right upper leg and was admitted again on February 13, 2024, on evaluation, she had a urinary infection, her urine was culture positive and started with antibiotics. She underwent bilateral lower limb venous Doppler which showed persistent thrombi. Later, she noticed bleeding PV, so the case was discussed with the cardiologist, tab rivaroxaban was stopped, and it was decided to put an IVCF to prevent further embolization. Accordingly, IVCF placement was done by the cardiologist team in CATH-LAB on February 22, 2024 (Fig. 4). In post-procedure, the patient was stable and discharged again without any oral anticoagulants.
After IVCF insertion, she was observed for any bleeding tendency (menstrual cycle) for 1 month. Tab rivaroxaban was started on March 26, 2024, and continued up to 16 May (3-month post-IVCF insertion). At 3-months postoperatively (April 2024), the fracture tibia was assessed radiologically and she started walking full weight bearing right lower limb without pain. This patient was treated by pharmacological agents, such as IV thrombolytic, IV anticoagulant, and oral anticoagulant. Finally, the mechanical agent- IVCF was used for persistent thrombi. The patient was followed up in orthopedics in April 2024, after 3 months of surgery (interlock nailing) which showed signs on fracture healing for shaft tibia fracture (Fig. 5). Patient was followed up in cardiology in May 2024, after 3 months of IVCF placement, for bilateral lower limb venous Doppler which showed no persistent thrombi.

Hence, the decision of IVCF removal was made at 3 months (Fig. 6). After assessing her bleeding in her menstrual cycle at the time of IVCF removal, we decided to continue tab rivaroxaban for further 3 months.

Lapidus et al. ^[10] reported that VTE events occurred in 2.2% of patients with internal fixation for tibial shaft fracture, and PE occurred in 0.6% resulted in fatal in all cases. In 2012, American college of chest physicians evidenced based clinical practice guidelines suggested no prophylaxis rather than pharmacologic thromboprophylaxis in patients with isolated lower-leg injures without history of VTE ^[4]. External mechanical devices should not be used in patients with lower limb trauma and compression stockings are contraindicated in patients with peripheral arterial disease and atherosclerosis. These methods do not increase the risk of bleeding compared to pharmacological prophylaxis ^[4]. Evidence suggests that these device use has been limited in the inpatient setting because of concerns with comfort and compliance ^[9]. LMWH decreases the risk of DVT by 50–60% and the risk of PE by approximately two-thirds ^[4]. The use of the anticoagulants can be accompanied by some negative effects. For example, heparin-induced thrombocytopenia may occur with the use of heparin ^[11], use of aspirin increases the risk of gastrointestinal bleeding ^[12] and gastric ulcers, and the use of various anticoagulants increases the risk of bleeding. One of the challenges in using pharmacologic agents is balancing benefits of anticoagulation and the risk of bleeding complications ^[13]. The impact of anticoagulation therapy on wound healing also makes orthopedic surgeons cautious about the use of anticoagulants post-operatively. Some surgeons therefore opt for prophylactic implantation of an IVCF to prevent PE and to avoid the risks associated with anticoagulation ^[14]. Considering aspiration of thrombus with a catheter, that is, catheter-directed thrombectomy (CDT), this procedure is performed emergently in phlegmasia cerulea dolens, where severe edema from venous obstruction threatens limb viability ^[15]. Urgent CDT is also indicated for IVC thrombosis, especially when patients are at risk of renal or hepatic vein involvement. Patients at high risk for bleeding may be more appropriately managed with aspiration thrombectomy techniques without the use of thrombolytic agents. Absolute contraindications to catheter-directed pharmacologic thrombolysis include cerebral infraction, neurological and eye procedures or head trauma within 3 months, and known intracranial lesion. Relative contraindications include major trauma, surgery, or obstetrical delivery within 10 days, uncontrolled hypertension, gastrointestinal bleeding within 3 months, pregnancy, infected venous thrombus, and bleeding diathesis or known severe allergy to anticoagulant, or thrombolytic agent. Since the patient had contraindication (major limb trauma), it was decided to consider IV thrombolysis over aspiration with CDT. With the presence of VTE events, IVCFs could be an indication for patients who have a high risk of bleeding under anticoagulation (as in our case), anticoagulant contraindication, recurrent PE despite anticoagulant treatment (failed treatment) ^[16] or patients with high-risk factors for acute VTE who are planned for pelvic or lower extremity surgery ^[17]. The placement of an IVCF could be indicated in the post-operative treatment of the fracture, because of residual DVT (floating thrombus) following the anticoagulation therapy (as in our case). Some other indications of IVCFs include use in high-risk burn or trauma patients, or in patients undergoing ilio-caval thrombolysis or pulmonary thrombectomy. When used in combination with anticoagulants or mechanical compression therapy in high-risk orthopedic patients, IVCFs are found to effectively prevent PE ^[18]. IVCF complications in descending order were filter migration/displacement, recurrent embolization, filter tilt, IVC perforation, and filter fracture ^[19]. Filter tilt is when the angle between the central axis of the filter and the longitudinal axis of the IVC exceeds 15°, slanted filters have a lower filtration capacity for smaller thrombi. Filter displacement is described as the filter being more than 10 mm away from the intended point, so the risk of renal vein embolism or renal failure increases. Filter migration to the heart and lungs, can lead to serious consequences. Vena cava perforation into structures surrounding the IVC wall, such as the aorta, psoas major, duodenum, and kidney. Filter fracture, according to Li et al., is caused by the IVC’s rhythmic expansion and contraction during the cardiac cycle. Recurrent thromboembolism is due to the adverse hemodynamic effects of the filter on the body after the interception of the thrombus by the IVCF, which slows the blood flow. Prolonged placement of IVCF affects the hemodynamics within the IVC and can lead to a higher incidence of DVT in patients with filters than in those without filters ^[20]. Most of the current literature and guidelines suggest that primary prophylaxis with an IVCF is not recommended for major surgery in patients without known VTE [4, 21]. These complications of IVCF make the risks of filter placement for the average patient undergoing orthopedic surgery higher relative to the benefits. In summary, it is recommended that IVCFs be withdrawn as soon as indications disappeared (between 29 and 54 days after placement) to avoid complications and obtain the maximum clinical benefit.

Clinical evaluation of patients is of utmost importance for detection of DVT-PE. Our patient only had a complaint of breathlessness on exertion and we immediately investigated the patient in a sequence of investigations- ECG, Chest X-ray, ABGA (baseline investigations) followed by D-Dimer. She was diagnosed with PE and confirmed by 2D ECHO and CTPA, and immediately treated by the cardiac team with thrombolytics and anticoagulants. In such conditions where a patient is on anticoagulants and develops bleeding tendencies (like bleeding PV in our case), insertion of IVCF is the best option for treatment and prophylaxis of a future VTE episode. Ideally, removal of the IVCF is done at 3 months when purpose is solved.

Clinical evaluation of our patient’s complaint of breathlessness on exertion was important for early diagnosis of DVT-PE and was followed by immediate treatment with thrombolytics and anticoagulants. When our patient on anticoagulant therapy, developed a bleeding tendency, it was advisable to stop this therapy and plan for insertion of IVCF for prophylaxis of VTE.