(1522) Obstructive Shock Secondary to Clot-in-Transit in a Young Trans-Male Patient

Introduction: Clot in transit (CIT), or right heart thrombo-embolus, is an uncommon, high-mortality entity with an incidence of up to 18% in patients with pulmonary embolism (PE). As with PE, hemodynamic instability and/or right ventricular dysfunction (RVD) is central to risk stratification. We present a case of a trans-male patient who underwent recent surgery and developed obstructive shock due to CIT.

Description: A 32-year-old trans-male presented with acute on chronic left leg pain and swelling. They had a recent prolonged hospitalization for abdominal trauma from assault requiring colectomy. Vitals were significant for hypotension, tachycardia, and mild hypoxia. Troponin and BNP were negative, as were blood cultures. They remained hypotensive despite fluids, requiring vasopressors. Bilateral lower extremity ultrasound identified an occlusive thrombus extending from the left common iliac vein to the common femoral vein. CTA of the chest identified small bilateral PE. Echocardiogram identified a CIT located within the right atrium, prolapsing into the right ventricle without RVD. The patient was stratified as high-risk given hemodynamic instability attributed to obstruction of venous return secondary to the space-occupying right intra-atrial mass. The patient was started on IV heparin and underwent catheter directed thrombectomy per interventional radiology. With use of the Inari clot retrieval device, a large chronic-appearing thrombus was successfully extracted from the right atrium. The patient's obstructive shock improved and pressors discontinued. The same device was used for thrombectomy of the left lower extremity thrombi. The patient was seen by hematology and discharged home on Eliquis.

Discussion: There are no clear guidelines for treatment of CIT, thus we extrapolate from the recommended treatment options for the varying severities of pulmonary embolism from systemic anticoagulation for low to intermediate risk PE to thrombolysis, mechanical suction thrombectomy or catheter directed thrombolysis for intermediate to high-risk PE. Newer techniques afford the patient the benefit of thrombolysis with reduced bleeding. Studies are lacking on the true thrombotic risks in transgender medicine and we will continue to learn more as these individuals become more prevalent and seek medical care.