Accidente cerebrovascular y embolia pulmonar en el posoperatorio temprano de una fleboextracción. Reporte de caso

Stroke and pulmonary embolism in the early postoperative period following varicose vein surgery: A case report

Resumen

Introducción. El tromboembolismo venoso (TEV) representa una complicación postoperatoria grave que puede evitarse con una profilaxis adecuada. Su incidencia reportada tras cirugía vascular mayor oscila entre 1% y >10%. Por su parte, el accidente cerebrovascular (ACV) perioperatorio es una complicación importante asociada con morbimortalidad a largo plazo.

Presentación del caso. Mujer de 65 años, previamente sana, quien fue sometida a una fleboextracción bilateral bajo anestesia conductiva y dada de alta el mismo día con indicación de uso de vendajes, deambulación temprana y tromboprofilaxis con enoxaparina 40mg, pero que al despertar al día siguiente presentó disartria, hemiplejia derecha y desviación de la comisura labial. Se diagnosticó un ACV isquémico extenso que afectó las arterias cerebrales anterior y media izquierdas, por lo que se le realizó una trombectomía con un buen resultado. Durante la hospitalización, se diagnosticó hipertensión arterial de novo y un forámen oval permeable (FOP) con paso moderado de burbujas; no se documentó trombosis venosa profunda. Cinco días después desarrolló embolia pulmonar aguda, por lo que se inició manejo con anticoagulación, y a los 18 días se realizó cierre percutáneo del FOP. A los 6 meses había logrado una recuperación clínica casi completa, sin presentación de nuevos eventos tromboembólicos.

Conclusión. El presente caso destaca la importancia de una adecuada evaluación de los factores trombóticos, incluso en cirugías menores, y refuerza el papel del cierre del FOP en la prevención de ACV recurrentes.

Abstract

Introduction: Venous thromboembolism (VTE) is a serious postoperative complication that can be prevented with adequate prophylaxis. Its reported incidence after major vascular surgery ranges from 1% to >10%. Perioperative stroke is an important complication associated with long-term morbidity and mortality.

Case presentation: A previously healthy 65-year-old woman underwent bilateral varicose vein surgery under conductive anesthesia and was discharged the same day with indication to use bandages, early ambulation, and thromboprophylaxis with enoxaparin 40 mg. However, upon waking up the next day, she presented dysarthria, right hemiplegia, and deviation of the labial commissure. An extensive ischemic stroke affecting the left anterior and middle cerebral arteries was diagnosed, so thrombectomy was performed, achieving a good outcome. During hospitalization, de novo arterial hypertension and a patent foramen ovale (PFO) with moderate passage of bubbles were diagnosed; no deep vein thrombosis was documented. Five days later, she developed an acute pulmonary embolism, which prompted management with anticoagulation. Percutaneous closure of the PFO was performed 18 days following this event, and after 6 months, she was almost completely recovered, with no new thromboembolic events observed.

Conclusion: This case highlights the importance of proper assessment of thrombotic factors, even during minor surgeries, and reinforces the role of PFO closure in prevention of recurrent strokes.

https://doi.org/10.15446/cr.v11.119501

Stroke and pulmonary embolism in the early postoperative period following varicose vein surgery: case report

Keywords: Pulmonary Embolism; Ischemic Stroke; Foramen Ovale, Patent

Palabras clave: Embolia Pulmonar; Accidente Cerebrovascular Isquémico; Foramen Oval Permeable

Sofia Barrientos-Villegas

Miguel Navarro-Zuluaga

Universidad CES - Faculty of Medicine - General Surgery Seedbed of the Universidad CES (SCIRCES) - Medellín - Colombia

Martha Ofelia Correa-Posada

John Fernando García-Velez

Víavascular, Centro de Enfermedades Vasculares - Department of Angiology - Medellín - Colombia

Corresponding author

Sofia Barrientos-Villegas. Semillero de Cirugía General de la Universidad CES (SCIRCES), Facultad de Medicina, Universidad CES. Medellín. Colombia. E-mail: sofia.btosv@hotmail.com

Received: 25/03/2025 Accepted: 18/11/2025

Introduction

Venous thromboembolism (VTE) occurs when a blood clot forms in a vein. It can be classified into two types: pulmonary embolism (PE) and deep vein thrombosis (DVT) (1-3). VTE is the third most common cardiovascular diagnosis after heart attack and stroke, affecting between 300 000 and 600 000 individuals every year, according to the American Heart Association (4). It is also a serious postoperative complication that can be prevented with adequate prophylaxis (5). Its incidence in surgical patients has been reported to be 1.45% (0.54% of PE and 1.02% of DVT) (6), but it ranges from 1% to >10% following major vascular surgery (7).

In turn, perioperative stroke, defined as a cerebrovascular accident occurring during surgery or within 30 days after surgery (8), is an important postoperative complication associated with long-term morbidity and mortality. Its incidence ranges from 0.2% to 9.7% depending on the type of surgery performed and the risk factors of the patient (9). Risk factors for stroke include high blood pressure (HBP) and patent foramen ovale (PFO). HBP accounts for 32–50% of strokes, and its impact is evident in the fact that a 7.5mmHg increase in diastolic blood pressure is associated with up to a 46% increase in stroke risk (10). Likewise, several studies have reported an association between PFO and cryptogenic stroke (OR=2.9), especially in young adults, which may be related to three mechanisms: paradoxical embolism, in situ thrombosis, and dysrhythmia (11).

Thromboprophylaxis, which uses antithrombotic drugs and mechanical methods to promote venous drainage of the legs, is the most effective way to reduce morbidity and mortality in surgical patients. While evidence supports its use, it remains underutilized because surgeons often consider that the risk of VTE is not high enough to justify the potential bleeding complications resulting from anticoagulant use (12). In patients undergoing general, urological, gastrointestinal, bariatric, gynecological, vascular, or plastic surgery, prophylaxis is defined based on an assessment of thrombotic risk (Caprini score) and hemorrhagic risk, lasting 5-10 days or until the patient recovers mobility. In cases with a high risk of bleeding, the use of mechanical prophylaxis instead of pharmacological agents should be considered until the risk is reduced and anticoagulants can be prescribed (13).

The Caprini score is a tool used to assess the risk of developing VTD. It has been used both in patients undergoing surgery and hospitalized patients with risk factors (10), and it evaluates aspects such as body mass index; surgery duration; diagnosis or history of malignancy; family and personal history of VTE or thrombophilia; age; confinement to bed; smoking; chemotherapy treatment; diabetes; transfusion requirements; among others (14).

Patients undergoing major vascular surgery are particularly prone to develop VTE; however, early initiation of thromboprophylaxis is associated with a reduced risk of this complication. Furthermore, post-discharge VTE rates could reach thresholds that warrant thromboprophylaxis. In this regard, it has been demonstrated that the use of low molecular weight heparin (LMWH) reduces the risk of VTE in high-risk patients without increasing the risk of bleeding (3), but in low- or intermediate-risk cases, the decision to use it must be made on an individual basis, taking into account the risk of postoperative bleeding.

The following is the case of a patient who developed early VTE with pulmonary and cerebral involvement after undergoing varicose vein ligation and stripping. This case highlights the importance of considering paradoxical embolic causes in patients without relevant cardiovascular risk factors during the preoperative period before performing surgical procedures associated with an increased risk of VTE. It also strengthens the association between perioperative stroke and PFO, raising questions about preoperative thromboembolic risk assessment and highlighting the need to design and implement more effective prophylaxis strategies.

Case presentation

A 65-year-old mixed-race female patient, a housewife, with obesity, dyslipidemia, and chronic venous insufficiency, and no relevant family, medical, or surgical history, presented to the vascular surgery service of a secondary care institution in Medellín, Colombia, in March 2016 with lower-limb edema and fatigue. Her treatment included compression stockings and general recommendations such as skin care, leg elevation, regular exercise, and avoidance of prolonged standing or sitting.

In December 2023, she presented to the vascular surgery service of the same institution again due to varicose veins in the lower limbs (CEAP C2 classification) that did not involve the saphenous trunks, but caused fatigue, edema, and a feeling of heaviness. During this examination, a duplex ultrasound of the lower limbs was performed, showing chronic venous insufficiency of the great saphenous vein and its accessory veins in both legs, with the lesser saphenous vein and deep venous system within normal limits. Given the findings, bilateral ligation and stripping under local anesthesia was indicated, together with a recommendation to lose weight before the procedure.

On preoperative physical examination, the patient was in good general condition, with normal pulmonary evaluation and no cardiac murmurs. Varicose veins were observed in the limbs; however, arterial pulses were palpable and no other pathological findings were identified. Routine preoperative paraclinical tests (blood count, coagulation times, and electrocardiogram) were within normal limits.

The procedure was successfully performed on May 30, 2024, at the same institution and lasted approximately 40 minutes. The patient was discharged the same day with instructions to use multilayer bandaging and to initiate early ambulation and thromboprophylaxis 12 hours postoperatively with enoxaparin 40 mg every 24 hours for 5 days. When the patient woke up the day after the surgery, however, she presented dysarthria, right hemiplegia, and deviation of the lip commissure, so she was taken by her relatives to the emergency department of the same institution.

Physical examination on admission revealed hemodynamic stability, a National Institutes of Health Stroke Scale score of 18, right hemiparesis, a Daniels and Worthingham Manual Muscle Test score of 3 in the right upper and lower limbs, and dysarthria. A simple CT scan of the skull showed a stroke of the left anterior cerebral artery (ACA) and left middle cerebral artery (MCA), resulting in an ASPECTS score of 5 (Figure 1), while CT angiography showed atheromatosis in the M1 and M2 segments on the left side, with no evident signs of bleeding (Figure 2). Given the findings, the patient was diagnosed with a wake-up ischemic stroke and, on the same day of admission, percutaneous thrombectomy with recanalization was performed without complications.

Figure 1. Simple CT scan of the skull on admission.

Source: Image obtained while conducting the study.

Figure 2. CT angiography of the skull.

Source: Image obtained while conducting the study.

After surgery, the patient was transferred to the intensive care unit for monitoring and, on the second day of admission, the stroke was classified in accordance with the TOAST (Thrombolysis in Acute Cerebral Thromboembolism) system, with the cause being identified as new-onset hypertension. The following day, a CT angiography of the chest showed acute central, lobar, and segmental PE with no signs of overload (Figure 3).

Figure 3. CT angiography of the thorax.

Source: Image obtained while conducting the study.

Four days after admission, a contrast-enhanced transesophageal echocardiogram was performed, revealing a PFO with moderate passage of bubbles into the left heart chambers. The following day, a follow-up cranial CT scan showed an MCA infarction without hemorrhage (Figure 4). According to the Risk of Paradoxical Embolism (RoPE) score, in which a score of 5 was obtained, the likelihood of PFO as the cause of the stroke was classified as moderate.

Figure 4. Follow-up simple CT scan of the skull.

Source: Image obtained while conducting the study.

Due to the high risk of PE and the extensive damage caused by the stroke, apixaban 5 mg every 12 hours was initiated on the day of admission to the emergency department, followed by percutaneous PFO closure with an Amplatzer occluder device 18 days later. Finally, 4 days after this procedure, the patient was discharged with indications for management with apixaban 5 mg every 12 hours for 3 months, clopidogrel 75 mg every 24 hours for 3 months, and multidisciplinary rehabilitation (physical therapy, speech therapy, and occupational therapy).

At the six-month follow-up, the patient, who remained on anticoagulant therapy, showed a favorable progress but continued to have sequelae, including hemiparesis and mild motor aphasia, with no new thrombotic events.

Discussion

The case herein illustrates the complexity of the perioperative management of patients undergoing varicose vein surgery, particularly when selecting the appropriate approach and deciding on the indications for thromboprophylaxis.

Some of the key aspects of this case include adherence to current thromboprophylaxis recommendations through the use of mechanical methods and pharmacological therapy. However, one limitation in the management of this patient was the lack of more specific preoperative tools to assess the risk of paradoxical embolism. In this regard, it should be noted that the cause of stroke remains unidentified with routine diagnostic testing in approximately 40% of patients (15). Also. in our case, the simultaneous occurrence of ischemic stroke and acute PE in the early postoperative period is noteworthy, as this may be related to the fact that the patient presented with several risk factors for stroke, such as PFO, new-onset hypertension, and obesity (10,11).

As a consequence of reduced mobility after surgery, the likelihood of developing a blood clot and, consequently, postoperative VTE is higher during the first 3 months but decreases over time (16). It has been reported that the incidence of symptomatic VTE within the first postoperative month in patients treated for abdominal or pelvic cancer or after bariatric surgery is approximately 2%, but this has not been adequately documented in patients who do not have cancer (17). Concerning the cumulative risk of VTE within the first 4 weeks (28 days) after surgery, Singh et al. (18) reported that 47.1% of VTE events occurred in the first week, 26.9% in the second week, 15.8% in the third week, and 10.1% in the fourth week after surgery.

Thromboprophylaxis for varicose vein surgery continues to be a matter of discussion because, although the use of LMWH is recommended in patients with risk factors, its benefit in patients at intermediate and low risk has not been clearly understood, as this type of surgery can cause hematomas that may be aggravated by anticoagulation (3,19). In the present case, the patient was started on enoxaparin 40mg 12 hours after the end of the procedure, in accordance with neuraxial anesthesia recommendations, which support the safe administration of LMWH thromboprophylaxis as early as 4 hours after surgery (20).

PFO is a congenital cardiac anomaly with a reported prevalence of 14-35% in autopsy series (21). The presence of PFO in the reported patient may be associated with the occurrence of postoperative stroke, given that this defect has been shown to significantly increase the likelihood of stroke across all surgical specialties evaluated (9). The most common pathophysiological mechanism by which PFO triggers stroke is paradoxical embolism, whereby the defect allows venous emboli to bypass the pulmonary circulation, enter the arterial system, and reach the cerebral circulation (11). In the present case, early detection of PE could support the hypothesis of a paradoxical embolic event as the possible cause of the stroke, considering that the presence of new-onset hypertension and PFO with significant bubble passage may have facilitated the paradoxical embolic event (22).

Although the Caprini score is one of the most widely used tools to assess the risk of perioperative VTE, its applicability in the field of vascular surgery is questionable because it has not been validated in patients undergoing vascular surgery (7). Moreover, it does not incorporate specific factors such as the presence of PFO. In our case, the risk was calculated using this instrument, resulting in a score of 4, which indicates a low risk (7).

VTE is one of the main preventable causes of death in the postoperative period, so it is essential to assess the risk of thromboembolic events in the preoperative period by using risk scores to define the best thromboprophylaxis strategy (23). However, it should be kept in mind that there is no consensus on the duration of thromboprophylaxis after vein surgery, which can lead to uncertainty in patients who do not exhibit obvious risk factors. It is also worth mentioning that the incidence of perioperative stroke in patients undergoing minor vascular surgery is extremely low, with reported rates of 0.1% (24), which shows how difficult it can be to predict this type of events and complications.

In view of the above, this case raises the hypothesis that the combination of predisposing factors (new-onset arterial hypertension, obesity, chronic venous insufficiency, and PFO) could have provided a favorable environment for the development of paradoxical embolism in the context of early post-surgical VTE. Nevertheless, further studies are needed to analyze this hypothesis in depth, to identify different preventive strategies in patients undergoing varicose vein surgery, and to establish the risk factors for cryptogenic stroke, highlighting the need for individualization of thrombotic risk assessment in varicose vein surgery. Furthermore, it stresses the importance of the early detection of factors that may lead to a prothrombotic environment, such as PFO, in patients who experience unexplained thromboembolic events in the perioperative period.

Conclusion

Thromboembolic events continue to be challenging in the postoperative period, even after minor surgeries, as they put patients’ lives at risk. The origin of complications such as early embolic stroke has not yet been fully elucidated, and the implementation of preventive measures recommended in the literature remains insufficient to completely prevent these events. Therefore, more studies are needed to develop more effective protocols and to achieve a lower risk of occurrence of these events in the perioperative period.

Ethical considerations

The patient’s informed consent was obtained for the publication of this case report. The information herein was anonymized to protect their identity. This report follows the ethical principles established in the Declaration of Helsinki (25) and the applicable national regulations.

Conflicts of interest

None stated by the authors.

Funding

None stated by the authors.

Acknowledgments

None stated by the authors.

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