Multiple thrombotic sources and embolic events at arterial sites in a patient with protein-C deficiency

Protein-C deficiency causes a thrombophilic environment in circulation. Although venous thromboembolism is the most common presentation, arterial events are rare. A 45 year-old woman with protein-C deficiency presented with multiple thromboembolic events including bilateral renal infarct and inferior ST-elevation myocardial infarction 3-days after coronary angiography via femoral approach which were normal coronary arteries. Computed tomographic angiography and transesophageal echocardioraphy displayed multiple thrombi sources including left atrium, left subclavian artery, sinus valsalva and descending aorta. Unfractionated-heparin and tissue plasminogen activator infusion were given. Although regression in ST-segment elevation and chest pain, no reduction in sizes of left atrial and aortic thrombus was observed by imaging modality. The patient refused surgical removal of thrombi, then warfarin therapy was planned. In patients with congenital thrombophilia and history of thromboembolism, anticoagulant treatment should be carefully managed during percutaneous diagnostic and interventional treatments and they should be performed by radial approach without interruption of anticoagulants.