Scrotal variceal bleeding during rivaroxaban therapy as alarming sign in senescent patients: A clinical case

Background. The past decade has witnessed the advent of direct oral anticoagulants (DOACs) into clinical practice for the prevention and treatment of venous thromboembolism, as well as stroke prevention in atrial fibrillation (AF) patients. A serious complication of anticoagulant treatment is bleeding. Randomised controlled trials have shown that the risk of already developed bleeding does not reduce upon a DOAC replacement. In such cases, the bleeding cause diagnosis and elimination are recommended instead of a anticoagulant replacement. An anticoagulant treatment can only be resumed once the elimination is completed.Clinical Case Description. Patient K., 81 yo, was emergently admitted to a cardiology ward of the Rostov Regional Clinical Hospital with a clinical picture of bilateral pulmonary embolism of small arterial branches confirmed in multislice computed angiopulmonography. Apart from venous embolism, persistent atrial fibrillation was detected as an additional indication for DOAC treatment. A CHA2DS2-VASc risk of thrombosis was 6, HAS-BLED risk of bleeding — 2. Glomerular filtration rate at bleeding was 90 mL/min/1.73 m2. The patient was prescribed rivaroxaban at 20 mg daily. Past 2 years and 3 months, rivaroxaban has been withdrawn due to bleeding developing from scrotal veins. An urologist examination revealed a bilateral spermatic cord veins dilation. A Valsalva test revealed persistent retrograde veinous blood flow. Varicocele detected on both sides.The patient underwent venous occlusion of left internal spermatic vein following an Ivanissevich procedure. The cause of bleeding was eliminated. The patient resumed rivaroxaban 1 week since the operation.Conclusion. The case describes a rare cause of bleeding that has been established at a continued new DOAC therapy.