Background/Objective: Current guidelines recommend a 50% dose reduction of apixaban for patients receiving strong CYP3A4/P-glycoprotein (P-gp) inhibitors regardless of body habitus. However, evidence supporting this dose adjustment in patients with severe obesity (BMI >40 kg/m[2]) is limited. This report describes the use of dose-reduced apixaban for the treatment of venous thromboembolism in a patient with a BMI >50 kg/m[2] receiving a strong CYP3A4/P-gp inhibitor. Summary: A 38-year-old female with a BMI of 81.71 kg/m[2] and a history of HIV on a cobicistat-containing antiretroviral regimen was diagnosed with a left femoral deep vein thromboembolism. She was initially treated with warfarin and enoxaparin bridge therapy but was transitioned to apixaban prior to discharge. Apixaban was initiated at a 50% dose reduction due to the concomitant use of cobicistat, a strong CYP3A4/P-gp inhibitor. The patient successfully completed therapy without recurrence of thromboembolism or bleeding complications. Conclusion: This case demonstrates the successful use of dose-reduced apixaban in a patient with a BMI >50 kg/m[2] receiving a CYP3A4/P-gp inhibitor for the treatment of venous thromboembolism and adds to available literature on apixaban dosing in patients with obesity.

Acute limb ischemia is a time-sensitive vascular emergency, but in older patients with active cancer and multimorbidity, the threatened limb can become a diagnostic attractor: a correct specialized diagnosis that narrows attention before whole-patient physiology is integrated. We report an 81-year-old man with metastatic cecal adenocarcinoma receiving folinic acid, fluorouracil, and oxaliplatin (FOLFOX) who presented on day one with three days of progressive left lower limb claudication, coldness, discoloration, absent pulses, preserved motor and sensory function, and no rest pain. The presentation was clinically compatible with Rutherford I-IIa acute limb ischemia; bedside Doppler signals were not documented, precluding a definitive retrospective distinction between these categories. Concurrent findings included new atrial fibrillation, basal crackles, peripheral edema, markedly elevated N-terminal pro-B-type natriuretic peptide and troponin, bilateral pleural effusions, and radiological concern for low cardiac output. Computed tomography angiography (CTA) showed severe distal superficial femoral artery stenosis, long popliteal occlusion, slow distal flow, and limited runoff, favoring an acute-on-chronic ischemic process. On day two, a 6 mm x 60 mm covered stent was placed across the distal superficial femoral artery lesion. The treated lesion had a satisfactory technical result, but distal runoff remained severely compromised. Therapeutic anticoagulation initiated on day one was not maintained; discharge treatment on day three included prophylactic-dose enoxaparin and aspirin, with no rationale for the change documented in the available record. He returned on day five with recurrent coldness and toe necrosis despite normal lactate. No repeat vascular imaging was available to define the mechanism. Care became palliative on day 13, and he died on day 58. This case illustrates that a correct vascular diagnosis should not terminate integrative emergency reasoning. We propose that a vascular-plus-physiology cross-check may help preserve attention to systemic physiology and goals of care, but it is an educational framework rather than a validated clinical algorithm.

Graves' disease is a common cause of autoimmune hyperthyroidism and is frequently associated with cardiovascular manifestations, including sinus tachycardia, atrial fibrillation and high-output heart failure. Severe left ventricular (LV) systolic dysfunction complicated by LV thrombus is an uncommon presentation. Recognition may be challenging when concurrent illness and antithyroid treatment complicate the interpretation of thyroid function tests. A 27-year-old woman with Graves' disease diagnosed in 2021 presented in March 2025 with progressive dyspnoea, orthopnoea, profound lethargy, jaundice and generalised oedema. Following relapse in September 2024, carbimazole had been recommenced, but adherence was suboptimal, and heart failure symptoms had developed over several months. Examination revealed sinus tachycardia, diffuse goitre, exophthalmos, hepatomegaly and marked anasarca. Community-acquired pneumonia was also diagnosed. Admission free thyroxine was 8.5 pmol/L (reference range: 8.9-17.3), thyroid-stimulating hormone (TSH) was 0.48 mIU/L (0.30-4.40), and free triiodothyronine was unavailable. This biochemical pattern was interpreted in the clinical context as consistent with non-thyroidal illness. N-terminal pro-B-type natriuretic peptide (NT-proBNP) was elevated at 9,326 ng/L. Electrocardiography demonstrated sinus tachycardia, and transthoracic echocardiography showed LV dilatation with severe global systolic dysfunction and an estimated LV ejection fraction (LVEF) of approximately 10%. Contrast-enhanced computed tomography demonstrated an LV apical thrombus and hepatic congestion. Graves' disease-associated myocardial dysfunction was considered an important contributor; however, tachycardia-mediated dysfunction, myocarditis and critical illness-related myocardial dysfunction remained potential contributing causes. Management included adjustment of carbimazole, diuresis, bisoprolol, valsartan, spironolactone and dapagliflozin, alongside treatment of pneumonia. Therapeutic anticoagulation was initiated with enoxaparin, followed by intravenous unfractionated heparin and bridging to warfarin. Clinical improvement was accompanied by recovery of LVEF to 36% during admission, approximately 40% in June 2025 and 52%-54% on echocardiography in September 2025. Cardiac magnetic resonance imaging during the same time confirmed normal biventricular size and systolic function, with an LVEF of 54% and no residual intracardiac thrombus. A small area of nonspecific non-infarct-pattern fibrosis could represent previous myocarditis. Definitive thyroidectomy was planned. This case highlights severe but reversible LV systolic dysfunction with apical thrombus in a young woman with relapsed Graves' disease and suboptimal treatment adherence. Although the clinical course suggests a thyroid-related contribution, the myocardial dysfunction may have been multifactorial. The reduction in thyroid-stimulating immunoglobulins (TSIs) alongside cardiac recovery represents a temporal association and does not establish causation. Careful clinical assessment and cardiac imaging are essential to recognising significant cardiac involvement when thyroid biochemistry is complicated by concurrent illness.

Superior ophthalmic vein thrombosis (SOVT) is a rare but potentially life-threatening condition associated with significant risk of vision loss. It may arise from infectious or inflammatory orbital diseases, trauma, neoplasms, or hypercoagulable states, with Staphylococcus aureus being a common pathogen in orbital cellulitis. We report the case of a 23-year-old male who presented with periorbital swelling, upper lip edema, and pustular lesions. During evaluation in the emergency department, he developed sudden-onset horizontal diplopia and left eye esotropia. Magnetic resonance imaging (MRI) of the brain revealed thrombosis of the left superior ophthalmic vein. Empiric therapy with ceftriaxone, vancomycin, metronidazole, and enoxaparin was initiated. Wound and blood cultures later demonstrated heavy growth of methicillin-resistant Staphylococcus aureus (MRSA), prompting adjustment of antimicrobial therapy to meropenem and vancomycin. The patient subsequently improved and was discharged in stable condition. This case highlights the aggressive nature of MRSA infection and its potential to rapidly progress to orbital and intracranial complications such as SOVT. Early diagnosis, prompt imaging, targeted antimicrobial therapy, and timely intervention are essential to preserve vision and improve clinical outcomes.

Adventitial cystic disease (ACD) is a rare, nonatherosclerotic disorder caused by mucin-filled cysts within the vessel wall that produce luminal compression. Venous ACD is uncommon and may mimic deep vein thrombosis. A 24-year-old woman presented with right leg pain and swelling from a 2.8-cm common femoral vein cyst. The patient underwent cyst excision and bovine patch venoplasty but developed postoperative thrombosis from venoplasty-site stenosis and hematoma compression. Thrombectomy and angioplasty failed, requiring venous stenting. Pathology confirmed ACD. The patient recovered on enoxaparin and clopidogrel. This case emphasizes confirming durable venous outflow after cyst excision.

Thromboembolic disease (TED), including deep vein thrombosis (DVT) and pulmonary embolism (PE), remains a serious postoperative risk after total knee arthroplasty (TKA). Enhanced recovery after surgery (ERAS) protocols emphasize early mobilization, warranting reassessment of mechanical prophylaxis, such as compression therapy. This systematic review evaluates the benefits of compression therapy in preventing TED in TKA patients under ERAS protocols combined with pharmacological prophylaxis. A systematic review was conducted, analyzing seven studies comparing combined mechanical and pharmacological prophylaxis with pharmacological prophylaxis alone. Primary outcomes included DVT and PE incidence, compliance, adverse events, and efficacy. Seven studies were included in this systematic review, including 871 patients. Combined mechanical and pharmacological prophylaxis reduced DVT rates. Continuous enhanced circulation therapy (CECT) with enoxaparin lowered DVT from 19.5% to 6.6% (relative risk reduction (RRR) 66.2%, p=0.018), while intermittent pneumatic compression (IPC) with rivaroxaban reduced rates from 18.3% to 8.3% (RRR 54.5%, p<0.01). Pneumatic plantar compression (PPC) decreased DVT from 67% to 27% in unilateral and 52% to 28% in bilateral TKA (combined RRR 54.2%, p<0.001). Graduated compression stockings (GCS) with anticoagulation reduced DVT from 13.0% to 6.0% (RRR 53.8%, p=0.0872). IPC with nadroparin lowered DVT from 3.9% to 2.6% (RRR 33.3%, p=0.65). PE incidence remained minimal across studies. When combined with anticoagulants, mechanical prophylaxis may have an additional role in diminishing DVT incidence while alleviating postoperative swelling and pain. However, optimizing compliance, standardizing protocols, and tailoring thromboprophylaxis to patient-specific risks remain key challenges. Future research should refine mechanical and pharmacological strategies to enhance safety, efficacy, and recovery in TKA patients.