# A Case of Thromboembolic Cerebral Infarction Occurring Perioperatively in Acute Lower Limb Embolic Ischemia

## TL;DR

An elderly patient with atrial fibrillation and chronic kidney disease experienced multiple embolic events despite anticoagulation therapy, leading to a switch from direct Xa inhibitors to warfarin.

## Contribution

The case highlights the potential benefits of using warfarin over direct Xa inhibitors in high-risk perioperative embolism management.

## Key findings

- The patient developed acute lower limb embolic ischemia and cerebral embolism while on direct Xa inhibitors.
- Switching to warfarin prevented further embolic events for two years.
- Warfarin's adjustable dosing may be preferable in high-risk perioperative settings.

## Abstract

Recurrent embolic events are not unusual in patients with non-valvular atrial fibrillation, and management of anticoagulation in these patients can be particularly challenging. We report a case of a patient who experienced multiple embolic events in the lower extremities and cerebral circulation despite ongoing anticoagulant therapy for atrial fibrillation. The patient was an 88-year-old woman with chronic kidney disease Stage G3b who was taking oral steroids for rheumatoid arthritis. She was also taking a direct Xa inhibitor (edoxaban) for chronic atrial fibrillation, with a CHADS2 score of 2 (age ≥75 years, and presence of hypertension) and a high CHA2DS2-VASc score of 4 (2 points for age ≥75 years, 1 point for hypertension, and 1 point for female sex, for a total of 4 points). The patient had been admitted to another hospital for calculous cholangitis and experienced symptomatic improvement after stone extraction and endoscopic sphincterotomy. During treatment for cholangitis, the patient required fasting and temporary discontinuation of edoxaban for only one day. On the day after resuming the direct oral anticoagulant following a one‑day interruption, she developed acute lower limb embolic ischemia and was referred to us. The patient underwent thrombectomy for an occluded superficial femoral artery. Following the restoration of blood flow, she developed cerebral embolism perioperatively while taking a different direct Xa inhibitor (rivaroxaban). She was subsequently switched to warfarin, and no further embolism has occurred for two years. In high‑risk cases of embolism, the use of warfarin, which permits precise dose adjustment, as the anticoagulant in the relatively early postoperative period may be a reasonable consideration, although this approach remains subject to debate.