ksmaКубанский научный медицинский вестникKuban Scientific Medical Bulletin1608-62282541-9544Kuban State Medical University10.25207/1608-6228-2022-29-3-89-102ksma-2865Research ArticleКЛИНИЧЕСКИЙ СЛУЧАЙCLINICAL CASEКровотечение из варикозно расширеннных вен мошонки на терапии ривароксабаном как индикатор проблемы у пожилого пациента: клинический случайScrotal variceal bleeding during rivaroxaban therapy as alarming sign in senescent patients: A clinical casehttps://orcid.org/0000-0002-3834-4699ЧепурненкоС. А.ChepurnenkoS. A.

Чепурненко Светлана Анатольевна — доктор медицинских наук, доцент кафедры общей врачебной практики (семейной медицины) (с курсами гериатрии и физиотерапии)

тел.: 8 (918) 507-28-93

пер. Нахичеванский, д. 19, г. Ростов-на-Дону, 344022 

ул. Благодатная, д. 170, г. Ростов-на-Дону, 344015

пер. Нахичеванский, д. 29, г. Ростов-на-Дону, 344022

Svetlana A. Chepurnenko — Dr. Sci. (Med.), Assoc. Prof., Chair of General Medical Practice (Family Medicine) with training in geriatrics and physiotherapy

tel.: 8 (918) 507-28-93

Nakhichevanskiy per., 19, Rostov-on-Don, 344022 

Blagodatnaya str., 170, Rostov-on-Don, 344015

Nakhichevanskiy per., 29, Rostov-on-Don, 344022

ch.svet2013@yandex.ruhttps://orcid.org/0000-0003-4441-1832ШавкутаГ. В.ShavkutaG. V.

Шавкута Галина Владимировна — доктор медицинских наук, профессор, заведующая кафедрой общей врачебной практики (семейной медицины) (с курсами гериатрии и физиотерапии)

пер. Нахичеванский, д. 29, г. Ростов-на-Дону, 344022

Galina V. Shavkuta — Dr. Sci. (Med.), Prof., Head of the Chair of General Medical Practice (Family Medicine) with training in geriatrics and physiotherapy 

Nakhichevanskiy per., 29, Rostov-on-Don, 344022

https://orcid.org/0000-0001-6341-6749НасыткоА. Д.NasytkoA. D.

Насытко Алина Дмитриевна — лаборант кафедры общей врачебной практики (семейной медицины) (с курсами гериатрии и физиотерапии)

пер. Нахичеванский, д. 29, г. Ростов-на-Дону, 344022

Alina D. Nasytko — Laboratory Assistant, Chair of General Medical Practice (Family Medicine) with training in geriatrics and physiotherapy 

Nakhichevanskiy per., 29, Rostov-on-Don, 344022

Государственное бюджетное учреждение Ростовской области «Ростовская областная клиническая больница»; Федеральное государственное бюджетное образовательное учреждение высшего образования «Ростовский государственный медицинский университет» Министерства здравоохранения Российской ФедерацииРоссияRostov Regional Clinical Hospital; Rostov State Medical UniversityRussian FederationФедеральное государственное бюджетное образовательное учреждение высшего образования «Ростовский государственный медицинский университет» Министерства здравоохранения Российской ФедерацииРоссияRostov State Medical UniversityRussian Federation20222806202229389102Copyright © Чепурненко С.А., Шавкута Г.В., Насытко А.Д., 20222022Чепурненко С.А., Шавкута Г.В., Насытко А.Д.Chepurnenko S.A., Shavkuta G.V., Nasytko A.D.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://ksma.elpub.ru/jour/article/view/2865

Введение. В течение последнего десятилетия были разработаны и введены в клиническую медицину прямые пероральные антикоагулянты (ПОАК) для профилактики и лечения венозной тромбоэмболии, а также для профилактики инсульта у пациентов с фибрилляцией предсердий (ФП). Серьезным осложнением лечения антикоагулянтами является кровотечение. Рандомизированные контролируемые испытания показали, что в случае развития кровотечения на фоне одного из ПОАК замена на другой не приведет к снижению риска кровотечения. При развитии кровотечения рекомендована не замена одного антикоагулянта на другой, а поиск возможного источника кровотечения и его устранение. При этом возобновление приема антикоагулянта возможно только после полной ликвидации причины кровотечения.Описание клинического случая. Пациент К., 81 года, госпитализирован в отделение неотложной кардиологии государственного бюджетного учреждения Ростовской области «Ростовская областная клиническая больница» (ГБУ РО «РОКБ») с клиникой тромбоэмболии мелких ветвей обеих легочных артерий, что было подтверждено спиральной компьютерной ангиопульмонографией. Наряду с венозной тромбоэмболией у пациента выявлена постоянная форма фибрилляции предсердий, что являлось еще одним показанием для приема ПОАК. Риск тромбоэмболии по шкале CHA2DS2-VASc — 6 баллов, кровотечения по шкале HAS-BLED — 2 балла. Скорость клубочковой фильтрации на момент кровотечения — 90 мл/мин/1,73 м2. Пациенту был назначен ривароксабан в дозе 20 мг в сутки. Через 2 года 3 месяца пациент прекратил прием ривароксабана в связи с развитием кровотечения из вен мошонки. При осмотре уролога выявлено с двух сторон расширение вен семенного канатика. При пробе Вальсальвы в венах стойкий ретроградный кровоток. Установлено наличие варикоцеле с обеих сторон.Пациенту выполнено прерывание венозного кровотока по левой внутренней семенной вене по методике Иваниссевича. Причина кровотечения была устранена. Через 1 неделю после оперативного вмешательства пациент возобновил прием ривароксабана.Заключение. Случай представляет интерес редко встречающейся причиной кровотечения, которую удалось установить на фоне приема нового орального антикоагулянта.

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.

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The authors declare that there are no conflicts of interest present.