Concurrent Intramuscular Thigh Hematoma and Femoropopliteal Venous Thrombosis During Supratherapeutic Warfarin Anticoagulation

An anticoagulated patient with unilateral thigh swelling may have more than one process. A 79-year-old man receiving long-term warfarin for atrial fibrillation and a previous ischemic stroke presented with 3 days of atraumatic left-thigh pain, swelling, and inability to walk. His international normalized ratio was 6.41. Computed tomography (CT) showed an approximately 4 cm × 7 cm intramuscular hematoma in the left vastus intermedius. Duplex ultrasonography additionally demonstrated femoropopliteal venous thrombosis causing partial occlusion, with absent spectral flow in the sampled femoral vein segment and residual popliteal venous flow. Warfarin was initially withheld without reversal therapy. CT-guided drainage was performed after the international normalized ratio decreased to 1.44, and follow-up CT angiography showed no active bleeding. Edoxaban 60 mg once daily was started 8 days after drainage. Following rehabilitation, the patient was discharged in stable condition and was able to walk independently. These images illustrate that hemorrhage and venous thrombosis can coexist despite supratherapeutic anticoagulation; CT and duplex ultrasonography provide complementary information that can prevent diagnostic anchoring and guide the sequence of source control and anticoagulation resumption.