Bilateral lower extremity amputation in a transgender female on estrogen therapy suffering from recurrent, medication-resistant arterial thrombi

Abstract

This case report presents a 40-year-old transgender female with a history of gender-affirming hormone therapy who experienced recurrent, medication-resistant arterial thrombi leading to bilateral lower extremity amputations. Despite multiple endovascular and surgical interventions, including bypass grafting and catheter-directed thrombolysis, the patient developed recurrent thrombotic events even while on anticoagulation therapy. Hematologic evaluation for coagulopathy was unremarkable. The case underscores the need for greater understanding of gender-affirming hormone therapy's long-term cardiovascular effects while highlighting the challenges in managing arterial thrombosis in transgender patients. Further research is required to guide optimal anticoagulation strategies in this population.

Keywords: Acute limb ischemia; Arterial thrombi; Estrogen therapy; Gender-affirming hormone therapy (GAHT); Transgender.

Fig 1

Initial computed tomography angiography (CTA) and angiogram, pre- and post-thrombolysis, during the index encounter for right acute limb ischemia. (A) Reconstructed three-dimensional CTA runoff posterior view showing occluded right popliteal artery proximal to stent; (B-D) Pre-intervention angiogram of the right leg; (E) post-thrombolysis angiogram of the right leg.

Fig 2

Computed tomography angiography (CTA) and angiogram, pre- and post-thrombectomy, during the third encounter, for left (contralateral to prior) acute limb ischemia. (A) Reconstructed three-dimensional CTA runoff posterior view showing occluded left popliteal artery proximal to stent; (B-D) Pre-intervention angiogram of the left leg; (E) Post-thrombectomy angiogram of the left leg.