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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1349019

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Case Details

VAERS ID: 1349019 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Unknown  
Vaccinated:0000-00-00
Onset:2021-05-01
Submitted: 0000-00-00
Entered: 2021-05-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Deep vein thrombosis, Imaging procedure, Pulmonary embolism, Ultrasound scan
SMQs:, Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Comments: The patient had no family or personal history of clots and no provoking factors.
Allergies:
Diagnostic Lab Data: Test Date: 20210518; Test Name: Imaging procedure; Result Unstructured Data: Filling defect in the lobar and interlobar pulmonary arteries; Test Date: 20210518; Test Name: Diagnostic ultrasound; Result Unstructured Data: Deep vein thrombosis positive; Comments: Deep venous thrombosis in the left lower extremity in distal femoral and popliteal
CDC Split Type: USJNJFOC20210540053

Write-up: DEEP VEIN THROMBOSIS; PULMONARY EMBOLISM; This spontaneous report received from a patient via a company representative concerned a male of unspecified age. The patient''s height, and weight were not reported. The patient had no family or personal history of clots and no provoking factors. The patient received covid-19 vaccine (suspension for injection, route of admin, and batch number were not reported) dose was not reported, 1 total, administered on 05-APR-2021 for prophylactic vaccination. The batch number was not reported. The Company is unable to perform follow-up to request batch/lot numbers. No concomitant medications were reported. On 18-MAY-2021, the patient presented to the emergency department with one week of leg swelling and pain. The patient work up was notable for deep vein thrombosis ultrasound positive for deep venous thrombosis in the left lower extremity in distal femoral and popliteal and PE study showing filling defect in the lobar and interlobar pulmonary arteries extending to segmental and subsegmental pulmonary arteries, right greater than left. On MAY-2021, the subject experienced deep vein thrombosis and pulmonary embolism. The action taken with covid-19 vaccine was not applicable. The outcome of deep vein thrombosis and pulmonary embolism was not reported. This report was serious (Other Medically Important Condition).; Sender''s Comments: COVID-19 VACCINE deep vein thrombosis, pulmonary embolism. This event(s) is considered unassessable . The event(s) has a compatible/suggestive temporal relationship, is unlabeled, and has unknown scientific plausibility. There is no information on any other factors potentially associated with the event(s).


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