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From the 9/10/2021 release of VAERS data:

This is VAERS ID 1430127



Case Details

VAERS ID: 1430127 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-06-01
Onset:2021-06-21
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-06-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Deep vein thrombosis
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? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine Melatonin Metoprolol Succinate
Current Illness:
Preexisting Conditions: COPD Alcoholism
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient developed a lower extremity DVT approximately 2 weeks after receiving the J&J COVID-19 Vaccine. Patient was treated and discharged from our facility on apixaban.


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