Acute thrombosis of the inferior vena cava

Budd-Chiari syndrome following abdominal trauma

We report a case of Budd-Chiari syndrome (BCS) in a 44-year-old man with inferior vena cava (IVC) thrombosis and nephrotic syndrome. This case was complicated by right atrial clot and pulmonary emboli. Endothelial injury of the IVC was the likely mechanism, following a kick from a donkey. Abdominal ultrasonography revealed a large thrombosis located in a segment of IVC near its orifice in the right atrium. Transthoracic echocardiography (TTE) revealed IVC thrombosis that extended to the right atrium; however, pulmonary emboli (PE) were not documented in TTE. Intraoperative exploration revealed multiple clots in the main and left pulmonary artery branches. The patient recovered well after open-heart surgery with resection of the right atrium, IVC, and pulmonary artery emboli. BCS should be routinely considered for patients with nephrotic syndrome.

Aspiration Thrombectomy Using Inari FlowTriever System for Inferior Vena Cava Tumor Thrombus: A Case Report

Pharmacomechanical therapy and catheter-directed thrombolysis are potent treatments for venous thromboembolism. However, limited data exist regarding the management of thrombi in the inferior vena cava (IVC). IVC thrombus resulting from tumors is a particularly uncommon condition. Managing IVC tumor thrombi poses even greater challenges, as conventional therapies such as systemic anticoagulation and thrombolysis are often ineffective. In this report, we present the case of a 73-year-old male with an inferior vena cava tumor thrombus successfully managed through aspiration thrombectomy utilizing the Inari FlowTriever system.

Angio-Jet Thrombolysis for Traumatic Inferior Vena Cava Thrombosis; Case Report and Review of Literature

Background

Inferior vena cava thrombosis (IVC-Th) is a rare clinical entity after blunt abdominal trauma. It has both diagnostic and therapeutic dilemmas. Pulmonary embolism is the most dreadful complication and the leading cause of mortality after IVC-Th. Therefore, accurate prompt diagnosis is crucial.

Objective

The aim of this article was to present a case of IVC-Th in a young male patient who had a blunt traumatic abdominal injury after a motor vehicle accident.

Case presentation

The patient was brought to emergency department and was successfully managed by angio-jet thrombolysis. He developed a transient contrast nephropathy that was recovered after continuous renal replacement therapy. Several management options have been proposed in the literature, including conservative, endovascular and operative management.

Conclusion

Angio-jet is a recent promising technique for managing of venous thrombosis. However, its use in cases of IVC-Th is not extensively discussed in the literature.

Risk factors and a predictive model for nonfilter-associated inferior vena cava thrombosis in patients with lower extremity deep vein thrombosis

Objective

Nonfilter-associated inferior vena cava thrombosis (IVCT) is an under-recognized but severe state of venous thromboembolism. The aims of this study were to investigate risk factors and develop a prediction model based on clinical data and imaging findings to evaluate the probability of IVCT in patients with lower extremity deep vein thrombosis (LEDVT).

Methods

A single-center retrospective cohort study was conducted. We analyzed the clinical data and multimodal imaging findings of consecutive patients with confirmed LEDVT between February 2016 and January 2022. The demographics, presentation of LEDVT, laboratory examination, thrombus characteristics, comorbidities and risk factors for LEDVT, and imaging findings were analyzed using an independent t-test, Chi-square test, Fisher's exact test, and regression analysis to determine the univariable and multivariable associations and to establish a predictive model to assess the probability of IVCT.

Results

A total of 267 eligible patients were included, of whom 40 were in the IVCT group and 227 were in the non-IVCT group. The incidence of nonfilter-associated IVCT was 15.0% (40/267). Age < 63.5 years [odds ratio (OR) 2.54; 95% confidence interval (CI), 1.10-5.85, p = 0.029], male sex (OR 2.82; 95% CI, 1.19-6.72, p = 0.019), proximal DVT (OR 8.21; 95% CI, 1.01-66.76, p = 0.049), bilateral DVT (OR 7.30; 95% CI, 3.28-16.21, p < 0.001), and D-dimer >4.72 μg/ml (OR 4.64; 95% CI, 1.80-11.72, p = 0.001) were risk factors for IVCT's occurrence. Then, we established a prediction model based on these risk factors. The diagnostic efficiency [area under the curve (AUC) of receiver operating characteristic (ROC) curve was 0.858] for predicting IVCT was superior to that of isolated risk factors, including age < 63.5 years (AUC of ROC curve was 0.624) or D-dimer >4.72 μg/ml (AUC of ROC curve was 0.656).

Conclusion

Age < 63.5 years, male sex, proximal LEDVT, bilateral LEDVT and D-dimer >4.72 μg/ml were risk factors. The diagnostic efficiency of the predictive model for predicting IVCT was superior to that of a single risk factor alone. It may be used for predicting the probability of nonfilter-associated IVCT in patients with LEDVT.

Inferior Vena Cava Thrombosis, Appendicitis Mimic

Right lower quadrant abdominal pain is a common presentation to the Emergency Department. While appendicitis is a frequently diagnosed pathology associated with this complaint, there are multiple, well-documented alternatives that must be considered. The authors present a unique case of a 20 year old active duty male who presented with 3 days of acutely worsening right lower quadrant abdominal pain, right flank pain, and anorexia. Following a detailed work-up, computed tomography and magnetic resonance imaging (MRI) demonstrated a bland thrombus within the inferior vena cava (IVC) secondary to a vascular web. This case highlights the difficulty in astutely diagnosing appendicitis utilizing clinical examination and scoring metrics. While IVC thrombosis is a rare phenomenon, it should be considered in the emergency physician's differential for right lower quadrant abdominal pain, particularly when additional nonspecific symptoms are present.

Anesthetic management of gigantic pheochromocytoma resection with inferior vena cava and right atrium tumor thrombosis: a case report

Background

This report describes one case of anesthetic management about surgical resection of a malignant phaeochromocytoma with tumor extension into vena cava and right atrium in a patient. Report for anesthetic management is limited in these patients under surgical resection until now.

Case presentation

In September 2015, a 24-year-old male presented to the department of cardiology with right flank pain and hypertensive urgency in our hospital. Contrast-enhanced CT abdomen and MRI abdomen revealed a mass phaeochromocytoma in right adrenal, which invaded the right inferior vena cava(IVC)wall along with IVC thrombus. Echocardiography shown no abnormal detection. Finally, this patient gave up the surgical resection of phaeochromocytoma and chose the expectant treatment. In April 2018, this patient once again presented to the emergence department in our hospital, he had experienced persistent cough and intermittent wheezing for 5 h. Contrast-enhanced CT and echocardiography shown existing IVC thrombus had extended into the right atrium. After the careful preoperative preparation, adrenalectomy with complete thrombus excision by inferior vena cava exploration and right atriotomy were performed successfully by a multidisciplinary team. After one month post-operation care, this patient healthily left our hospital.

Conclusion

To the best of our knowledge, the occurrence of pheochromocytoma with IVC and right atrium thrombosis has not been reported in mainland China so far. This clinical case may supply a rare reference experience for surgical treatment and anesthetic management in the group of phaeochromocytoma patient with distance vascular extension.

Use of blood pool agents with steady-state MRI to assess the vascular system

Over the past two decades there have been significant advances in the use of magnetic resonance imaging (MRI) to assess the vascular system. New imaging sequences and improvements in magnet design have enabled the creation of higher spatial resolution images. MRI is now a viable alternative imaging modality when compared to both invasive angiography and computed tomographic angiography. The use of blood pool agents has further facilitated the use of MR angiography (MRA); their high molecular weight allows for lower doses of contrast medium administration while their prolonged presence in the blood stream allows for repeated high-quality volumetric imaging of both the arterial and venous circulation. As such, MRA is now no longer constrained by the tight windows for first-pass arterial and venous enhancement, which has resulted in the ability to assess and diagnose a large range of vascular pathologies in both arterial and venous systems. The intent of this review is to highlight MRI findings in common vascular pathologies including peripheral arterial disease (PAD), abnormalities of the abdominal aortic branches, postendovascular aortic aneurysm repair (EVAR) endoleak assessment, popliteal artery entrapment syndrome (PAES), deep venous thrombosis (DVT), vascular thoracic outlet syndrome (TOS), and vascular malformations. In addition, the latest MRI techniques currently used to optimally assess each of these pathologies will be discussed.

LEVEL OF EVIDENCE

5 Technical Efficacy: Stage 3 J. MAGN. RESON. IMAGING 2017;45:1559-1572.

Catheter directed interventions for inferior vena cava thrombosis

Inferior vena cava (IVC) thrombosis, although similar in many aspects to deep venous thrombosis (DVT), has distinct clinical implications, treatments and roles for endovascular management. Etiologies of IVC thrombosis vary from congenital malformations of the IVC to acquired, where indwelling IVC filters have been implicated as a leading cause. With an increasing incidence of IVC thrombosis throughout the United States, clinicians need to be educated on the clinical signs and diagnostic tools available to aid in the diagnosis as well as available treatment options. Untreated IVC thrombus can result in serious morbidity and mortality, both in the acute phase with symptoms related to venous outflow occlusion and embolism, and in the long-term, sequelae of post-thrombotic syndrome (PTS) related to chronic venous occlusion. This manuscript will discuss the clinical presentation of IVC thrombosis, diagnostic and treatment options, as well as the role of endovascular management.

Etiology and treatment of acute inferior vena cava thrombosis

Inferior vena cava thrombosis (IVCT) is a rare but severe disease that is associated with a high rate of mortality. IVCT can be categorized into primary versus secondary thrombosis dependent upon the underlying pathophysiology. The diagnosis includes both clinical probability assessment as well as the imaging evaluation. The optimal therapeutic strategy remains the target of continued research. Although anticoagulation therapy remains fundamental in treating IVCT, its inherent limitations have led to the use of minimally invasive, endovascular treatment options, including transcatheter thrombolysis, mechanical thrombectomy or a combination of these techniques. This review focuses on the etiology, diagnostic assessment, and endovascular treatment options for IVCT.

Inferior Vena Cava Thrombosis

Thrombosis of the inferior vena cava (IVC) is an under-recognized entity that is associated with significant short- and long-term morbidity and mortality. In absence of a congenital anomaly, the most common cause of IVC thrombosis is the presence of an unretrieved IVC filter. Due to the substantial increase in the number of IVC filters placed in the United States and the very low filter retrieval rates, clinicians are faced with a very large population of patients at risk for developing IVC thrombosis. Nevertheless, there is a paucity of data and societal guidelines with regards to the diagnosis and management of IVC thrombosis. This paper aims to enhance the awareness of this uncommon, but morbid, condition by providing a concise, yet comprehensive, review of the etiology, diagnostic approaches, and treatment strategies in patients with IVC thrombosis.

Combined Direct and Indirect CT Venography (Combined CTV) in Detecting Lower Extremity Deep Vein Thrombosis

This study aimed to evaluate the diagnostic accuracy of combined direct and indirect CT venography (combined CTV) in the detection of lower extremity deep vein thrombosis (LEDVT). The institutional review board approved the study protocol, and patients or qualifying family members provided informed consent. A total of 96 consecutive patients undergoing combined CTV were prospectively enrolled. A combined examination with digital subtraction angiography (DSA) plus duplex ultrasonography (US) was used as the criterion standard. Three observers were blinded to clinical, DSA, and US results, and they independently analyzed all combined CTV datasets. Interobserver agreement was expressed in terms of the Cohen k value for categorical variables. Accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of combined CTV in the detection of LEDVT were determined by using patient- and location-based evaluations. Of the 96 patients, DSA plus US revealed LEDVT in 125 segmental veins in 63 patients. Patient-based evaluation with combined CTV yielded an accuracy of 96.9% to 97.9%, a sensitivity of 95.2% to 96.8%, a specificity of 100% to 100%, a PPV of 100% to 100%, and an NPV of 91.7% to 94.3% in the detection of LEDVT. Location-based evaluation yielded similar results. Through combined direct and indirect CTV, patients obtained a combined CT angiogram on the diseased limb and an indirect CT angiogram on the opposite side. The image quality of combined CTV was superior to an indirect venogram. Combined CTV shows promising diagnostic accuracy in the detection of LEDVT with 3-dimensional modeling of the lower limb venous system.

Supra hepatic inferior vena cava and right atrial thrombosis following a traffic car crash

We present a case of nephrotic syndrome associated with right atrial and supra hepatic vein part of inferior vena caval thrombosis. This patient presented with dyspena, lower extremity edema and back pain after a vehicle accident and blunt trauma to the abdomen. Trauma should be considered not only as a thrombophilic pre-disposition, but also as a predisposing factor to IVC endothelium injury and thrombosis formation. Echocardiography revealed supra hepatic vein IVC thrombosis floating to the right atrium. A C-T scan with contrast also showed pulmonary artery emboli to the left upper lobe. With open heart surgery, the right atrial and IVC clot were extracted and the main left and right pulmonary arteries were evaluated for possible clot lodging. The patient had an uneventful postoperative recovery and thrombosis has not reoccurred with periodical follow-up examinations.

Venous Thromboembolic Disease: The Use of the Aspiration Thrombectomy Device AngioVac

Central venous thrombosis is a complex problem, particularly in cases where the thrombus burden is large. Several interventional techniques and devices have been developed over the past 15 to 20 years to manage this entity, but the vast majority of them still need the concomitant use of thrombolytics to achieve an optimal result. AngioVac (AngioDynamics, Latham, NY) is the first aspiration thrombectomy device capable to remove a larger burden of undesired intravascular material such as thrombus, tumor, and foreign bodies without the need of lytics. This review focuses on the AngioVac device in the management of iliocaval thrombosis and pulmonary embolism.

Severe low back pain as the initial symptom of venous thrombosis of the inferior vena cava

A 45-year-old previously well male truck driver presented to the emergency department with severe low back pain; lumbosacral X-ray was normal and he was given analgaesics and discharged. The following day, he presented to the emergency department again, his pain had not responded to the analgaesics; this time he also presented with massive bilateral swelling of lower limbs and left testicle that started 3 h earlier. The pain was severe, dull and interfered with the patient's ability to walk. An urgent workup revealed extensive thrombosis of the inferior vena cava.

Inferior vena cava thrombosis: a review of current practice

Inferior vena cava (IVC) thrombosis remains under-recognised as it is often not pursued as a primary diagnosis. The aetiology of IVC thrombosis can be divided into congenital versus acquired, with all aetiological factors found among Virchow's triad of stasis, injury and hypercoagulability. Signs and symptoms are related to aetiology and range from no symptoms to cardiovascular collapse. Painful lower limb swelling combined with lower back pain, pyrexia, dilatation of cutaneous abdominal wall veins and a concurrent rise in inflammatory markers are suggestive of IVC thrombosis. Following initial lower limb venous duplex, magnetic resonance imaging (MRI) is the optimal non-invasive imaging tool. Aetiology directs treatment, which ranges from anticoagulation and lower limb compression to open surgery, with endovascular therapies increasingly favoured. The objective of this review is to assess current literature on the aetiology, presentation, investigation, treatment, prognosis and other factors pertaining to IVC thrombosis.

Coexistence of pheochromocytoma with uncommon vascular lesions

BACKGROUND

Pheochromocytoma/paragangliomas have been described to be associated with rare vascular abnormalities like renal artery stenosis. Coexistence of physiologically significant renal artery lesions is a compounding factor that alters management and prognosis of pheochromocytoma patients. Apart from individual case reports, data on such association in Indian population is not available. The aim of this study is to find the nature and prevalence of associated vascular abnormalities.

MATERIALS AND METHODS

From 1990 to 2010, a total of 50 patients were diagnosed with pheochromocytoma/paragangliomas. Hospital charts of these patients were reviewed retrospectively to identify those with unusual vascular abnormalities. Available literature was also reviewed.

RESULTS

Of the 50 patients with pheochromocytoma, 7 (14%) had coexisting vascular lesions including renal artery stenosis in 4, aortoarteritis in 1, aortic aneurysm in 1 and inferior vena cava thrombosis in 1. Pheochromocytoma was adrenal in 42 and extra adrenal in 8. Laparoscopic adrenalectomy was done in the patients. One patient with renal artery stenosis due to intimal fibrosis was subjected to percutaneous balloon angioplasty; the other three improved after adrenalectomy and lysis of fibrous adhesive bands. The patient with aortoarteritos was treated with oral steroids. Inferior vena cava thrombosis was reversed with anticoagulants. The patient with abdominal aortic aneurysm was advised for annual follow-up on account of its size of 4.5 cm and asymptomatic presentation.

CONCLUSION

There are multiple mechanisms that can lead to renal artery stenosis and other vascular abnormalities in a case of pheochromocytoma. A high index of suspicion is necessary to enable both entities to be diagnosed preoperatively and allow proper planning of surgical therapy. Incomplete diagnosis may lead to persistent hypertension postoperatively in a case of associated renal artery stenosis.

Pheochromocytoma with inferior vena cava thrombosis: An unusual association

Pheochromocytomas have been described in association with vascular abnormalities like renal artery stenosis. A 48-year-old man was admitted to our hospital with the complaints of headache, sweating, anxiety, dizziness, nausea, vomiting and hypertension. For last several days, he was having a dull aching abdominal pain. Abdominal computed tomography (CT) revealed the presence of a left adrenal pheochromocytoma. An inferior vena cava (IVC) venogram via the right jugular vein demonstrated occlusion of the IVC inferior to the right atrium. Surgical removal of pheochromocytoma was done, followed by anticoagulant treatment for IVC thrombosis, initially with subcutaneous low molecular weight heparin, and then with oral warfarin, resulting in restoration of patency. To the best of our knowledge, the occurrence of pheochromocytoma in IVC thrombosis has not been reported so far from India. Possible mechanisms of such an involvement are discussed.

High inferior vena cava thrombosis in a 16-year-old postpartum patient: a case report

Postpartum inferior vena cava (IVC) thrombosis is a rare, but potentially life-threatening disorder. Here we reported one case of the youngest woman to date who presented with massive IVC thrombus extending from deep veins of the right leg to the level of the 11th thoracic vertebra, associated with asymptomatic pulmonary embolism.