Etiology and VTE risk factor distribution in patients with inferior vena cava thrombosis

A Rare Presentation of Ascites Secondary to Inferior Vena Cava Thrombosis in a Patient With Factor V Leiden Mutation

We present the case of a 36-year-old female with Factor V Leiden mutation taking warfarin, who presented to the emergency department with swelling in the abdominal and bilateral lower extremities. Initial assessment revealed an international normalized ratio (INR) of 5.0. Abdomen/pelvis computed tomography (CT) and computed tomographic angiography (CTA) scans indicated chronic thrombosis of the inferior vena cava (IVC), leading to the development of ascites and swelling. Extensive investigations were conducted to explore potential contributing factors for the ascites and edema, all of which yielded negative results. Warfarin was discontinued, and unfractionated heparin was initiated once the INR decreased to 2.0. The patient underwent IVC angioplasty with stent placement, resulting in significant improvement of ascites and lower extremity swelling. Subsequently, heparin was transitioned to oral warfarin, and therapeutic INR levels were achieved before discharge. At the follow-up outpatient visit, the patient's ascites and lower extremity edema had completely resolved. This case highlights a rare instance of IVC involvement associated with Factor V Leiden mutation. Furthermore, the patient's history of noncompliance with medication, initial supratherapeutic INR, and chronic IVC thrombosis emphasize the importance of medication adherence and the crucial role of primary care in ensuring regular follow-up and monitoring.

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.

Severe compression of left iliac vein is a protective factor for the risk of inferior vena cava thrombosis

OBJECTIVE

The purpose of this study is to evaluate the association between left iliac vein (LIV) compression and inferior vena cava thrombosis (IVCT) in patients with LIV involvement of deep vein thrombosis (DVT).

METHODS

A total of 263 consecutive DVT patients were retrospectively reviewed and divided into group IVCT and non-IVCT. The influences of LIV smallest diameter and percentage compression on the risk of IVCT were investigated using logistic regression analysis.

RESULTS

The mean age of IVCT patients was significantly younger than that of non-IVCT patients (55.5±1.8 vs. 62.7±1.1, p=0.001). The percentage of provoked DVT in IVCT patients was higher than that in non-IVCT patients (67.1% vs 48.2%, p=0.01). The smallest diameter of LIV in ICVT patients was larger than that in non-IVCT patients (4.1±0.3 vs. 2.5±0.2, p<0.001). Mean percentage compression of LIV in IVCT patients was significantly lower than that in non-IVCT patients (63.5±2.2 vs. 74.3±1.3; P<0.001). Age was associated with decreased odds of ICVT (OR: 0.965, 95% CI: 0.965-0.985, P=0.001). Provoked DVT was associated with increased odds of ICVT (OR:2.011, 95% CI: 1.070-3.782, P=0.03). LIV compression was associated with decreased odds of ICVT for each 1mm decrease in smallest diameter of the LIV (OR, 0.717; 95% CI, 0.627-0.820; P <0.001), and for each 10% increase in percentage compression of the LIV (OR, 0.715; 95% CI, 0.612-0.835; P <0.001).

CONCLUSION

Among LIV involvement of DVT patients, non-IVCT patients had more severe LIV compression than IVCT patients. Severe LIV compression may be a protective factor for the risk of IVCT.

Review article inferior vena cava thrombosis: a case series of patients observed in Taiwan and literature review

Inferior vena cava thrombosis (IVCT) is rare and can be under-recognized. However, the associated complications and mortality may be severe. We report the first case series of IVCT observed in Taiwan with a brief literature review. Eight Taiwanese patients with IVCT between May 2012 and December 2019 were enrolled in this study. Deep venous thrombosis (DVT, 8/8) and pulmonary embolism (5/8) were reported. Various risk factors were identified, including an unretrieved inferior vena cava (IVC) filter, pregnancy, surgery, presence of lupus of anticoagulants, essential thrombocythemia, antithrombin deficiency, and hemoglobin H disease. Of note, four of our patients experienced complete IVC thrombosis with bilateral lower extremity swelling (due to DVT) and abdominal wall superficial venous dilatation, while four other patients presented with partial IVCT and unilateral DVT. The etiology, clinical characteristics, presentations, diagnosis, and treatment of IVCT were reviewed.

Endovascular therapy for floating thrombus in the inferior vena cava

Objective

We aimed to summarize the clinical characteristics of floating thrombus in the inferior vena cava (IVC).

Methods

From January 2014 to June 2019, four patients with floating thrombus in the IVC were admitted to our hospital and underwent intracavitary therapy. Diagnosis, therapy, and clinical characteristics of floating thrombus were summarized.

Results

Three patients presented with pulmonary embolism. Three of the patients had a floating thrombus discovered by inferior venacavography and one was found by contrast-enhanced computed tomography. Two patients had deep venous thrombosis in the lower extremities. One patient had a double IVC, one had left iliac vein compression syndrome, and one had right renal phlebothrombosis. The four patients underwent implantation of a temporary IVC filter and were treated with anti-coagulation, debulking, and thrombolysis. All four patients achieved satisfactory results.

Conclusions

Floating thrombus in the IVC is often caused by spread of branch vein thrombosis, and is more likely to lead to pulmonary embolism. Anti-coagulant therapy and debulking under the protection of filters can achieve satisfactory clinical results.

Clinical and procedural implications of congenital vena cava anomalies in adults: A systematic review

BACKGROUND

Although congenital vena cava (CVC) anomalies in adults have implications for surgical and radiological interventions, the literature is scare and disparate. The aim of this systematic review was to assess cardiovascular clinical and procedural implications of CVC anomalies in adults without congenital heart disease.

METHODS AND RESULTS

We searched PubMed and EMBASE from database conception through October 2018 for English-language studies describing the epidemiology of CVC anomalies or their clinical or procedural implications in humans. Two independent reviewers screened 7093 records and identified 16 relevant studies. We found two major implications of CVC anomalies: 1) congenital inferior vena cava (CIVC) anomalies are associated with a 50-100-fold higher risk of deep venous thrombosis, particularly among younger patients, and 2) persistent left superior vena cava (PLSVC) is associated with a 2-3-fold higher risk of supraventricular arrhythmias. PLSVC also poses technical challenges to cardiovascular electronic device implantation, requiring alterations in surgical approach and lengthening procedure and X-ray exposure times. Due to the large disparity in reported prevalence rates of CIVC anomalies, we performed a meta-analysis of CIVC anomaly prevalence including 8 studies, which showed a weighted prevalence of 6.8% (95% CI, 4.5-9.2%).

CONCLUSION

These findings challenge the notion that CVC anomalies are rare and asymptomatic in adults. Rather, the literature indicates that CVC anomalies are not uncommon and have important clinical and procedural implications. To further understand the prevalence and implications of CVC anomalies, a robust US population-based study and nationwide registry is warranted in the current era of venous interventions.

Endovascular Treatment of Inferior Vena Cava Thrombosis in Metastatic Malignancy: A Case Report and Review of Literature

Inferior vena cava (IVC) thrombosis is a specific form of thromboembolism that occurs at a rate of 1.5% in all patients hospitalized with a deep vein thrombosis. Malignant IVC thrombosis may occur due to compression from a tumor mass or metastasis or may also occur through tumor invasion of the venous vasculature. Obstruction of the IVC can lead to IVC syndrome, marked by ascites, lower extremity edema, and even congestive hepatic failure. We present a case of extensive IVC thrombosis in a 69-year-old female with metastatic adrenal cell carcinoma, presenting with severe bilateral lower extremity edema and ascites. Computed tomography showed IVC compression by the caudate lobe due to a metastatic liver mass and extensive clot burden of the IVC extending from the renal veins to the right atrium (RA). She underwent percutaneous IVC stenting with 4 stents placed in tandem from the IVC to the RA. Her hospital course was complicated by gastrointestinal bleed requiring clipping, acute liver failure, and hypophysitis due to trial therapy. Although her IVC symptoms were partially relieved with percutaneous intervention, her acute liver failure worsened and she was ultimately transitioned to hospice care.

Magnetic resonance angiography imaging of pulmonary embolism using agents with blood pool properties as an alternative to computed tomography to avoid radiation exposure

PURPOSE

To evaluate the feasibility and accuracy of a combined magnetic resonance angiography (MRA) - magnetic resonance venography (MRV) protocol using contrast agents with blood pool properties, gadofosveset trisodium and gadobenate dimeglumine, in the evaluation of pulmonary embolus (PE) and deep venous thrombosis (DVT) as compared to the standard clinical reference imaging modalities; computed tomography pulmonary angiography (CTPA) and color-coded Duplex ultrasound (DUS).

MATERIALS AND METHODS

This prospective clinical study recruited patients presenting to the emergency department with clinical suspicion for PE and scheduled for a clinically indicated CTPA. We performed both MRA of the chest for the evaluation of PE as well as MRV of the pelvis and thighs to evaluate for DVT using a single contrast injection. MRA-MRV data was compared to the clinical reference standard CTPA and DUS, respectively.

RESULTS

A total of 40 patients were recruited. The results on a per-patient basis comparing MRA to CTPA for pulmonary embolus yielded 100% sensitivity and 97% specificity. There was a small subset of patients that underwent clinical DUS to evaluate for DVT, which demonstrated a sensitivity and specificity of 100% for MRV.

CONCLUSIONS

This single-center, preliminary study using contrast agents with blood pool properties to perform a relatively rapid combined MRA-MRV exam to image for PE and above knee DVT shows potential as an alternative imaging choice to CTPA. Further large-scale, multicentre studies are warranted.

Unusual Causes of Venous Thrombosis: Bladder Distension and Uterine Mass

Thrombosis of the inferior vena cava (IVC) continues to be a rare event, and there is a scarcity of evidence with regard to its etiology. One source for IVC thrombosis is external compression from adjacent structures. In this case series, we present 1 case of IVC thrombosis caused by a severely distended bladder and a case of external iliac thrombosis caused by external compression from an abnormally enlarged uterus. The treatment of each case is varied and included novel oral anticoagulation, catheter-directed thrombolysis in conjunction with mechanical thrombectomy, or a combination of these. We conclude that the choice of therapy should be tailored on a case-by-case basis.

Thrombosis of the Abdominal Veins in Childhood

Abdominal venous thrombosis is a rare form of venous thromboembolic disease in children. While mortality rates are low, a significant proportion of affected children may suffer long-term morbidity. Additionally, given the infrequency of these thrombi, there is lack of stringent research data and evidence-based treatment guidelines. Nonetheless, pediatric hematologists and other subspecialists are likely to encounter these problems in practice. This review is therefore intended to provide a useful guide on the clinical diagnosis and management of children with these rare forms of venous thromboembolic disease. Herein, we will thus appraise the current knowledge regarding major forms of abdominal venous thrombosis in children. The discussion will focus on the epidemiology, presentation, diagnosis, management, and outcomes of (1) inferior vena cava, (2) portal, (3) mesenteric, (4) hepatic, and (5) renal vein thrombosis.

Impact of inferior vena cava thrombus extension on thrombolysis for acute iliofemoral thrombosis

BACKGROUND

Inferior vena cava (IVC) thrombosis may occur in patients with iliofemoral deep venous thrombosis (DVT), and its impact on thrombolysis outcomes is poorly defined. This study compared outcomes of patients undergoing thrombolysis for acute iliofemoral DVT with and without IVC involvement.

METHODS

Patients who underwent thrombolysis for iliofemoral DVT between May 2007 and March 2014 were identified from a prospectively maintained database and divided into two groups: those with IVC involvement and those without. End points were technical and clinical success (≥50% lysis or freedom from 30-day DVT recurrence), long-term DVT recurrence, and post-thrombotic syndrome (PTS; Villalta score ≥5). Multivariate regression models were used to determine predictors of anatomic and clinical failures.

RESULTS

There were 102 patients (127 limbs) treated with various combinations of catheter-directed or pharmacomechanical thrombolysis. In 46 patients, thrombus extended into the IVC (54.3% extended up to the renal veins; 87% had ≥50% luminal reduction; 50% occurred in association with an indwelling thrombosed IVC filter). The caval group had fewer women and more previous DVTs but otherwise was similar to the noncaval group. Pharmacomechanical thrombolysis was used more frequently in the caval thrombus group (97.8% vs 82.1%; P = .011), and iliac vein stenting was used more often in the noncaval group (41.3% vs 62.5%; P = .033). Clinical success was similar between the two groups (88.7% for caval vs 89.3% for noncaval; P = .921). All failures in the caval group occurred in patients with an indwelling thrombosed IVC filter. Primary patency at 2 years for the caval and noncaval groups was 76.7% and 78.0%, respectively (P = .787). Valve reflux and PTS at 2 years were higher in the noncaval group (50.8% and 34.3% vs 23.3% and 11.5% in the caval group; P = .013 and P = .035). On multivariate analysis, incomplete lysis was predictive of recurrence (hazard ratio [HR], 22.7; P < .001) and PTS (HR, 5.59; P = .010), whereas caval involvement (HR, 0.22; P = .005) was protective from PTS.

CONCLUSIONS

IVC thrombosis does not have an impact on the technical success of thrombolysis in patients with iliofemoral DVT; the presence of a thrombosed IVC filter, though, may make failure more likely. Caval thrombosis may not affect primary patency but is associated with a lower incidence of PTS after successful lysis.

Complete renal recovery from severe acute renal failure after thrombolysis of bilateral renal vein thrombosis

A previously healthy young man presented with acute renal failure due to extensive spontaneous deep vein thrombosis, including the inferior vena cava (IVC) and both renal veins. The patient was treated with selectively delivered thrombolytic therapy over a 7-day-period, which resulted in renal vein patency and complete recovery of renal function. A stent was placed over a segment stenosis of the IVC. No thrombophilic factors were identified. Bilateral renal vein thrombosis in young fit individuals is an unusual cause of acute renal failure. Thrombolytic therapy, even with delay, can completely restore renal function.

Thrombosis of the inferior vena cava and malignant disease

BACKGROUND

Inferior vena cava thrombosis (IVCT) is a rare event, and studies detailing its underlying aetiologies are scarce.

METHODS

One hundred and forty-one IVCT patients (57% females, median age 47 years) were analysed with a focus on malignancy-related thrombosis and compared with 141 age- and sex-matched control patients with isolated lower-extremity deep vein thrombosis.

RESULTS

Malignancies were more prevalent among IVCT patients compared with the control group (39% vs. 7.8%; P<0.001). Malignancy-related IVCT more frequently involved the suprarenal and hepatic segments of the IVC and extended more often to the right atrium than IVCT did in non-cancer patients. Among IVCT patients with malignancies, renal cell carcinoma (38%) and other malignancies of the genitourinary tract (25%) were the most common tumours. Analysis of the underlying pathological mechanisms of malignancy-related thrombosis identified external compression of the IVC by tumour masses in 9 cases (16%), and progression of malignancy into the IVC (so-called "tumour thrombosis") in 24 cases (44%). The remaining 22 cases (40%) were attributed to malignancy-related hypercoagulability and the presence of additional venous thromboembolism risk factors, such as previous surgery, immobilisation, or chemotherapy.

CONCLUSIONS

Malignancies substantially contribute to the risk of thrombosis involving the IVC. Tumour invasion, especially in cases of renal cell cancer and malignancy-related hypercoagulability are major triggering factors for thrombogenesis.

Three Different Morphologies of Inferior Vena Cava Thrombosis: Case Reports

Inferior vena cava (IVC) thrombosis is a rare but significant complication in hospitalized patients. However, relevant information regarding IVC thrombosis, especially on its morphology, remains scarce. We present three cases of IVC thrombosis, with each showing a different morphology: mural, floating, and small polyp-like thrombus.

Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

BACKGROUND

Neonates and children differ from adults in physiology, pharmacologic responses to drugs, epidemiology, and long-term consequences of thrombosis. This guideline addresses optimal strategies for the management of thrombosis in neonates and children.

METHODS

The methods of this guideline follow those described in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.

RESULTS

We suggest that where possible, pediatric hematologists with experience in thromboembolism manage pediatric patients with thromboembolism (Grade 2C). When this is not possible, we suggest a combination of a neonatologist/pediatrician and adult hematologist supported by consultation with an experienced pediatric hematologist (Grade 2C). We suggest that therapeutic unfractionated heparin in children is titrated to achieve a target anti-Xa range of 0.35 to 0.7 units/mL or an activated partial thromboplastin time range that correlates to this anti-Xa range or to a protamine titration range of 0.2 to 0.4 units/mL (Grade 2C). For neonates and children receiving either daily or bid therapeutic low-molecular-weight heparin, we suggest that the drug be monitored to a target range of 0.5 to 1.0 units/mL in a sample taken 4 to 6 h after subcutaneous injection or, alternatively, 0.5 to 0.8 units/mL in a sample taken 2 to 6 h after subcutaneous injection (Grade 2C).

CONCLUSIONS

The evidence supporting most recommendations for antithrombotic therapy in neonates and children remains weak. Studies addressing appropriate drug target ranges and monitoring requirements are urgently required in addition to site- and clinical situation-specific thrombosis management strategies.

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.

Inferior vena cava thrombosis and its relationship with the JAK2V617F mutation and chronic myeloproliferative disease

BACKGROUND

Splanchnic vein thrombosis (SVT) is a typical manifestation of polycythaemia vera (PV) or essential thrombocythaemia (ET). The recently discovered JAK2V617F somatic mutation is closely associated with chronic myeloproliferative disease (CMD). We investigated whether thrombosis involving the inferior vena cava (IVC) is also related to the JAK2V617F mutation or CMD.

METHODS

Blood samples were obtained from 40 IVC thrombosis patients. Fifty-three patients with isolated lower extremity deep vein thrombosis (LE-DVT) and 20 SVT patients served as controls. The presence of the JAK2V617F mutation was assessed by real-time polymerase chain reaction (RT-PCR).

RESULTS

The JAK2V617F allele was not detected in any of the IVC thrombosis patients but was detected in one patient (2%) with isolated LE-DVT. However, the mutation-carrying patient did not exhibit symptoms of CMD. Even after an observation period of 30months, the patient's complete blood cell count did not exhibit any pathology. In contrast, the JAK2V617F allele was detected in four patients with SVT (20%) and CMD.

CONCLUSION

According to our data, there is no evidence that IVC thrombosis is associated with the JAK2V617F mutation or the presence of chronic myeloproliferative disease.

Familial risks of unusual forms of venous thrombosis: a nationwide epidemiological study in Sweden

OBJECTIVE

This is the first nationwide study to determine familial risks of unusual forms of venous thrombosis amongst offspring of affected parents and amongst siblings.

DESIGN AND SETTINGS

The Swedish Multigeneration Register of 0- to 75-year-old subjects was linked to the Hospital Discharge Register for the period 1987-2007. Standardized incidence ratios (SIRs) were calculated for individuals whose relatives were hospitalized for venous thromboembolism (VTE), as determined by the International Classification of Diseases, compared to those whose relatives were not affected by VTE.

RESULTS

The total number of hospitalized patients with VTE was 45 362, of which 1824 (4.0%) were affected by a rare thrombotic condition. The familial SIRs in cases with a history of VTE in parents or siblings were significantly increased for migrating thrombophlebitis (1.81; 95% confidence interval (CI) 1.40-2.31), portal vein thrombosis (2.35; 95% CI 1.77-3.06), vena cava thrombosis (1.96; 95% CI 1.42-2.64) and cerebral venous thrombosis (1.74; 95% CI 1.30-2.28). Budd-Chiari syndrome (SIR, 0.92; 95% CI 0.24-2.38) and renal vein thrombosis (SIR, 1.72; 95% CI 0.62-3.77) were not significantly associated with parental or sibling history of VTE; however, these two conditions were very rare, and therefore, we cannot draw any definite conclusions from this finding.

CONCLUSIONS

Family history is an important risk factor for most unusual forms of VTE. Moreover, even the paraneoplastic phenomenon, migrating thrombophlebitis (Trousseau's syndrome), is associated with a family history of VTE. Thus, our data suggest that most rare forms of VTE have a familial background.

Treatment with low-molecular-weight heparin for deep venous thrombosis complicated with digestive tract cancer: an analysis of 63 cases

AIM: To compare therapeutic efficacy of long-term low-molecular-weigh heparin treatment with routine Warfarin treatment for digestive tract cancer complicated with deep venous thrombosis.

METHODS: Sixty three digestive tract cancer patients complicated with deep venous thrombosis were retrospectively allotted from February 2005 to December 2006 either into long-term low-molecular-weight heparin treatment group (LMWH group) or into warfarin treatment group (routine care group). The bleeding rate, the rates of recurrent venous thromboembolism and the platelet counts of patients of both groups were analyzed.

RESULTS: In long-term LMWH group, bleeding occurred in 6 patients (18.8%) and the platelet count of 1 patient (3.1%) decreased below normal level, which did not show significant difference compared with routine care group (25.8% and 6.5%, respectively). However, at 12 months, recurrent venous thromboembolism occurred in 3 of 32 cases (9.4%), which showed significant difference compared with routine care group (29.0%, P < 0.05).

CONCLUSION: Long-term low-molecular-weight heparin, more convenient and more effective than routine warfarin therapy, is considered to be more effective for digestive tract cancer complicated with deep venous thrombosis.