Perinatal inferior vena cava thrombosis and absence of the infrarenal inferior vena cava

Developmental or Procedural Vena Cava Interruption and Venous Thromboembolism: A Review

The inferior vena cava (IVC) and superior vena cava are the main conduits of the systemic venous circulation into the right atrium. Developmental or procedural interruptions of vena cava might predispose to stasis and deep vein thrombosis (DVT) distal to the anomaly and may impact the subsequent rate of pulmonary embolism (PE). This study aimed to review the various etiologies of developmental or procedural vena cava interruption and their impact on venous thromboembolism. A systematic search was performed in PubMed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines per each clinical question. For management questions with no high-quality evidence and no mutual agreements between authors, Delphi methods were used. IVC agenesis is the most common form of congenital vena cava interruption, is associated with an increased risk of DVT, and should be suspected in young patients with unexpected extensive bilateral DVT. Surgical techniques for vena cava interruption (ligation, clipping, and plication) to prevent PE have been largely abandoned due to short-term procedural risks and long-term complications, although survivors of prior procedures are occasionally encountered. Vena cava filters are now the most commonly used method of procedural interruption, frequently placed in the infrarenal IVC. The most agreed-upon indication for vena cava filters is for patients with acute venous thromboembolism and coexisting contraindications to anticoagulation. Familiarity with different forms of vena cava interruption and their local and systemic adverse effects is important to minimize complications and thrombotic events.

Thrombotic risk and features of patients with inferior vena cava agenesis: a multicentre, retrospective, observational study

BACKGROUND

Inferior vena cava agenesis (IVCA) is a rare anomaly predisposing affected people to lower-limb venous thrombosis with low frequency of pulmonary embolism. Antenatal thrombosis and inherited thrombophilia have been suggested as causes of IVCA. However, there is little evidence on the clinical course and management of this condition. We designed a patient registry to assess the thrombotic risk and features of IVCA.

METHODS

In this this multicentre, retrospective, observational study, we included patients with IVCA diagnosed by routine imaging from 20 hospitals in Spain (n=18), Portugal (n=1), and Italy (n=1). Patients were identified from a systematic search in radiology databases using data extraction software (cohort A) and alternative searches in medical records for confirmed IVCA (cohort B; option allowed when systematic approaches were unapplicable). Primary outcomes were clinical and imaging features, thrombotic risk, phenotype of IVCA-associated thrombosis, anticoagulant treatment, and the results of thrombophilia testing.

FINDINGS

We included patients with IVCA diagnosed by routine imaging studies done between Jan 1, 2010, and Dec 31, 2022. In the systematic search, 4 341 333 imaging exams were screened from the radiology databases of eight centres. 122 eligible patients were enrolled in cohort A. A further 95 patients were identified by screening medical records at 12 centres, of whom 88 were eligible and included in cohort B, making a combined cohort of 210 patients. 96 (46%) of 210 patients were female and 200 (95%) were European or Hispanic. 60 (29%) of 210 patients had hepatic IVC interruption, whereas 150 (71%) had extrahepatic IVCA. In cohort A, 65 (53%) of 122 patients had venous thrombosis, with an estimated annual risk of 1·15% (95% CI 0·89-1·46). Extrahepatic IVCA was associated with a greater risk of venous thrombosis than hepatic IVCA (56 [67%] of 84 patients vs nine [24%] of 38 patients, odds ratio 5·31, 95% CI 2·27-12·43; p<0·0001). Analysis of 126 patients with venous thrombosis pooled from cohorts A and B showed early-onset (median age 34·6 years, IQR 23·3-54·3) and recurrent events (50 [40%] of 126 patients). Patients with extrahepatic IVCA had greater proportions of lower-limb venous thrombosis (95 [87%] of 109 vs nine [53%] of 17, p=0·0010) and recurrence (48 [44%] of 109 vs two [12%] of 17, p=0·015), but lower rates of pulmonary embolism (10 [10%] of 99 vs four [33%] of 12, p=0·044) than did patients with hepatic IVCA. 77 (63%) of 122 patients with thrombosis underwent indefinite anticoagulation. 32 (29%) of 111 patients (29 [34%] of 86 with thrombosis) had coexisting thrombophilias. The recurrence risk was lower for patients receiving indefinite anticoagulation (adjusted odds ratio 0·24, 95% CI 0·08-0·61; p=0·010), and greater for thrombophilias (3·19, 1·09-9·32; p=0·034).

INTERPRETATION

This evaluation of a large patient cohort demonstrates the high thrombotic burden of IVCA. We have identified two distinct forms of IVCA, hepatic and extrahepatic, suggesting different underlying mechanisms. Beyond clinical characterisation, we draw attention to this orphan disease and highlight the need for its study and improved care.

FUNDING

Spanish Society of Thrombosis and Haemostasis, Instituto de Salud Carlos III, FEDER, Fundación Séneca.

Extensive iliofemoral and femoropopliteal venous thrombosis in a young patient with iliocaval atresia

Inferior vena cava (IVC) atresia is a rare congenital anomaly. Standardized treatment is not well defined due to its uncommon presentation, with this pathology associated with an increased risk of unprovoked lower extremity deep vein thrombosis (DVT). We present a case of a 32-year-old man who was admitted for bilateral lower extremity edema and pain and was found to have bilateral extensive iliofemoral and femoropopliteal DVT, absence of IVC filling, and extensive tortuous collateralization arising from the pelvic veins to the azygos vein. Bilateral mechanical thrombectomy and endovascular iliocaval reconstruction was performed. Three months later, the patient demonstrated widely patent iliocaval stents and the absence of DVT. Endovascular treatment of IVC atresia is feasible and optimizes the reduction of thrombus burden.

Deep venous thrombosis in patients with atresia of the inferior vena cava and right kidney hypoplasia (KILT syndrome): Systematic review of the literature

Inferior vena cava (IVC) anomalies are uncommon congenital causes of deep vein thrombosis (DVT). KILT syndrome (kidney and IVC abnormalities with leg thrombosis) has only been described as case reports in the literature. Therefore, the characteristics, evaluation, and management of patients with KILT syndrome have not yet been standardized. This study aimed to systematically review and analyze the clinical and radiographic data and treatment of previously reported cases of KILT syndrome. In this systematic review, we performed a literature search of the PubMed, Scopus, and Web of Science databases in December 2023, with no restrictions on the publication date. After duplicate extractions, 4195 articles were screened. Case reports and case series reporting on KILT syndrome were included. In addition to previously published cases, we included a new case of a previously healthy 25-year-old man with KILT syndrome in the analysis. A total of 34 cases were therefore included in this study. The majority (76.5%) were male patients with a median age of 24 years. In most patients, unprovoked bilateral iliofemoral thrombosis was diagnosed, and 64.7% had left kidney abnormalities. Our study suggests that anomalies of the IVC should be suspected in all young patients, especially male patients, with proximal, recurrent, or idiopathic DVT. If an IVC anomaly is confirmed, the kidneys should be examined to monitor and preserve healthy kidneys in cases of KILT syndrome. The data collected from all patients emphasize the requirement of long-term anticoagulation and risk factor control. Surgical measures may be effective for treating symptomatic refractory cases.

A rare cause of deep vein thrombosis: inferior vena cava agenesis

Inferior vena cava agenesis is a rare condition and is often misdiagnosed. This anomaly is asymptomatic in the majority of cases and is usually diagnosed during imaging tests carried out for other purposes. The most frequent manifestation is deep vein thrombosis (DVT) in lower limbs and anticoagulation therapy is the most frequent treatment option. Other techniques such as thrombolysis and venous bypass are also described. We report two cases diagnosed at our institution during the last year, both of which presented with an episode of DVT. We opted for indefinite anticoagulation therapy and both patients remain asymptomatic, after 1 year of surveillance in the first case and 6 months in the second, with no new episodes of DVT. Although it is not a life-threatening anomaly, it is important to make an appropriate diagnosis and provide treatment to improve the symptoms and quality of life of these patients.

Inferior Vena Cava agenesis presenting as deep vein thrombosis in an eight year-old girl

Agenesis of vena cava inferior (AVCI) is a rare congenital malformation with a prevalence of 0.0005-1% in the general population. High level of suspicion is required in young patients with deep vein thrombosis (DVT), particularly bilateral. We present an 8-year-old girl with AVCI presenting as bilateral lower extremity DVT and a review of the literature in pediatric cases with AVCI and DVT.

Venous Thromboembolism in a Patient with Interrupted Inferior Vena Cava and Compressed Azygos Continuation: A Case Report and Review of Literature

We report an unusual case of a 40-year-old male patient who experienced painful swelling of the left lower limb that persisted for 1 week. Imaging modalities not only confirmed the diagnosis of acute iliofemoral venous thrombosis and pulmonary embolism (PE), but also an incidental finding of interrupted inferior vena cava (IVC). This congenital anomaly is uncommon but rarely associated with venous thromboembolism (VTE). The azygos continuation was compressed by the descending aorta against the 11^th thoracic vertebrae, which was identified as the cause of VTE. He was treated successfully with anticoagulation and compression therapy. The patient was discharged with lifelong oral Rivaroxaban and remained asymptomatic. In the literature, only 9 cases of interrupted IVC-associated PE were identified but none was due to significant venous compression.

Agenesis of the Intrahepatic Inferior Vena Cava: A Case Report and Literature Review

Anomalies of the inferior vena cava (IVC) are an uncommon finding in the general population. A wide range of IVC anomalies has been described in the literature, the majority of which lack clinical significance. Agenesis of the IVC (AIVC) is a rare anomaly of the IVC in the general population. This anomaly may involve either complete agenesis of the IVC or agenesis of a segment of the IVC. Agenesis of the suprarenal segment is the most commonly occurring variant, while agenesis of the infrarenal and hepatic segments is less common. Here we report a case of agenesis of the intrahepatic segment of the IVC.

Recurring hematuria revealing absence of infrarenal segment of the inferior vena cava

Abnormal development of the inferior vena cava is a relatively rare condition. We report the case of a 47-year-old woman presenting with an absent infrarenal segment of the inferior vena cava revealed by recurring episodes of gross hematuria. This entity probably resulted from perinatal acquired thrombosis rather than from a congenital anomaly and is associated with compensatory dilation of collateral venous pathways. This extremely rare hemorrhagic presentation is presumably caused by rupture of small dilated renal or vesical veins. Ignorance of this atypical presentation can lead to erroneous or delayed diagnoses.

Conservative treatment vs thrombus removal for Iliofemoral vein thrombosis in patients with congenital abnormalities of the inferior vena cava: a case report and systematic review of the literature

Congenital abnormalities of the Inferior Vena Cava (IVC) should be suspected in cases of Deep Venous Thrombosis (DVT), especially in young patients, with no other risk factors and apparent causes. Currently, there is no guidance regarding the management of such patients. We report a case of Iliofemoral vein thrombosis in a young patient with congenital absence of the IVC that was successfully treated with catheter-directed thrombolysis (CDT) and perform a systematic review of the literature to identify evidence about the epidemiology, clinical presentation, management, and prognosis of this rare cause of DVT. A total of 42 studies reporting on 56 cases were included in the review. The mean age of the patients at the presentation of their first DVT episode is 23.6 years, 83.9% of patients were males, conservative management with anticoagulation was used in 68% of the reported cases, and thrombolysis was used in 32% of the cases. Only 10.7% of patients presented with PE potentially justified by the abnormal anatomy of the deep veins which makes the propagation of thrombi into the pulmonary arteries less possible. Comparing the long-term outcomes of the two treatment groups; 42.3% of the patients treated conservatively vs 15.4% of the patients treated with thrombolysis developed chronic symptoms (residual heaviness, pain, swelling, and cramping). 11.5% of patients who received conservative treatment developed post-thrombotic syndrome. None of the patients treated with thrombolysis developed post-thrombotic syndrome. There were no procedure-related complications and thrombolysis was well tolerated by the entirety of the thrombolysis treatment group. Recurrence of DVT occurred in 13% of the patients treated conservatively and in 7.7% of patients treated with thrombolysis. Thrombus removal by means of thrombolysis is the recommended treatment and can offer excellent short and long-term results. Anticoagulation with NOACs may be prescribed for life to prevent recurrence or for at least 6 months and then reconsidered following further evaluation of patients' bleeding risk. It may be of value to organise an international registry for such patients. Guidelines issued by the relevant scientific societies will then be able to make a clear recommendation about the management of such patients.

Bilateral proximal deep vein thrombosis and COVID-19 in a patient with absence of inferior vena cava: A case report and review of literature

Bilateral proximal deep vein thrombosis (DVT) in the lower extremities of young patients should raise suspicion over pro-thrombotic conditions and venous anatomical abnormalities, even in the presence of other precipitating factors, such as viral infection. The authors present a 33-year-old man with bilateral DVT and absence of inferior vena cava (AIVC), who also had concurrent COVID-19, and discuss the management of this patient.

Kidney and Inferior Vena Cava Abnormalities With Leg Thrombosis (KILT) Syndrome in a 24-Year-Old Man

Here, we present a case of kidney and inferior vena cava abnormalities with leg thrombosis (KILT) syndrome, which consists of the triad of congenital kidney anomalies, inferior vena cava anomalies, and deep venous thrombosis. KILT syndrome is usually an incidental finding while investigating other conditions.

Chronic occlusion mimicking agenesis of the inferior vena cava in patients with iliofemoral deep vein thrombosis

Agenesis of the inferior vena cava (IVC) has been described as a risk factor for proximal deep vein thrombosis (DVT). We have described the cases of two patients with iliofemoral DVT who had developed post-thrombotic syndrome (PTS). Both cases were misdiagnosed as IVC agenesis on routine imaging; however, an IVC lumen was successfully identified and recanalized during venography with significant improvement in the patients' PTS symptoms. Patients with iliocaval segment DVT with a misdiagnosis of IVC agenesis might have chronic occlusion imitating agenesis. It is worthwhile to attempt percutaneous recanalization of the IVC lumen in these patients and restoring normal venous flow to prevent the development of PTS.

High penetrance of inferior vena cava system atresia in severe thrombophilia caused by homozygous antithrombin Budapest 3 variant: Description of a new syndrome

Atresia of inferior vena cava (IVC) is a rare congenital malformation associated with high risk of venous thrombosis that still has unknown etiology, although intrauterine IVC thrombosis has been suggested to be involved. The identification of IVC atresia in a case with early idiopathic venous thrombosis and antithrombin deficiency caused by the homozygous SERPINC1 c.391C > T variant (p.Leu131Phe; antithrombin Budapest 3) encouraged us to evaluate the role of this severe thrombophilia in this vascular abnormality. We have done a cross-sectional study in previously identified cohorts of patients homozygous for the Budapest 3 variant (N = 61) selected from 1118 patients with congenital antithrombin deficiency identified in two different populations: Spain (N = 692) and Hungary (N = 426). Image analysis included computed tomography and phlebography. Atresia of the IVC system was observed in 17/24 cases (70.8%, 95% confidence interval [CI]: 48.9%-87.3%) homozygous for antithrombin Budapest 3 with available computed tomography (5/8 and 12/16 in the Spanish and Hungarian cohorts, respectively), 16 had an absence of infrarenal IVC and one had atresia of the left common iliac vein. All cases with vascular defects had compensatory mechanisms, azygos-hemiazygos continuation or double IVC, and seven also had other congenital anomalies. Short tandem repeat analysis supported the specific association of the IVC system atresia with SERPINC1. We show the first evidence of the association of a severe thrombophilia with IVC system atresia, supporting the possibility that a thrombosis in the developing fetal vessels is the reason for this anomaly. Our hypothesis-generating results encourage further studies to investigate severe thrombophilic states in patients with atresia of IVC.

Massive thrombosis in an infant with suspected nephrocalcinosis: case report and literature review

Introduction

Perinatal period is characterized by an increased risk of thrombosis due to low resources and limited compensatory capacity of the coagulation system in early stages of life.

Case report

We report a case of a second pregnancy female infant born at 39 weeks by caesarean section, due to pre-labor rupture of membranes, with body weight of 3,570 γ and Apgar score 10. The pregnancy was complicated by hypothyroidism, uterine myoma, urinary tract infections, and mother's appendectomy at 16 Hbd. At 3 months, the girl was admitted to our hospital due to kidney calcifications, which were incidentally found during ultrasound scan. In laboratory workup, no abnormalities in calcium and phosphate homeostasis were detected. However, in ultrasound scan, linear calcifications along pyramids were visualized in both kidneys. Due to atypical location of nephrocalcinosis, Doppler scan was performed, showing lack of visible blood flow from renal veins to inferior vena cava (IVC), with compensatory flow from renal veins to paravertebral plexuses, and IVC obliteration with a massive calcification in the hepatic section. Magnetic resonance confirmed obliteration of IVC and common iliac veins, segmental dilatation of IVC, and compensatory blood flow from kidneys and lower limbs to paravertebral plexuses. Clinical picture and formation of collateral circulation suggested intrauterine thrombosis. Congenital thrombophilia was excluded in laboratory examination.

Conclusions

The differential diagnosis of calcifications in renal parenchyma (nephrocalcinosis) should include renal vein thrombosis. Massive fetal and perinatal thrombosis can be asymptomatic due to high ability to form collateral circulation at the early stage of life.

A Literature Review and Case Series of DVT Patients with Absent IVC Treated with Thrombolysis

BACKGROUND

Congenital absence of the inferior vena cava is related to deep venous thrombosis (DVT) in 5% of cases with no other risk factors. DVT is normally diagnosed by Duplex, whereas computerized tomography or magnetic resonance imaging is required to visualize this absence, and so, it is often missed but ought to be considered in young patients. There are many existing cases in the literature illustrating this link, but these patients were often managed conservatively with anticoagulation.

CASE SERIES

We report five cases presenting with a DVT who were found to have an absent inferior vena cava after imaging and were treated successfully with thrombolysis and consequently managed with lifelong anticoagulation, between January 2014 and January 2019.

CONCLUSIONS

Anomalies of the inferior vena cava can cause unprovoked DVT. These anomalies are often incidental findings after CT but could change the management plan in these patients. Treatment can be with anticoagulants only, thrombolysis, thrombectomy, balloon angioplasty or stents, and long-term or lifelong anticoagulation to prevent DVT recurrence.

Ultrasound Guided Laparoscopic Port Placement in a Patient with Congenital Anomaly of IVC Undergoing Sleeve Gastrectomy

We report a patient with obesity who underwent laparoscopic sleeve gastrectomy after pre-operative ultrasound mark up to enable safe port insertion due to presence of venous collaterals in the abdominal wall as a result of congenial IVC anomaly. This patient was falsely presumed to have NASH cirrhosis. Detailed preoperative workup ruled this out and led to the discovery of congenital IVC anomaly as the cause of engorged blood vessels in the anterior abdominal wall. On table ultrasound mark up of safe sites for port insertion enabled a safe laparosocpic sleeve gastrectomy on this patient.

Thrombophlebitis hiding under a KILT - case report on 40 years long-term follow-up of neonatal renal vein thrombosis

Background

Neonatal renal vein thrombosis is a recognised cause of renal and inferior caval vein atresia (IVCA). However, the long-term impact of the condition is underrecognized with a high burden of morbidity for the patient, especially in adulthood. IVCA has been shown to be an independent risk factor for deep venous thrombosis (DVT) with a high risk of recurrence. The acronym KILT for kidney and inferior vena cava anomaly with leg thrombosis summarizes the pathological situation.

Case presentation

We present the case of a 40-year-old patient with pain in the right lower limb resulting from acute thrombophlebitis. No risk factors could be identified. His history was remarkable with two episodes of deep venous thrombosis first of the left, then the right leg 22 years earlier; at that time also, no risk factor was identified. Because of the idiopathic character of that thrombosis, the patient remained on long-term anticoagulation with phenprocoumon. The present thrombophlebitis occurred while the INR was not therapeutic in the preceding weeks. A CT with contrast showed atresia of the inferior vena cava and of the right kidney, and presence of numerous collaterals. A thorough medical history revealed a renal vein thrombosis as a neonate. Anticoagulation was intensified, and stent placement became necessary after a further 2 years.

Discussion and conclusions

KILT syndrome is a rare but underrecognized condition. Complications may arise in young adulthood only, and it is of prime importance to instruct parents of the pediatric patient of the possible consequences of renal vein thrombosis and to assure guidance from the treating physicians throughout adulthood. Diagnosis of IVCA is by CT with contrast or by MRI, and lifelong anticoagulation may be necessary. Since the KILT syndrome is widely underdiagnosed, we challenge the clinicians to keep it in mind when confronted with thrombophlebitis or thrombosis of the young, male and with no other identifiable risk factors for deep vein thrombosis.

Lower extremity endovenous reconstruction for symptomatic occlusive disease in pediatric patients: techniques, clinical outcomes, and long-term stent patencies

BACKGROUND

Endovascular stent reconstruction is the standard of care for chronic venous occlusive disease in adults, but it has not been reported in pediatric patients.

OBJECTIVE

This study reports the technical success, complications, clinical outcomes, and stent patency of iliocaval stent reconstruction for chronic iliocaval thrombosis in pediatric patients.

MATERIALS AND METHODS

Fourteen patients, 13 (93%) male with a mean age of 16.4 years (range: 8-20 years), underwent iliocaval stent reconstruction for chronic iliocaval thrombosis. The mean number of prothrombotic risk factors was 2.5 (range: 0-4), including 7 (50%) patients with inferior vena cava atresia. At initial presentation, the Clinical, Etiology, Anatomy, and Pathophysiology classification (CEAP) score was C3 in 2 (14%) patients, C4 in 11 (79%) patients, and C6 in 1 (7.1%) patient. Time course of presenting symptoms included chronic (>4 weeks) (n=7; 50%) and acute worsening of chronic symptoms (2-4 weeks) (n=7; 50%). Aspects of recanalization and reconstruction, stenting technical success, complications, clinical outcomes and stent patency were recorded. Clinical success was defined as a 1-point decrease in the CEAP. Primary, primary-assisted, and secondary patency were defined by Cardiovascular and Interventional Radiological Society of Europe guidelines.

RESULTS

Most procedures employed three access sites (range: 2-4). Intravascular ultrasound was employed in 11 (79%) procedures. Blunt and sharp recanalization techniques were used in 12 (86%) and 2 (14%) patients, respectively. Stenting technical success was 100%. Two (14%) minor adverse events occurred and mean post-procedure hospitalization was 2.8 days (range: 1-8 days). Clinical success rates at 2 weeks, 6 months and 12 months were 85%, 82%, and 83%, respectively. At a mean final clinical follow-up of 88 months (range: 16-231 months), clinical success was 93%. Estimated 6- and 12-month primary stent patencies were 86% and 64%, respectively. Six- and 12-month primary-assisted and secondary stent patency rates were both 100%.

CONCLUSION

Iliocaval stent reconstruction is an effective treatment for symptomatic chronic iliocaval thrombosis in pediatric patients with high rates of technical success, 6- and 12-month clinical success, and 6- and 12-month primary-assisted and secondary patency rates.

[Deep venous thrombosis caused by congenital inferior vena cava agenesis]

Congenital agenesis of the inferior vena cava, although rare, is found preferentially in young patients with proximal deep venous thrombosis. Exact diagnosis can be made thanks to enhanced computed tomography scan and/or magnetic resonance imaging, while Doppler ultrasonography is insufficient to establish an inferior vena cava malformation. A consensus has not yet been established for the treatment but lifelong anticoagulation with elastic stocking support to prevent post-thrombotic syndrome is commonly considered in most cases. We report a case of an unprovoked deep venous thrombosis caused by a congenital agenesis of the inferior vena cava localized to the infrarenal segment, in a 24-year-old man. An anticoagulation with low molecular weight heparin was started and prolonged oral anticoagulation was prescribed. In the absence of the usual thrombotic risk factors, the presence of an inferior vena cava anomaly should be considered.

Pelvic congestion syndrome due to agenesis of the infrarenal inferior vena cava

The inferior vena cava (IVC) is the main conduit of venous return to the right atrium from the lower extremities and abdominal organs. Agenesis of the IVC has an incidence of <1% in the general population [1], although it has been reported in the literature as occurring in up to 8.7% of the population [2]. Patients with absent IVC may present with symptoms of lower extremity venous insufficiency [6], idiopathic deep venous thrombosis [7], or pelvic congestion syndrome. To our knowledge there have only been a few cases reported in the literature of agenesis of the IVC associated with pelvic congestion syndrome [3,10,11]. We present another interesting case of pelvic congestion syndrome due to absent IVC.

Inferior Vena Cava Agenesis: A Rare Cause of Pelvic Congestion Syndrome

Complete absence of Inferior Vena Cava (IVC) is a rare anomaly with a reported incidence of 0.0005% to 1%. This is often asymptomatic with incidental detection during cross-sectional imaging. It may also present with deep venous thrombosis, pulmonary thromboembolism or compressive symptoms in form of nerve root compression. Pelvic Congestion Syndrome (PCS) is an increasingly recognized entity with well laid out diagnostic criteria and evolving management protocols. Complete absence of IVC is a rare cause of pelvic congestion syndrome. We present a case of young female presenting with symptoms typical of pelvic venous congestion who was found to have complete absence of IVC as the underlying cause. She also had associated small left kidney with compensatory hypertrophy of the right kidney which is another rare association.

Congenital absence of infrarenal inferior vena cava and deep veins of the lower limbs: a case report

BACKGROUND

Congenital anomalies of the venous system are known but congenital absence of infrarenal inferior vena cava with absent deep venous system of the lower limbs is extremely rare.

CASE PRESENTATION

We report the case of an 11-year-old Indian girl who presented with large venous collaterals on her anterior abdominal wall and recurrent non-healing venous ulcers on her left leg with complete absence of infrarenal inferior vena cava and absent deep veins of her lower limbs.

CONCLUSIONS

Congenital absence of infrarenal inferior vena cava may occur with absence of the deep venous system of the lower limbs. We have reported this case because of its extreme rarity and to enhance awareness of this entity that has no treatment currently.

Successful Surgical Management of Pelvic Congestion and Lower Extremity Swelling Owing to Absence of Infrarenal Inferior Vena Cava

Absence of isolated infrarenal inferior vena cava (IVC) is a rare condition documented in only a few published cases and typically treated with anticoagulation. We herein describe successful surgical management of the isolated infrarenal IVC absence in a healthy 35-year-old woman who presented with disabling pelvic congestion. An ascending venogram showed the absence of infrarenal IVC with a large left ovarian vein draining pelvic collateral vessels to the normal left renal vein and suprarenal IVC. The patient was successfully treated with a common femoral vein to the suprarenal IVC bypass using a bifurcated polytetrafluoroethylene graft, with rapid symptom resolution, and remained symptom free 6 months later. This is the first reported case describing a surgical strategy for isolated infrarenal IVC absence in a symptomatic patient.

Disappearing Inferior Vena Cava in A Pediatric Patient with Down Syndrome and Hereditary Thrombophilia

Absence of the infrarenal segment of the inferior vena cava is an extremely rare anomaly. The reasons for such a developmental failure are unclear. Most researchers believe that the cause lies in embryonic dysgenesis affecting separate segments or the entire inferior vena cava. Others suggest that absence of the inferior vena cava is not embryonic in origin, rather the result of intrauterine or perinatal thrombosis. We report a case here that during a period of six months, inferior vena cava first occluded, then become redundant in a baby girl with several chromosomal and gene defects, including Down syndrome and hereditary thrombophilia, admitted to our hospital due to the swelling and redness of the right lower extremity. From this observation, we propose that the absence of the inferior vena cave was not of embryonic origin but due to thrombosis.

Deep Vein Thrombosis Provoked by Inferior Vena Cava Agenesis

Inferior vena cava agenesis (IVCA) is a rare congenital anomaly that can be asymptomatic or present with vague, nonspecific symptoms, such as abdominal or lower back pain, or deep vein thrombosis (DVT). Here, we present a 55-year-old male who came with painless swelling and redness of his left lower limb. On examination, swelling and redness were noted extending from the left foot to the upper thigh; it was also warm compared to his right lower limb. Venous Doppler ultrasound was done which showed DVT extending up to the common femoral vein. Subsequently, computed-tomography (CT) of the chest and abdomen was done to exclude malignancy or venous flow obstruction; it revealed congenital absence (agenesis) of the infrarenal inferior vena cava (IVC).

Incidental Finding of Inferior Vena Cava Atresia Presenting with Deep Venous Thrombosis following Physical Exertion

Inferior vena cava atresia (IVCA) is a rare but well described vascular anomaly. It is a rare risk factor for deep venous thrombosis (DVT), found in approximately 5% of cases of unprovoked lower extremity (LE) DVT in patients <30 years of age. Affected population is in the early thirties, predominantly male, often with a history of major physical exertion and presents with extensive or bilateral DVTs. Patients with IVC anomalies usually develop compensatory circulation through the collateral veins with enlarged azygous/hemizygous veins. Despite the compensatory circulation, the venous drainage of the lower limbs is often insufficient leading to venous stasis and thrombosis. We describe a case of extensive and bilateral deep venous thrombosis following physical exertion in a thirty-six-year-old male patient with incidental finding of IVCA on imaging.

Inferior vena cava anomalies and variations: imaging and rare clinical findings

Purpose

The aim of this paper is to summarize imaging findings of some frequent and infrequent inferior vena cava (IVC) anomalies and variations.

Conclusions

IVC anomalies should be suspected in patients presenting with pulmonary emboli, chronic pain, and deep vein thrombosis. To correctly characterize and classify IVC anomalies and variations is of crucial importance for proper planning of surgical interventions and thus for avoiding serious complications.

Key Points

• IVC anomalies should be suspected in patients with pulmonary emboli, pain, and venous thrombosis.

• Awareness of IVC anomalies and variations is crucial for clinical and surgical procedures.

• Unawareness of these anomalies may lead to severe and deadly complications.

Caval agenesis in the pediatric liver donor

The following is the first report of a pediatric organ donor with caval agenesis and the subsequent use of this liver for transplantation. Caval embryology and potential implications of utilizing a donor liver with caval agenesis are reviewed.

Adult liver transplantation in the congenital absence of inferior vena cava

Whereas congenital absence of inferior vena cava observed in paediatric population more often than not, as an isolated or syndromic variety, this is seldom encountered in adult liver transplant recipients. There appear few sporadic reports in the literature on experience of such anomaly in adults. Given the rarity of situation, surprising encounters of such anomalies may pose challenge to the unprepared transplant surgeon and unfavourable outcomes may even have resulted in under-reportage of this condition. In this brief report we document our recent experience with two such cases and this is supplemented with extensive reference to the literature on classification of such anomalies with the endeavour to document implications of such in the adult liver transplant setting.

Absence of inferior vena cava in 14-year old boy associated with deep venous thrombosis and positive Mycoplasma pneumoniae serum antibodies--a case report

Background

Absence of the inferior vena cava is a rare vascular anomaly, which usually remains asymptomatic in childhood. It is recognized as the risk factor for deep venous thrombosis, since the collateral circulation does not provide adequate drainage of the lower limbs. Mycoplasma pneumoniae is a common cause of community-acquired pneumonia in school-aged children and adolescents. Mycoplasma pneumoniae infection might be associated with deep venous thrombosis but its pathophysiology remains unknown. According to previous reports, deep venous thrombosis due to Mycoplasma pneumoniae infection is associated with positive serum anticardiolipin antibodies. To our knowledge, we describe the first case of deep venous thrombosis associated with Mycoplasma pneumoniae serum antibodies indicating early stage of infection with negative anticardiolipin serum antibodies in adolescent with absence of inferior vena cava.

Case presentation

14-year old boy was admitted to the pediatric unit few days after the appendectomy complaining with pain of the left hip that caused him unable to walk. The pain was accompanied with subfebrile temperature. After clinical examination and additional tests, the boy was diagnosed with a deep venous thrombosis. Computed tomography revealed absence of the vena cava inferior distally to the hepatic veins and varices of the collateral circulation in the pelvis. Anticardiolipin IgM and IgG antibodies and antinuclear antibodies were not detected. Additionally, the Mycoplasma pneumoniae antibodies in classes IgM, IgA and IgG were detected in serum as another risk factor of thrombosis. After the initial treatment with low-molecular-weight heparin in combination with clarithromycin the clinical condition of the patient improved. The patient became a candidate for life-long anticoagulation therapy.

Conclusions

In this case Mycoplasma pneumoniae antibodies were associated with deep venous thrombosis in child with congenital absence of inferior vena cava. Uncommonly for deep venous thrombosis due to Mycoplasma pneumoniae infection, anticardiolipin antibodies were not detected in serum. It is important to remember in clinical practice that Mycoplasma pneumoniae affects coagulability and may trigger thrombosis, especially in the presence of other risk factors. The pathophysiology of this process remains unknown.

Elevated risk of thrombophilia in agenesis of the vena cava as a factor for deep vein thrombosis

Background

Congenital absence of the inferior vena cava (AIVC) is a rare malformation which may be associated with an increased risk for deep vein thrombosis (DVT). However, the role of thrombophilia in AIVC and DVT is unknown.

Methods

Between 1982 and 2013 41 patients (12 female, 29 male, mean age 28 S.D. 11 years) were detected at the University of Düsseldorf, Germany, with AIVC. Based on medical history, clinical examination, imaging and coagulation studies, we performed on this collective a risk characterisation. Extensive literature research added further 123 published cases during 1993 and 2013. AIVC-patients were compared with iliocaval DVT-patients without AIVC (n = 168) treated during the same period in our clinic (90 female, 78 male, mean age 38 S.D. 17 years).

Results

In contrast to classical DVT younger men were more often affected. Factor-V-Leiden-mutation, 5,10-methylenetetrahydrofolate reductase (MTHFR) polymorphism and hyperhomocysteinemia individually are associated with an increased risk of DVT in patients with AIVC. Aplasia/hypoplasia of the right or left kidney is also associated with IVCA.

Conclusions

AIVC should be considered in young patients who present with DVT involving the vena cava. Analysis of publications with AIVC and our patients yielded a typical spectrum of AIVC-associated DVT characteristics: AIVC occurs in young male adults, is revealed by proximal DVT, not necessarily accused by precipitating factors like immobilisation, and is mostly located bilateral. Hereditary coagulation abnormalities seem to be more often a contributing factor for DVT in AIVC.

Electronic supplementary material

The online version of this article (doi:10.1186/s13023-014-0223-4) contains supplementary material, which is available to authorized users.

Utero-ovarian varices and absent inferior vena cava in pregnancy

Extensively distended and tortuous vessels on both sides of the uterus are rare incidental findings on transvaginal sonography in early pregnancy. A 31-year-old woman with a history of surgical repair for congenital intestinal stenosis was noted to have utero-ovarian varices on a transvaginal ultrasound examination during her first prenatal visit at 6 weeks' gestation. Magnetic resonance imaging revealed dilated ovarian veins along with infrarenal absence of inferior vena cava as well as the absence of external and common iliac veins. Despite concerns regarding spontaneous utero-ovarian vessels rupture, her antenatal course was uneventful. A vaginal delivery was successfully achieved without any postpartum complication. We also demonstrated an intraoperative view of the utero-ovarian vessels during cesarean section in her subsequent pregnancy. Absence of inferior vena cava and pelvic varices can occur in women with a history of neonatal surgery. Although the risk of utero-ovarian varices rupture remains unclear, vaginal delivery may be safely achieved.

A rare case: Vena cava inferior agenesis with aberrant hepatic vein in an asymptomatic patient

Inferior vena cava agenesis is a rare anomaly in an asymptomatic patient. A 58-year-old female patient with complete absence of the inferior vena cava and aberrant right hepatic vein is presented with radiologic findings. To our best knowledge, such a combination of venous anomalies has not previously been documented in the literature and this is the first case in the literature due to the coincidence of total inferior vena cava agenesis with aberrant hepatic vein.

The curious case of the disappearing IVC: a case report and review of the aetiology of inferior vena cava agenesis

We report the case of a previously well 18-year-old male who presented to the Emergency Department with lower limb pain. An ultrasound demonstrated extensive left sided deep vein thrombosis and computed tomography demonstrated inferior vena cava agenesis, leading to the diagnosis of inferior vena cava agenesis associated deep vein thrombosis. The aetiology of inferior vena cava agenesis is explored in depth.

Bilateral lower-extremity numbness and ataxia in a young female runner

Inferior vena cava (IVC) absence is thought to have either embryologic or developmental etiologies, depending on the degree of absence. Entire absence of the IVC is thought to be due to embryologic insult, whereas recent studies propose that infrarenal IVC absence is developmental, secondary to perinatal thrombosis. Here we report on an adolescent woman with infrarenal absence of IVC and common iliac veins. Clinically, she presented with bilateral lower-extremity numbness and ataxia following strenuous exercise (running > 1 mile). Symptoms resolved with 30 seconds of rest. Radiographically, MRI revealed extensive collateral vasculature that had developed within the paravertebral soft tissues and epidural space of the spinal canal; these collaterals coursed through the neural foramina and caused moderate stenosis at L4/5 and L5/S1.

Dysgenesis of the inferior vena cava associated with deep venous thrombosis and a partial Protein C deficiency

Dysgenesis of the inferior vena cava is rare but it is being increasingly diagnosed by cross-sectional imaging techniques. Patients are usually asymptomatic with abnormalities detected incidentally. An 11 year old boy presented with a 10 day history of fever, vomiting and abdominal pain, which progressed to his back and lower limbs. Magnetic resonance imaging, computerised tomography and Doppler ultrasonography showed the absence of a suprarenal inferior vena cava with bilateral superficial femoral vein thrombi extending cranially to the end of the aberrant inferior vena cava. Haematological testing revealed a partial Protein C deficiency. The presenting clinical picture in this case is unique within the English literature and highlights that deep venous thrombosis associated with inferior vena cava dysgenesis may not present with typical symptoms in children. Early use of advanced imaging modalities would expedite diagnosis and subsequent treatment.

A very rare cause of low-back pain and sciatica: deep vein thrombosis due to absence of the inferior vena cava mimicking the clinical and radiological signs of lumbar disc herniation

The authors report a very rare cause of low-back pain and sciatica in a patient with iliac vein thrombosis attributed to absence of the infrarenal segment of the inferior vena cava (IVC) with massively dilated venous collaterals draining via a paraspinal plexus into the azygous system. This 21-year-old man presented with acute low-back pain radiating to the left ventral thigh. The initial CT scan revealed an intraspinal lesion that mimicked lumbar disc herniation. Further clarification revealed an iliac vein thrombosis, which was triggered by the absence of the infrarenal segment of the IVC, a very rare vascular anomaly. Collateral venous return was developed and led to lumbar varicosities and epidural vein engorgements. Laboratory examinations revealed factor V mutation as a predisposing factor for thrombosis. The patient's symptoms were relieved with anticoagulation and antiinflammatory therapy. Absence of the infrarenal IVC associated with iliac vein thrombosis should be regarded as a very rare cause of radicular and low-back pain, and this condition can mimic the clinical and radiological signs of lumbar disc herniation. Sciatica might be the first clinical manifestation of this rare venous anomaly.