Systemic to pulmonary venous shunt and the focal hepatic hot spot sign from SVC obstruction in Behcet's disease

Bicaval thrombosis and systemic-to-pulmonary venous shunting: A case report and systematic review of the literature

Systemic-to-pulmonary venous shunts (SPVSs) in the setting of combined superior and inferior venae cavae occlusion are exceedingly rare. A 52-year-old female with antiphospholipid syndrome and venous thromboembolism (on Coumadin) was admitted with shortness of breath and profound hypoxia. She had a retained fractured dialysis catheter from the superior to inferior vena cava. Imaging showed thrombotic bicaval occlusion, with extensive collateralization from peri‑hepatic and chest wall veins to the right pulmonary veins. Due to poor neurological status due to hypoxic brain injury and refractory hypoxemia, family opted to pursue comfort care. A comprehensive literature search yielded 29 additional cases of SPVSs, with a male majority (53 %) and mean age of 43.5 years. Only 7 cases (∼23 %) reported bicaval obstruction, all occurring during or after the year 2000. We highlight SPVSs as a possible cause of refractory hypoxia. Early intervention to relieve central obstruction and exclude SPVSs is the cornerstone of management.