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.

Sport and Venous Thromboembolism

BACKGROUND

The occurrence of venous thromboembolisms (VTE) in association with sporting activity has been described but not yet systematically explored. The aim of this study was to determine the sites at which VTE occur in athletes, the accompanying features, and the special features of the symptoms and diagnosis, so that physicians can take the findings into consideration.

METHODS

A search of the literature in the databases PubMed, Web of Science, and Cochrane in accordance with the PRISMA criteria, together with a search of Google Scholar up to 29 February 2020.

RESULTS

No observational studies were identified. A total of 154 case descriptions were evaluated: 89 on upper-extremity deep vein thrombosis (DVT), 53 on lower-extremity DVT, and 12 on pulmonary embolisms with no evidence of thrombosis. Ninety-five percent of the upper-extremity DVT involved the region of the subclavian/axillary vein. Thoracic outlet syndrome (38%), hereditary thrombophilia/a family history of VTE (16%), intensive training (12%), and the use of oral contraceptives (7%) were identified as accompanying features. The upper-extremity DVT occurred mainly in male strength athletes and ball sports players. The lower-extremity DVT were located in the lower leg/knee (30%), the thigh (19 %), or occurred in combination in the lower leg-to-pelvis region (30 %). The features accompanying lower-extremity DVT were hereditary thrombophilia/a family history of VTE (30%), trauma (25%), immobilization (21%), and the use of oral contraceptives (11%). The lower-extremity DVT were found in endurance sports and ball sports. The symptoms may be obscured by sport-specific symptoms/trauma, and diagnosis is often delayed. Early D-dimer determination is useful and is complemented by diagnostic imaging.

CONCLUSION

VTE are found in association with sports. The background factors, the sites of VTE, the types of sports involved, and the accompanying features are all important to know. The symptoms may be obscured, and it may be difficult to reach the correct diagnosis. The possible presence of DVT must be borne in mind.

[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.

Anomalous development of the inferior vena cava: Case reports of agenesis and hypoplasia

We reported the cases of two adult male patients who were admitted to our emergency room with abdominal pain and dyspnea caused by gallstones and pulmonary embolism respectively. During the radiological investigations, as collateral findings, we found two anomalous development of the inferior vena cava. These conditions affect about 4% of population and, although asymptomatic or mildly symptomatic, are associated with thrombotic manifestations as deep vein thrombosis and pulmonary embolism. The prompt recognition of these anomalies is necessary in order to prevent the complications associated with these conditions and to set the best therapy for patients.

An unusual occurrence: a case of venous thromboembolism in pregnancy associated with heterotaxy syndrome

BACKGROUND

Heterotaxy is a relatively uncommon congenital anomaly that is usually diagnosed incidentally on imaging studies in adults. We present an unusual case of venous thromboembolism in a 26 year old pregnant female with Heterotaxy syndrome.

CASE PRESENTATION

A 26 year-old pregnant female at 13 weeks gestation suffered cardiac arrest with successful cardiac resuscitation and return of spontaneous circulation. The cardiac arrest was secondary to massive pulmonary embolism requiring thrombolytic therapy and stabilization of hemodynamics. She had extensive evaluation to determine the etiology for the pulmonary embolism and was noted to have an anatomic variation consistent with heterotaxy syndrome on imaging studies. After thrombolysis the patient was treated with UFH and then switched to enoxaparin without complication until 25 weeks of gestation when she experienced worsening abdominal pain with associated headaches, lightheadedness and elevated blood pressures needing elective induction of labor. The infant died shortly after delivery. The anticoagulation was continued for additional 3 months and she was subsequently placed on low dose aspirin to prevent recurrent venous thromboembolic episodes. She is currently stable on low dose aspirin and is into her third year after the venous thromboembolism without any recurrence.

CONCLUSION

To our knowledge, this is the first reported case of venous thromboembolism in pregnancy associated with heterotaxy syndrome. A discussion on pathophysiology of venous thromboembolism in pregnancy and heterotaxy syndrome has been undertaken along with treatment approach in such situations.

Unique venocaval anomalies: case of duplicate superior vena cava and interrupted inferior vena cava

Venocaval anomalies are uncommon in the general population and often go unrecognized, but physicians should be aware of their significance. Duplicate superior vena cava should be identified during cardiac imaging, surgery, and catheter insertions. While interrupted inferior vena cava can predispose to thrombus formation, they protect against pulmonary embolism from lower extremity deep vein thrombosis. We describe a unique case of a patient in which combined superior vena cava and inferior vena cava anomalies were found incidentally. This is the first reported case of a duplicate superior vena cava and interrupted inferior vena cava in a single patient in English literature. This article also provides a literature review on the topic.

Recurrent deep venous thrombosis in a patient with agenesis of inferior vena cava

BACKGROUND

Agenesis of the inferior vena cava (IVC) as a cause of recurrent deep vein thrombosis (DVT) is uncommon.

CASE

A 33-year-old male with no family history of thrombophilia, who had experienced multiple recurrent episodes of DVT over a 15-year period of unknown cause, was admitted into our hospital because of cellulitis in the right leg. Computer tomography with contrast of the abdomen showed an absence of IVC.

CONCLUSION

Congenital absence of the IVC could be a rare risk factor for idiopathic DVT, especially in young individuals.

Thrombectomy and surgical reconstruction for extensive iliocaval thrombosis in a patient with agenesis of the retrohepatic vena cava and atresia of the left renal vein

In 80% of the patients presenting with deep-venous thrombosis (DVT), a risk factor can be identified. An absent or hypoplastic infrarenal vena cava is a rare risk factor for DVT in young adults. In these cases, the prevalence of congenital anomalies of the inferior vena cava (IVC) is estimated at 0.5% of the general population, up to 5% in young people. The association with coagulopathy increases the risk of DVT. We report a case of a young man who presented with a massive caval and iliofemoral-popliteal thrombosis in presence of the agenesis of retrohepatic inferior vena cava and atresia of the left renal vein. Open thrombectomy and caval reconstruction with a polytetrafluoroethylene graft were performed. Surgical option with vein reconstruction was preferred to prevent new episodes of thrombosis and the risk of acute renal failure.

Inferior vena cava agenesis and deep vein thrombosis: 10 patients and review of the literature

Inferior vena cava agenesis (IVCA) is a rare condition, found in almost 5% of patients under 30 years old with unprovoked deep venous thrombosis (DVT). We describe 10 consecutive patients with IVCA-associated DVT and conducted an extensive literature review to investigate the typical spectrum of IVCA-associated DVT. Among our patients (eight men and two women; mean age, 25 ± 4.5 years), DVT followed intense and unusual (major) physical activity for eight of them. DVT was bilateral in six patients and unilateral in four. Ultrasonography was unable to detect IVCA, which was visualized by computed-tomography scans for seven patients, and magnetic resonance imaging and angiography for 10. Hereditary thrombophilia screening, to detect factor V Leiden or prothrombin gene heterozygosity (G20210A mutation), was positive for only two patients. Wearing elastic stockings and taking an indefinite or long-term vitamin K antagonist were prescribed for all 10 patients and nine complied with the latter. To date, 62 patients with IVCA-associated DVT have been reported in the English literature. Analysis of them and our patients yielded a typical spectrum of IVCA-associated DVT characteristics: IVCA occurs in young adults, particularly males, and is revealed by proximal DVT following major physical exertion. All were treated with a prolonged vitamin K antagonist and advised to wear elastic stockings. No precise duration of anticoagulation has been established.