Thrombosis in inferior vena cava (IVC) due to intra-cystic hemorrhage into a hepatic local cyst with autosomal dominant polycystic kidney disease (ADPKD)

Incoercible Vomiting in a Polycystic (ADPKD) Patient on Peritoneal Dialysis

Although gastrointestinal symptoms are not uncommon in PD patients due to several causes, such as infusion volume with early satiety, constipation, or peritonitis, sometimes the differential diagnosis is more challenging for nephrologists. We present the case of a woman with end-stage renal disease due to autosomal dominant polycystic kidney disease on PD who presented with swollen legs and incoercible vomiting. After ruling out constipation and infection, an abdominal CT was done, revealing extrinsic compression of the intrahepatic inferior cava vein (ICV) and massive venous thrombosis from ICV to bilateral iliofemoral deep veins. In addition, CT also showed displacement and extrinsic compression of the stomach, pylorus, and duodenum due to an enlarged liver cyst. Percutaneous drainage and sclerosis of the cyst compressing the stomach was performed, anticoagulation was started, and the patient clinically improved with complete resolution of symptoms.

Varicose Veins and Chronic Venous Disease

Chronic venous disease is a worldwide problem associated with significant morbidity and is expected to increase in prevalence as the current population ages. This is a comprehensive review of the anatomy, pathophysiology, genomics, clinical classification, and treatment modalities of chronic venous disease.

Pulmonary Embolism in Autosomal Dominant Polycystic Kidney Patient Induced by Inferior Vena Cava Mechanical Compression

Introduction

Autosomal dominant polycystic kidney disease is a common syndrome. Renal and hepatic cysts can cause discomfort, bleeding, rupture, infection, hypertension and a mass effect with compression of adjacent organs.

Case presentation

A 48-year-old man with polycystic kidney disease and hypertension presented to the emergency department for bilateral flank pain. An abdominal computed tomography scan with contrast showed a 7 cm heterogeneous process posteriorly and laterally to the right kidney. It appeared to be a renal cyst associated with bleeding and bilateral pulmonary artery filling defects, apparently due to pulmonary embolism. Cavography following inferior vena cava filter insertion did not show any deep vein thrombosis.

Discussion and conclusion

The pulmonary embolism was probably caused by extrinsic inferior vena cava compression by a liver cyst. Virchow's triad of stasis, vessel damage and hypercoagulability probably resulted in a thrombus which moved on the right side to the pulmonary artery.

LEARNING POINTS

Autosomal dominant polycystic kidney disease is a common syndrome.Renal and hepatic cysts can compress adjacent organs.The mass effect of a large cyst on the right side compressed the inferior vena cava, resulting in Virchow's triad of stasis, vessel damage and hypercoagulability, which can cause pulmonary embolism.

Prevalence of Inferior Vena Cava Compression in ADPKD

Introduction

Kidney and liver cysts in autosomal dominant polycystic kidney disease (ADPKD) can compress the inferior vena cava (IVC), but IVC compression prevalence and its risk factors are unknown.

Methods

Patients who have ADPKD (n = 216) with abdominal magnetic resonance imaging (MRI) studies and age-/sex-matched controls (n = 216) were evaluated for IVC compression as well as azygous vein diameter (a marker of collateral blood flow) and IVC aspect ratio (left-to-right dimension divided by anterior-to-posterior dimension with a value of 1 corresponding to a circular (high pressure) IVC caudal to compression.

Results

Severe IVC compression (≥70%) was observed in 33 (15%) ADPKD subjects and mild compression (≥50% to <70%) was observed in 33 (15%) subjects; whereas controls had no IVC compression (P < 0.001). Severe IVC compression was associated with larger azygous vein (4.0 ± 1.3 mm versus 2.3 ± 0.8 mm without IVC compression; P < 0.001) and a more circular IVC cross-section upstream (mean IVC aspect ratio: 1.16 ± 0.27 vs. 1.69 ± 0.67, P < 0.001), suggesting higher pressure upstream from the compression. IVC compression was associated with older age, lower estimated glomerular filtration rate (eGFR), greater height-adjusted total kidney volumes, greater height-adjusted liver volume (ht-LV), and greater liver and renal cyst fractions (P < 0.001). No subject younger than 30 years had IVC compression, but ADPKD subjects ≥40 years old had 12-fold higher risk of IVC compression (95% confidence interval [CI]: 4.2–42.4), with highest predicted probability for Mayo Clinic classes 1D (59%; 95% CI: 39%–76%) and 1E (74%; 95% CI: 49%–90%) after adjustment (P < 0.001). Women with ht-LV ≥ 2000 ml/m had 83% (95% CI: 59%–95%) prevalence of IVC compression. Complications of IVC compression included deep vein thrombosis (DVT) and symptomatic hypotension.

Conclusions

IVC compression is common in ADPKD patients >40 years old, with Mayo Clinic class 1D/E, and in females with ht-LV > 2000 ml/m.

[Deep Vein Thrombosis Due to Compression of Huge Hepatic Cyst Successfully Treated by Inferior Vena Cava Filter and Cyst Drainage]

An 88-year-old woman complained of right quadrant abdominal pain and severe edema in both legs. She had a history of pulmonary embolism one month ago. Abdomen CT showed a huge hepatic cyst compressing the intrahepatic portion of the inferior vena cava (IVC). The venogram CT showed multifocal thrombosis in the iliocaval and both lower extremity veins. Percutaneous hepatic cyst drainage was carried out. Fluid analysis presented leukocytosis, which suggested an infected hepatic cyst. To prevent secondary pulmonary thromboembolism, an IVC filter was inserted before catheter drainage for the hepatic cyst. One week later, abdominal pain was relieved. Then, sclerotherapy for the remnant hepatic cyst was performed by ethanol. Follow-up CT showed an increased amount of thrombosis in the iliocaval and left calf vein, but the IVC filter prevented another thromboembolic event successfully. The patient started dabigatran, a new oral anticoagulant, and compression stockings were applied to both legs. After one month, no visible thrombosis in the pelvis or either extremity was detected in abdominal CT. This case suggests that a huge hepatic cyst, especially with infection, should be considered as a possible cause of deep vein thrombosis if no other risk factors for thromboembolism exist.

Differential Diagnosis of an Inferior Vena Cava Thrombosis/Hepatic Cyst Using an Abdominal Sonogram, Echocardiogram, Venography, and Computed Tomography Angiogram

The role of cardiac sonographers, as health care professionals, comprises facilitating a cardiologist’s diagnosis of valvular lesions, coronary artery disease, and congenital defects and assessing right-side pulmonary complications and so on. Occasionally, communication of differential diagnoses across several modalities, specialties, and healthcare providers is compulsory, in order to accurately confirm or deny an appropriate diagnosis for patients with unique presentations. This case study highlights the vital role of abdominal sonography, echocardiography, venography, and computed tomography in the diagnosis of a hepatic cyst. In addition, it demonstrates the appropriate measures that cardiac sonographers can take to fully investigate these lesions, especially when they are presumed to be a thrombosed inferior vena cava.

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.

Supra Hepatic Inferior Vena Cava Thrombosis-Surgical Challenges

Autosomal Dominant Polycystic Kidney Disease (ADPKD) is a chronic affliction characterized by numerous liver and kidney cysts. There is a gradual but progressive renal and liver impairment which may require combined liver-kidney transplantation. Compression of the retrohepatic Inferior Vena Cava (IVC) by an enlarged polycystic liver may impede clear visualization on pre-operative imaging and miss an underlying thrombosis or obliteration. This may result in an intra-operative surprise. Management can be challenging requiring modification of conventional surgical approach. We present our experience of a 67-year-old patient who underwent combined liver-kidney deceased donor transplantation for decompensated chronic liver disease with chronic kidney disease due to ADPKD. She was diagnosed with ADPKD for 16 year, with progressive deterioration in kidney function over the last 6 year and liver decompensation following knee replacement surgery requiring regular renal replacement therapy. We report this case to highlight the peri-operative challenges and their management along with a review of published literature on this uncommon occurrence.

Case report of renal pelvis squamous cell carcinoma with tumor embolus in autosomal dominant polycystic kidney disease

INTRODUCTION

Autosomal dominant polycystic kidney disease (ADPKD) is a multisystem hereditary disease characterized by formation of cysts in the ductal organs. Renal pelvis malignancy in ADPKD is very rare and sporadically reported in the previous literature. Here, we report the first case of renal pelvis squamous cell carcinoma with tumor embolus in a 35-year-old ADPKD patient. The patient presented with 3 months of persistent backache and intermittent fever, and was initially diagnosed as intracystic hemorrhage with inferior vena cava thrombosis formation. As a result, he received anticoagulation therapy in a local hospital. However, his backache got worsened during the therapy, and he lost 10 kg of his body weight from the onset of illness. In our hospital, computed tomography demonstrated a heterogeneous right renal mass as well as emboli in the inferior vena cava and bilateral renal veins. Positron emission tomography computed tomography and biopsy were also performed, but the results were equivocal. Considering the patient's willingness and the potential malignancy, we performed thoracoabdominal nephrectomy and embolectomy, and histological examination made the diagnosis of renal pelvis squamous cell carcinoma. After adjuvant chemotherapy including paclitaxel and carboplatin, the patient obtained improved physical status and was disease free at the 6-month follow-up. Although rare, renal pelvis squamous cell carcinoma should be considered in the differential diagnosis of renal mass in ADPKD patients.

CONCLUSION

Our case suggested surgery combined with adjuvant chemotherapy might be effective treatments in such a condition.

Simple hepatic cyst causing inferior vena cava thrombus

INTRODUCTION

Thrombosis of the inferior vena cava (IVC) is governed by Virchow's triad of stasis of blood flow, endothelial damage and hypercoagulability. Causes may be secondary to malignancy, congenital anomalies or other infrequent events such as external compression. We present a case of external compression of the IVC leading to extensive thrombus burden secondary to a benign hepatic cyst.

PRESENTATION OF CASE

A 72 year old African American female presented to the emergency department with new onset shortness of breath, right lower extremity weakness and swelling. CT imaging demonstrated multiple hepatic cysts compressing the IVC, leading to extensive clot burden. Treatment with heparin drip was initiated without resolution of her symptoms. Transcatheter mechanical thrombectomy and tPA infusion was performed. After 24 h, swelling and weakness were nearly resolved. The patient was bridged to therapeutic low molecular weight heparin in preparation for surgery.

DISCUSSION

Management of IVC thrombosis has typically been with a heparin drip and transition to oral anticoagulants. Thrombolysis has been shown to promote complete clot lysis more often than compared to standard anticoagulant therapy. In addition, venous patency was better maintained.

CONCLUSION

We feel that the added benefit of short term effects of improved venous patency and long term benefits of less post thrombotic syndrome, catheter based tPA administration and mechanical thrombectomy for thrombus offers an adjuvant treatment in the setting of large clot burden refractory to standard treatment.

Renal relevant radiology: radiologic imaging in autosomal dominant polycystic kidney disease

Autosomal-dominant polycystic kidney disease is a systemic disorder and the most common hereditary renal disease, which is characterized by cyst growth, progressive renal enlargement, and development of renal failure. The cystic nature of autosomal dominant polycystic kidney disease and its renal and extrarenal complications (kidney stones, cyst hemorrhage, intracerebral aneurysm, liver cysts, cardiac valve abnormalities, etc.) give radiologic imaging studies a central role in the management of these patients. This article reviews the indications, comparative use, and limitation of various imaging modalities (ultrasonography, magnetic resonance imaging, computerized tomography scan, Positron emission tomography scan, and renal scintigraphy) for the diagnosis and management of complications in autosomal dominant polycystic kidney disease. Finally, this work provides evidence for the value of total kidney volume to predict disease progression in autosomal dominant polycystic kidney disease.

Hemorrhagic hepatic cysts mimicking biliary cystadenoma

The hemorrhagic simple hepatic cyst is extremely rare and can sometimes be confused with biliary cystadenoma or cystadenocarcinoma. Here we present two cases of huge hemorrhagic simple hepatic cysts. Case 1 was a 43-year-old man with a cystic lesion measuring 13 cm × 12 cm in the right hepatic lobe. Ultrasound and computed tomography showed several mural nodules on the irregularly thickened wall and high-density straps inside the cyst. Case 2 was a 60-year-old woman with a huge cyst measuring 15 cm × 14 cm in the central liver. Ultrasound and magnetic resonance imaging showed the cystic wall was unevenly thickened and there were some flame-like prominences on the wall. The iconographic representations of the two cases mimicked biliary cystadenoma. Cystectomy and left hepatectomy were performed for the two patients, respectively. Both patients recovered quickly after their operations and showed no recurrence.

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

INTRODUCTION

Inferior vena cava (IVC) thrombosis is a rare event and data detailing the underlying etiology are scarce.

MATERIALS AND METHODS

Therefore, we reviewed all available cases of IVC thrombosis consecutively registered in the MAISTHRO (MAin-ISar-THROmbosis) database and described the prevalence of VTE risk factors and other conditions contributing to IVC thrombosis development.

RESULTS

53 patients (35 F, 18 M) with IVC thrombosis aged 12 to 79 years were identified. 40 patients (75.5%) developed thrombosis under the age of 45. Local problems, such as IVC anomalies or external venous compression, contributed to the development of thrombosis in 12 cases (22.6%). Lupus anticoagulants (10.9 vs. 2.3%, p=0.013) and malignoma (17.0 vs. 6.4%, p=0.023) were more prevalent in IVC thrombosis patients compared to 265 age and sex matched controls with isolated lower extremity DVT. No difference was identified with regard to inherited thrombophilia or other known VTE risk factors. Symptomatic pulmonary embolism (PE) occurred in 32.1% of IVC thrombosis patients compared to 15.2% of controls (p=0.005).

CONCLUSIONS

Local problems such as IVC anomalies and external venous compression, malignancy and the presence of lupus anticoagulants contribute to the risk of IVC thrombosis. The risk of symptomatic pulmonary embolism in the acute setting is high.

Fatal thrombotic complications of hepatic cystic compression of the inferior vena: A case report

Of 5% of patients who develop liver cysts, only 10-15% of them come for medical attention, typically because of dull right upper quadrant pain, abdominal bloating or early satiety. We treated a 77-year-old female with a rare complication of inferior vena cava thrombosis. The patient expired due to septic shock and multiple organ failure.