Author + information
- Received August 13, 2018
- Revision received August 23, 2018
- Accepted August 30, 2018
- Published online November 19, 2018.
- Raviteja R. Guddeti, MDa,∗ (, )
- Geetanjali Dang, MDa,
- Abilash Akinapelli, MDa,
- Himanshu Agarwal, MDa and
- Joseph Stavas, MDb
- aDepartment of Medicine, Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, Nebraska
- bDepartment of Radiology, Division of Interventional Radiology, Creighton University School of Medicine, Omaha, Nebraska
- ↵∗Address for correspondence:
Dr. Raviteja R. Guddeti, Division of Cardiovascular Diseases, Creighton University School of Medicine, 7500 Mercy Road, Omaha, Nebraska 68124.
Inferior vena cava (IVC) anomalies are uncommonly described. Many are associated with a higher rate of thromboembolic complications. Here we report a case of IVC thrombosis in a 20-year-old woman with a large isolated retroperitoneal venolymphatic malformation (VLM) with IVC envelopment in which a multimodality imaging approach was implemented to confirm the diagnosis and guide treatment strategy.
A previously healthy 20-year-old woman on oral contraceptive pills presented with a 5-day history of right lower quadrant abdominal pain with severe tenderness, nausea, and vomiting. Computed tomography of the abdomen with contrast showed large thrombus occluding the IVC and retroperitoneal cystic changes at the level of the renal veins (Figure 1A). Doppler ultrasound of the lower extremities was positive for extensive acute deep vein thrombosis. Factor V Leiden, prothrombin gene mutation, and anticardiolipin antibodies were negative. Inferior vena cavography after an initial mechanical thrombectomy of the iliac veins and IVC showed a patent-appearing IVC, but her abdominal pain persisted (Figure 1B). Magnetic resonance imaging of the abdomen showed renal and suprarenal IVC thrombus with early and late contrast filling of an 11.8 × 9.5 cm retroperitoneal mass encasing the IVC and aorta at the level of the renal veins consistent with a benign VLM, which was confirmed on computed tomography–guided biopsy (Figures 1C and 1D). Because of her continued symptoms, intravascular ultrasound (IVUS) of the IVC, using a 3.5-F, 20-MHz coronary IVUS catheter (Eagle Eye Platinum, Volcano, San Diego, California) was performed, revealing cystic and septated changes in the IVC wall and focal near-occlusive thrombus (Figure 1E, Online Video 1). There was an 8 mm Hg venous pressure gradient across the occlusion. Catheter-directed thrombolysis was performed, and follow-up IVUS 18 h later (Figure 1F, Online Video 2) showed significantly reduced thrombus burden and improved IVC flow with no residual pressure gradient. The patient was placed on rivaroxaban 20 mg daily for 3 months for deep vein thrombosis. She subsequently underwent sclerotherapy for VLM and remained symptom free at 6 months.
In this unusual case of VLM-associated IVC thrombus, IVUS was used to diagnose VLM caval wall involvement and thrombosis and assist in thrombolysis management.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 13, 2018.
- Revision received August 23, 2018.
- Accepted August 30, 2018.