Acute thrombosis of the inferior vena cava associated with chronic narrowing in a former runner: a case report

    Authors

    Keywords

    inferior vena cava thrombosis, chronic inferior vena cava narrowing, pulmonary embolism

    DOI

    https://doi.org/10.15836/ccar2024.537

    Full Text

    **Introduction**: Inferior vena cava (IVC) thrombosis is associated with high morbidity. Common causes include the presence of an IVC filter, malignancy, congenital abnormalities, thrombophilia, or trauma. Delayed treatment may lead to post-thrombotic syndrome or pulmonary embolism with potentially fatal outcome (1, 2). **Case report**: 44-year-old male with no significant medical history presented to the emergency department with acute pain in the left groin and swelling of the left leg. Duplex ultrasound showed slow flow in the dilated left common femoral vein, with absent respiratory flow modulation, suggesting a proximal obstruction. Computed tomography (CT) venography revealed narrowing in the suprarenal segment of the IVC with intraluminal calcification and stenosis of the right renal vein, accompanied by formed venous collaterals, suggesting unrecognized prior thrombosis. Partial thrombosis of the infrarenal IVC and complete thrombosis of left iliac veins was also noted, along with bilateral lobar pulmonary embolism with no signs of right heart strain (**Figure 1**). Upon admission, the patient was immediately started on low molecular weight heparin. Further workups for thrombophilia, malignancy and urological pathology returned negative. Detailed history revealed that he was an ultra-distance trail runner, a factor that may have contributed to thrombosis via dehydration and endothelial injury. Given the favorable clinical course he was discharged with a recommendation for long-term anticoagulation with rivaroxaban. Follow-up at 2 months showed normalization of D-dimers and sonographic improvement. After 5 months, CT venography revealed significant recanalization of affected vessels, and the patient was in excellent clinical condition, without venous claudication or leg swelling (**Figure 2**). FIGURE 1. Computed tomography venography showing acute left iliocaval thrombosis (black thin arrows). Amorphous calcification in the lumen of the pararenal inferior vena cava and ostium of the right renal vein (black thick arrow) accompanied by venous collaterals around the left kidney (white arrow) suggesting prior thrombosis (A). Acute emboli in the right lobar (thick arrow) and segmental (thin arrow) pulmonary arteries (B). FIGURE 2. Computed tomography venography in a 5-month follow-up revealing resolution of prior thrombosis in the inferior vena cava and left iliac veins (white arrows). **Conclusion**: IVC thrombosis is an under-recognized condition, commonly associated with malignancy or thrombophilia. Abdominal trauma, microtrauma, and dehydration related to intense physical exertion, particularly in athletes, can also contribute to its development. Current guidelines for IVC thrombosis management are limited, but anticoagulation remains essential, while interventional treatment may be considered depending on the disease severity (2, 3).

    Literature

    1. Hollingsworth CM, Mead T. Inferior Vena Caval Thrombosis. [Updated 2023 Aug 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK537175/
    2. Alkhouli M, Morad M, Narins CR, Raza F, Bashir R. Inferior Vena Cava Thrombosis. JACC Cardiovasc Interv. 2016 April 11;9(7):629–43. https://doi.org/10.1016/j.jcin.2015.12.268
    3. McAree BJ, O’Donnell ME, Fitzmaurice GJ, Reid JA, Spence RA, Lee B. Inferior vena cava thrombosis: a review of current practice. Vasc Med. 2013 February;18(1):32–43. https://doi.org/10.1177/1358863X12471967
    Cardiologia Croatica
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    Acute thrombosis of the inferior vena cava associated with chronic narrowing in a former runner: a case report

    Extended Abstract
    Issue11-12
    Published
    Pages537-538
    PDF via DOIhttps://doi.org/10.15836/ccar2024.537
    inferior vena cava thrombosis
    chronic inferior vena cava narrowing
    pulmonary embolism

    Authors

    Anica Milinković*ORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Petra Grubić RotkvićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Mia Maria JurinjakORCIDUniversity of Zagreb School of Medicine, Zagreb, Croatia
    Ana ŠutaloORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Ivana JurcaORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Majda Vrkić KirhmajerORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia

    *Correspondence email: anica.milinkovic@outlook.com

    Full Text

    Introduction: Inferior vena cava (IVC) thrombosis is associated with high morbidity. Common causes include the presence of an IVC filter, malignancy, congenital abnormalities, thrombophilia, or trauma. Delayed treatment may lead to post-thrombotic syndrome or pulmonary embolism with potentially fatal outcome (1, 2).

    Case report: 44-year-old male with no significant medical history presented to the emergency department with acute pain in the left groin and swelling of the left leg. Duplex ultrasound showed slow flow in the dilated left common femoral vein, with absent respiratory flow modulation, suggesting a proximal obstruction. Computed tomography (CT) venography revealed narrowing in the suprarenal segment of the IVC with intraluminal calcification and stenosis of the right renal vein, accompanied by formed venous collaterals, suggesting unrecognized prior thrombosis. Partial thrombosis of the infrarenal IVC and complete thrombosis of left iliac veins was also noted, along with bilateral lobar pulmonary embolism with no signs of right heart strain (Figure 1). Upon admission, the patient was immediately started on low molecular weight heparin. Further workups for thrombophilia, malignancy and urological pathology returned negative. Detailed history revealed that he was an ultra-distance trail runner, a factor that may have contributed to thrombosis via dehydration and endothelial injury. Given the favorable clinical course he was discharged with a recommendation for long-term anticoagulation with rivaroxaban. Follow-up at 2 months showed normalization of D-dimers and sonographic improvement. After 5 months, CT venography revealed significant recanalization of affected vessels, and the patient was in excellent clinical condition, without venous claudication or leg swelling (Figure 2).

    FIGURE 1. Computed tomography venography showing acute left iliocaval thrombosis (black thin arrows). Amorphous calcification in the lumen of the pararenal inferior vena cava and ostium of the right renal vein (black thick arrow) accompanied by venous collaterals around the left kidney (white arrow) suggesting prior thrombosis (A). Acute emboli in the right lobar (thick arrow) and segmental (thin arrow) pulmonary arteries (B).

    FIGURE 2. Computed tomography venography in a 5-month follow-up revealing resolution of prior thrombosis in the inferior vena cava and left iliac veins (white arrows).

    Conclusion: IVC thrombosis is an under-recognized condition, commonly associated with malignancy or thrombophilia. Abdominal trauma, microtrauma, and dehydration related to intense physical exertion, particularly in athletes, can also contribute to its development. Current guidelines for IVC thrombosis management are limited, but anticoagulation remains essential, while interventional treatment may be considered depending on the disease severity (2, 3).

    Literature

    1. 1.
      Hollingsworth CM, Mead T. Inferior Vena Caval Thrombosis. [Updated 2023 Aug 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.Link
    2. 2.
      Alkhouli M, Morad M, Narins CR, Raza F, Bashir R. Inferior Vena Cava Thrombosis. JACC Cardiovasc Interv. 2016 April 11;9(7):629–43.DOI
    3. 3.
      McAree BJ, O’Donnell ME, Fitzmaurice GJ, Reid JA, Spence RA, Lee B. Inferior vena cava thrombosis: a review of current practice. Vasc Med. 2013 February;18(1):32–43.DOI