The Missing Inferior Vena Cava With Acute on Chronic Undiagnosed DVT'S

Clinical Vignette

A 45 year old Caucasian man presented to the emergency department with worsening left leg swelling and pain since four days prior to visit. Symptoms were progressively worse over the last 4- days and associated with moderate to severe discomfort and tingling sensation involving the entire left leg. He had 3- month history of mild swelling of the left lower extremity, heaviness and tingling , but the symptoms become significantly worse as described.Denied any recent trauma or travel history. He had been taking testosterone injections 200 mg intramuscularly every week for the past 4 months prescribed by local Low T- center provider for improving his mental health. There was no significant family history of any disease states and no family h/o of clotting disorder.

The Physical examination revealed that the entire left lower extremity has 3+ edema, increased temperature and had a light red color. No neurovascular deficit was present. The pulsations of the arteries of the lower extremities were intact. There were varicose veins on the left lower extremity and pain on palpation over the deep veins with areas of induration over the deep veins of the left leg.

Because we suspected Left lower extremity deep venous thrombosis we performed Venous Doppler of the lower extremities. The venous Doppler study showed complete thrombosis of left lower extremity deep veins and left common and external and Internal Iliac veins and calf veins/DVT/. Also, there was acute deep venous thrombosis of the right commoniliac vein.

We performed venogram to assess the ability of treatment with thrombolytic or mechanical thrombectomy. The venogram showed extensive left lower extremity DVT involving the left iliac veins with suspected chronic occlusion of the left common iliac vein and acute on top of it deep venous thrombosis of the deep venous system on the left lower extremity.

CT of the abdomen and pelvis revealed chronic IVC occlusion with extensive cavo-portal collaterals, and a short segment acute right common iliac DVT. The IVC at the common iliac vein confluence was diminutive. Large bilateral parapelvic cysts were also noted without hydro nephrosis. What would be the appropriate management option for this patient?

A. Thrombolysis by Interventional Radiology
B. Initiate Anticoagulation
C. Continue to observe as an inpatient
D. Discharge and schedule outpatient follow up

Introduction

Deep venous thrombosis secondary to congenital anomalies involving Inferior Vena Cava (IVC) are extremely rare (Figure 1). They are seen in up to 5% of the younger patient population with confirmed DVT (Figure 2). Cautions should be taken to modify the risk factor that can cause hypercoagulable states. One such risk factor is IM testosterone, which can cause polycythemia and stasis of blood, thereby increasing the risk of clot formation, especially in patients who have hypercoagulable state. This is why testosterone is contraindicated in patients with hypercoagulable disorders. It is important to consider IVC anomalies in younger population who present with DVT to prevent life threatening pulmonary embolisms, acute limb ischemia and chronic leg ulcers in the future.