QVI Case of the
For past cases,
Patient is an interesting 84
y/o female who presents with a one month history of bilateral
lower extremity swelling, varicose veins and tenderness.
According to the patient, the swelling is marginally
gravitational with the right leg worse than the left.
She denies any previous history of DVT, SVT or malignancy. She
also denies history of cardiac or arterial disease. She
does have a history of hypertension and angina.
and left leg pulses are easily palpable at the femoral
and popliteal; however ankle pulses are diminished
bilaterally. No hair is noted on the toes and great toe
capillary refill time appears slightly delayed
bilaterally. Significant swelling is noted below the
level of the knee bilaterally.
Ultrasound Findings :
There is clear evidence of
venous thrombosis in the right popliteal vein as well as
the posterior tibial and peroneal veins. There was
also thrombus noted in the small saphenous vein
bilaterally. However, there was not sufficient evidence of
infrainguinal venous obstruction that would explain the
patients bilateral symptoms. Therefore, the examination was
extended into the abdomen to evaluate the inferior vena
cava (IVC) and iliac veins.
Inferior Vena Cava (IVC)
Proximal IVC showing flow around obstruction long (left) and
cross section (right)
Spectral analysis of the flow in the proximal IVC
(left) and the iliac vein (right)
high quality images demonstrate near occlusion of the
inferior vena cava. Given the infrainguinal thrombus, IVC
thrombosis could be a distinct possibility. This however is
not the case and the differentiation is made largely by the
presentation, ie: no iliac involvement. Tumor should always
be considered in isolated IVC obstruction.
The patient was admitted to the emergency department
and anticoagulants were started; however there was no
placement of a Greenfield
filter due to the fact that the inferior vena cava diameter
exceeds the 2.8 centimeter limitation.
Computed Axial Tomography (CAT) exams were order of the chest,
abdomen and pelvis with results as dictated by the interpreting
The CT chest exam showed no signs of pulmonary
embolism and only trace pericardial and pleural
The CT pelvis exam with contrast revealed a small
amount of free fluid in the pelvis as well as
sigmoid diverticulosis without diverticulitis. No
pelvic mass was identified.
The CT abdominal exam with contrast revealed a
markedly enlarged right kidney with no normal
appearing parenchyma present with abnormal
diminished enhancement. There is an abnormal soft
tissue density which appears to filling the right
renal vein and entering the inferior vena cava
which is enlarged. Findings are highly worrisome
for a tumor with intravascular extension. Enlarged
retroperitoneal lymph nodes present greatest on the
right, with a large soft tissue mass on the right
worrisome for metastatic lymph node.
In general the incidence of thombosis of the inferior vena cava
(IVC) is relatively low compared to the incidence of deep vein
thombosis (DVT). Exact incidence of IVC thombosis
(IVCT) is unknown due to the variability in the clinical
presentations. According to WebMD:
The DVT rate in the
United States is
60-180 cases per 100,000 population per year.
The frequency of IVCT in
patients with DVT is 4-15%.
In the United States, 165,000-493,000
cases of DVT occur each year.
In the United States, 6600-74,000 cases of IVCT occur each
Numerous malignancies have
been associated with IVCT. Perhaps the most common is
renal cell carcinoma. The intravascular tumor extends from
the renal vein and can propagate as far as the heart. The
tumor can partially or completely occlude the IVC. Not all
intravascular irregularities of the kidney represent tumor
either. One case has been reported of a patient who
underwent radical nephrectomy for presumed renal cell
carcinoma and was subsequently found to have only renal vein
thrombosis. Other genitourinary tumors that reportedly cause
IVCT include seminomas and teratomas.
Numerous other less common
tumors reportedly involve the IVC. Intuitively, any
structure that is anatomically related to the IVC can
generate either direct compression or vascular invasion.
Retroperitoneal leiomyosarcoma, adrenal cortical carcinoma,
and renal angiomyolipoma have all been reported as
presenting in association with IVCT. Even hepatic hemangioma
has caused IVCT from extrinsic compression. Additionally,
malignancy itself is a risk factor for DVT and thus
represents a risk factor for the extension of DVT into the