Case Presentation:
19 year old woman with sickle cell anemia and nephrotic syndrome presented with leg and back pain. While treated for vaso-occlusive crisis, patient developed dyspnea and chest pain. She underwent CT chest which revealed a right lower lobe pulmonary embolism. The patient was started on anticoagulation. Her transthoracic echocardiography revealed normal right heart function but nearly occlusive inferior vena cava (IVC) thrombus just distal to the right atrium. Subsequently a CT venogram demonstrated extensive thrombus from the left external iliac vein to the right atrium as well as compression of the left common iliac vein. Multidisciplinary discussion was performed to discuss options including medical therapy, surgical removal, or catheter-based removal. Given concern for further pulmonary embolization, patient underwent catheter based thrombus removal. A 26 french access was obtained in the right internal jugular vein and a 17 french access was obtained in the right femoral vein. Using the Angiovac system, mechanical thrombectomy was performed in the IVC. The angiovac system is a 24 french suction catheter with filtration and reperfusion through the right femoral vein. Limited thrombus removal was achieved. Next,14 french left femoral vein access was obtained and the Inari Clottriever device was used to mechanically score and remove a significant amount of thrombus (Figure 1). Post removal angiography revealed a patent IVC with minimal residual thrombus.
Discussion:
IVC thrombosis is a rare presentation of venous thromboembolism (VTE). This patient had multiple reasons for VTE including nephrotic syndrome and likely May Thurner Syndrome (MTS). MTS is an underdiagnosed entity resulting in mechanical compression of the left iliac vein in upto 50% of patients presenting with left lower extremity VTE. While proximal extension of thrombus is rare as seen in this case, high clinical suspicion is warranted for accurate diagnosis and treatment.
Noncompaction of the ventricular myocardium in a patient with Behcet's disease showing multiple thrombus formations in the right atrium, inferior vena cava and right iliac vein: A case report
