An Unusual Etiology For Iliocaval Deep Venous Thrombosis
John F. Charitable, MD, Thomas S. Maldonado, MD.
NYU Langone Health, New York, NY, USA.
Demographics: Thirty-four year old healthy Caucasian female.
The patient presented with right lower extremity (RLE) swelling and pain that developed after a flight. She also endorsed abdominal and back pain for several weeks prior. RLE venous duplex ultrasound (DUS) demonstrated acute iliofemoral deep venous thrombosis (DVT), treated with Rivaroxaban. She returned one week later with unremitting RLE pain and swelling. A computed tomographic venogram (CTV) demonstrated a left-sided inferior vena cava (IVC) with thrombus centrally to the renal veins and peripherally through the right femoral vein, a partially occlusive DVT in the left common femoral vein (CFV), and a 7.5cm mass around the pararenal IVC, confirmed with magnetic resonance imaging (MRI).
She underwent open excision of the mass en bloc with the IVC from the confluence of the hepatic veins through the distal IVC. Bifurcated Dacron graft was used to reconstruct the IVC. The peripheral limbs were anastomosed to the distal IVC and the right renal vein trunk, the left renal vein was ligated. Pathology revealed high grade leiomyosarcoma, T2N0. On post-operative day 5 she underwent percutaneous mechanical thrombectomy (PMT) utilizing the ClotTriever (Inari Medical, Irvine, CA), and right common iliac venoplasty and stent. Her post-operative course was complicated by a hematoma at the incision which was taken for washout. She recovered well with complete resolution of her RLE symptoms and was discharged with low-molecular weight heparin and compression hose.
Vascular tumors affecting the IVC are relatively uncommon. With only 13% of soft tissue sarcomas occurring in the retroperitoneum, and an incidence of 2.7 cases per million for all retroperitoneal sarcomas, they are low on the differential diagnosis when evaluating iliofemoral DVT (1,2). Vague abdominal pain preceding leg pain and swelling support the insidious nature of this disease. After diagnosis, excision of the mass with IVC reconstruction was performed as IVC ligation risked significant morbidity (3). Given her recent laparotomy but persistent RLE symptoms, thrombectomy without pharmacologic lytic therapy was crucial. PMT led to complete resolution of her symptoms. Similar success with ClotTriever has been reported but this appears to be the first for this etiology of DVT (4). This patient did well owing to the multidisciplinary approach from vascular and oncologic surgery, as well as employing open surgery and interval percutaneous endovascular surgery.
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