Giant Hepatic Hemangioma: An Incidental Finding Causing Pulmonary Embolism

Abstract

Hepatic hemangiomas are typically discovered as incidental findings.1 We present a patient with pulmonary embolism (PE) likely due to IVC thrombosis caused by a giant hepatic hemangioma. Diagnosing IVC thrombosis is a difficult task and often requires a high index of suspicion as early recognition can help decrease the risk of PE through appropriate intervention. A 44-year old female with no significant past history presented to the ER with a six-month history of chest pain, leg heaviness, abdominal fullness, and dyspnea. A few weeks ago, she was evaluated for lower extremity (LE) DVT which was negative. On admission she was hemodynamically stable with a benign physical exam. She had no recent surgery, prolonged immobilization, prior venous thromboembolic event, or family history of a hypercoagulable disorder. D-dimer was elevated, however, other labs were unremarkable and a repeat ultrasound (US) to assess for LE DVT was negative. PE was diagnosed by CTA of the chest. A 7.4 x 7.5 x 8.7 cm giant hemangioma (incidentally diagnosed earlier that year) was also evident. As she could not tolerate an MRI, CT abdomen with portal venous phasing was obtained. It showed complete compression of the intrahepatic inferior vena cava (IVC) and portal vein abutment. She was started on anticoagulation and referred to specialists. Giant hepatic hemangiomas may present with a constellation of symptoms depending on size, location, and compression of adjacent structures.1 PE attributable to giant hepatic hemangiomas has been reported in the past. IVC thrombosis can lead to PE in 30% of the population with 2.6% - 4.0% of patients with LE DVT having IVC thrombosis.2 Presenting as a diagnostic challenge due to nonspecific symptoms, insidious course, and physician unfamiliarity, IVC thrombosis is often diagnosed when clot migration has already occurred.2 Mechanisms for IVC thrombosis include sluggish flow caused by IVC compression from a mass, migration of thrombi from a hemangioma into the IVC, and prothrombotic factors.1,2 Individuals with DVT and one or more high-risk features (Table I) for IVC thrombosis should undergo initial screening with an IVC duplex US with anticoagulation as the mainstay of treatment in IVC thrombosis.2 Although this patient's clinical presentation made diagnosing IVC thrombosis a challenge, recognizing that it can result in PE is of paramount importance as early detection and treatment can decrease the risk of PE.2379_A Figure 1. Computed tomography with IV contrast of the abdomen, axial image of liver demonstrates 7.4 x 7.5 x 8.7 cm lesion with evidence of globular discontinuous enhancement on portal venous phase (red arrow) compatible with giant cavernous hemangioma. The lesion causes mass effect on the intrahepatic portion of the inferior vena cava with evidence of complete compression (yellow arrowhead).2379_B Figure 2. Table adapted from: 2. Mohamad, Alkhouli, Mohammad Morad, et al. “Inferior Vena Cava Thrombosis.” JACC: Cardiovascular Interventions [Online], Volume 9, Issue 7, Pages 629-643