Obstruction Of Inferior Vena Cava Research Articles

Malignant perineurioma derived from the retroperitoneum with an aggressive clinical course: a case report

BackgroundMalignant perineurioma is a rare malignant counterpart of perineurioma derived from perineural cells. Resection is the primary option for the treatment of malignant perineuriomas; however, patients often develop recurrence after resection, and effective treatment for advanced or recurrent lesions needs to be established. This report describes a 51-year-old female with a rare malignant perineurioma in the retroperitoneum, which contributing valuable insights to the literature.Case presentationThe patient presented with abdominal distension and the imaging work-up revealed a huge hemorrhagic tumor in the retroperitoneum and obstruction of inferior vena cava by the tumor. The patient underwent surgery retrieving the tumor combined with left hemiliver and retrohepatic vena cava, which confirmed the diagnosis of a malignant perineurioma based on histopathological and immunohistochemical examination. Cancer gene panel testing identified mutations in NF2. Radiotherapy was administered for peritoneal dissemination 2 months after surgery, and the patient died from disease progression 6 months after surgery.ConclusionsThis rare case highlights the challenges in managing retroperitoneal malignant perineuriomas. The aggressive characteristics and limited treatment options for advanced malignant perineuriomas underscore the need for understanding the pathogenesis and developing effective systemic therapies. The identification of an NF2 mutation provides significant insights into potential therapeutic target.

How should the liver be approached in patients with severe abdominal wall varices?

AbstractAlthough liver resection in patients with abdominal wall varices (AWV) is rare, we should have a special surgical strategy for the liver in such cases. We report our experience of approaching the liver in a patient with severe AWV. The patient was a 77‐year‐old man who had undergone inferior vena cava (IVC) filter placement for a pulmonary embolism 10 years prior. Severe AWV due to complete IVC obstruction appeared 3 years ago. The patient was diagnosed with intraductal papillary neoplasm of the bile duct and referred to our hospital. Although it was difficult to see the small AWV, it was necessary to avoid bleeding due to AWV injury. The ports were inserted while confirming the AWV with indocyanine green (ICG) imaging, and laparoscopic left hepatectomy was performed. Our approach to the liver using abdominal wall ICG imaging might be a standard strategy to avoid severe AWV injury.

Feasibility of transcatheter device closure of secundum atrial septal defect under transthoracic echocardiography guidance.

Objective: To determine the usefulness and safety of transthoracic echocardiography (TTE) imaging for real time guidance in transcatheter device closure of atrial septal defect (ASD) secundum. Study Design: Cross-sectional study. Setting: Department of Paediatric Cardiology, CPEIC, Multan, Pakistan. Period: January 2022 to December 2023. Material & Methods: Patients of both genders aged above 3 years with clinical and echocardiographic evidence of ASD secundum with significant left to right shunt were analysed. All cases had morphologically suitable margins of defect confirmed on TTE. Usefulness and safety of intra-procedure and immediate post-procedure transcatheter device closure of secundum ASD were noted. Results: In a total of 34 patients, 20 (58.8%) were female and 14 (41.2%) male. The mean age was 21.32±17.21 years. The TTE findings revealed that the mean ASD side was 17.47±4.32 mm. Aortic margins were deficient among 28 (82.4%) cases. The mean fluoroscopy and procedure time were 9.29±6.98 minutes and 49.91±39.76. Residual leak was noted in one (2.9%) cases while none of the cases were observed to have superior vena cava, inferior vena cava or pulmonary vein obstructions. Post-procedure, transient supraventricular tachycardia (SVT) arrhythmia was the most common type of complication reported among 2 (5.9%) cases. None of the cases needed any kind of emergency surgical exploration. No cases of pericardial effusion were found. No mortality was reported. Conclusion: Transcatheter device closure of secundum atrial septal defect was found to be effective and safe using TTE.

Atrial Transseptal Catheterisation: Challenging Scenarios and Techniques to Overcome Them.

Atrial transseptal catheterisation is a fundamental skill of any interventional electrophysiologist. In this review, various scenarios that pose unique challenges to atrial transseptal catheterisation are discussed. These scenarios include post-surgical or congenital malformations of the interatrial septum, presence of interatrial septal closure devices, absent or obstructed inferior vena cava and complex congenital heart disease after palliative surgery. Transseptal catheterisation in all of the above situations is feasible and can be performed safely with the aid of dedicated tools and specific techniques.

#6841 IS NEPHRECTOMY ALWAYS USEFUL IN ADPKD? A CASE REPORT OF HEPATIC FIBROSIS WITH SPLENOMEGALY AND PANCYTOPENIA AS LATE CONSEQUENCE

Abstract Background and Aims Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetic kidney disease. Its main feature is the progressive enlargement of both kidneys with progressive loss of kidney function. ADPKD is the 4th leading cause of dialysis in the world. The disease has systemic involvement. Liver cysts are the most common extrarenal manifestations of ADPKD and are often incidental findings. However the liver can reach considerable size but its function is always preserved. Cysts lead to structural changes of the biliary tree and determine discomfort related to mass effect when significant liver enlargement occurs. Few cases of Budd Chiari syndrome (BCS) or of hepatic fibrosis have been reported in ADPKD patients after nephrectomy. Probably the removal of the kidneys can lead to obstruction of inferior vena cava by liver cysts. Method We report a case of hepatic fibrosis with splenomegaly and severe pancytopenia as a tardive complication after bilateral nephrectomy. Case report A 47 years old man was admitted c/o Division of Nephrology of San Raffaele Hospital in August 2018 because of a high-grade fever, general malaise, nausea and abdominal pain. The patient had a previous diagnosis of ADPKD. Genetic test indicative of PKD1 truncating mutation. He was chronically attended in the outpatient clinic of the same Division. On admission in hospital his renal function was severely impaired (crea 10 mg/dl; urea 213 mg/dl). No abnormalities at the blood count. Reactive C protein was elevated (156 mg/l nv 0-6). Urine culture was found negative. Abdominal NMR showed an important volumetric increase (compared with a NMR performed in 2014) of both kidneys with diameters of about 30 cm, several cysts with hemorrhagic and infective features and numerical and dimensional increase of the hepatic cysts; spleen was reported with normal diameters. Multiple antibiotic treatments were performed unfortunately without benefit. Therefore considering the state of end stage renal disease, the persistent infection and the severe symptoms, in September 2018 the patient underwent bilateral nephrectomy and hemodialysis was started. During the following years imaging studies aimed at the preparation for transplantation were performed. In November 2020 an abdominal NMR showed for the first time splenomegaly with a bipolar diameter of 14 cm. A NMR follow up was started. In January 2021 a further increase was reported as spleen diameter resulted of 14.5 cm and a volumetric increase of hepatic cysts was shown. In September 2022 spleen reached to a diameter of 17 cm. Contextually in November 2020 patient started to present pancytopenia that had progressively been worsening with many concomitant infective and bleeding episodes. All hematologic causes were excluded. Just to explain the genesis of the splenomegaly in September 2022 a fibroscan was performed and a pathological liverstiffness was found. All hepatitis markers were negative and immunologic ones as well. Splenectomy was assumed, but patient clinical conditions so far do not allow it. Transplantation is currently contraindicated Conclusion These evidences underline the necessity of scrupolous evaluation of polycystic kidneys and their anatomic relationship with the liver before nephrectomy. Nephrectomy is frequently considered in the preparation for renal transplantation. In light of these possible complications, maybe removal of kidneys should be considered carefully in ADPKD patients with large involvement of the liver by cysts.

Post-traumatic giant thrombosis of inferior vena cava induced right-sided blunt traumatic diaphragmatic injury: a case report

BackgroundInferior vena cava thrombosis is a severe disease as it carries a higher risk of developing pulmonary embolism associated with a high mortality rate. The incidence of inferior vena cava thrombosis is extremely low and is commonly associated with outflow obstruction of the inferior vena cava. The frequency of traumatic diaphragmatic injuries is less than 1% of all traumatic injuries. In addition, it was not a typical cause of inferior vena cava obstruction. We report the case of the patient who presented with giant thrombosis of the inferior vena cava, which required surgical treatment-induced right-sided blunt traumatic diaphragmatic injury.Case presentationA 60-year-old male presented to the emergency department with pelvic and lower leg pain. He was working on a dump truck with the bed raised position. Suddenly, the bed came down, and his body was crushed and injured. Primary CT showed a right lung contusion and elevation of the right diaphragm but no apparent liver injury. The right pleural effusion gradually worsened after admission, as the traumatic diaphragmatic injury was highly suspected. Repeat CT showed aggravation of elevation of the right-sided diaphragm, narrowing of the inferior hepatic vena cava due to left cephalic deviation of the liver, and formation of a giant thrombus in the inferior vena cava. No adverse hemodynamic effects were observed due to thrombus formation, and we performed thrombolytic therapy. The day after starting thrombolytic therapy, the patient developed pulmonary embolism due to a dropped in SpO2 needed oxygen, and dyspnea triggered by coughing. Thrombolytic therapy was continued after the diagnosis of pulmonary embolism. However, thrombolytic therapy was ineffective, so we decided on surgical thrombectomy and inferior vena cava filter placement. The postoperative course was not eventful, and an anticoagulant was started. The patient was transferred to the hospital on the 62nd day for rehabilitation.ConclusionsWhen a diaphragmatic hernia is suspected of causing hepatic hernia and narrowing of the inferior vena cava, it may be necessary to consider emergency surgical treatment to prevent secondary inferior vena cava thrombosis and fatal pulmonary embolism.

Role of Inferior Vena Cava (IVC) Recanalization in Patients with Back Pain, Secondary to IVC Obstruction in Budd-Chiari Syndrome.

To study the prevalence of back pain in patients of Budd-Chiari syndrome (BCS) with inferior vena cava (IVC) obstruction, and to evaluate the role of IVC recanalization in resolution of back pain. All patients with BCS and IVC obstruction who underwent IVC recanalization between January 2018 and October 2022 were included. Patients with degenerative spine disease or other identifiable causes for back pain were excluded; remaining patients were assessed for the presence of back pain. In patients with back pain, pain relief was assessed at 24 h following IVC recanalization. Fifty-eight patients with BCS and IVC occlusion were identified, of which six with degenerative spine diseases were excluded. Of the remaining 52 patients, 34 (65.4%) had back pain, with pain score between 3 and 9. Engorged epidural venous plexus on preprocedural imaging (p = 0.002), and degree of luminal narrowing (p = 0.021) had a significant association with back pain. Twenty-nine of thirty-four patients (85.3%) with back pain had pain relief immediately following IVC recanalization, more so in patients with engorged epidural venous plexus on preprocedural imaging (p < 0.001). Back pain is one of the under-reported symptoms of IVC obstruction in BCS. IVC recanalization by IVC angioplasty with or without stenting relieves back pain due to the decompression of engorged epidural veins.

Survival and clinical success of endovascular intervention in patients with Budd-Chiari syndrome: A systematic review.

Budd-Chiari syndrome is a complex clinical disorder of hepatic venous outflow obstruction, originating from the accessory hepatic vein (HV), large HV, and suprahepatic inferior vena cava (IVC). This disorder includes both HV and IVC obstructions and hepatopathy. This study aimed to conduct a systematic review of the survival rate and clinical success of different types of endovascular treatments for Budd-Chiari syndrome (BCS). All participant studies were retrieved from four databases and selected according to the eligibility criteria for systematic review of patients with BCS. The survival rate, clinical success of endovascular treatments in BCS, and survival rates at 1 and 5 years of publication year were calculated accordingly. A total of 3398 patients underwent an endovascular operation; among them, 93.6% showed clinical improvement after initial endovascular treatment. The median clinical success rates for recanalization, transjugular intrahepatic portosystemic shunt (TIPS), and combined procedures were 51%, 17.50%, and 52.50%, respectively. The median survival rates at 1 and 5 years were 51% and 51% for recanalization, 17.50% and 16% for TIPS, and 52.50% and 49.50% for combined treatment, respectively. Based on the year of publication, the median survival rates at 1 and 5 years were 23.50% and 22.50% before 2000, 41% and 41% in 2000‒2005, 35% and 35% in 2006‒2010, 51% and 48.50% in 2010‒2015, and 56% and 55.50% after 2015, respectively. Our findings indicate that the median survival rate at 1 and 5 years of recanalization treatment is higher than that of TIPS treatment, and recanalization provides better clinical improvement. The publication year findings strongly suggest progressive improvements in interventional endovascular therapy for BCS. Thus, interventional therapy restoring the physiologic hepatic venous outflow of the liver can be considered as the treatment of choice for patients with BCS which is a physiological modification procedure.

Assessing the Complicated Venous Hemodynamics and Therapeutic Outcomes of Budd-Chiari Syndrome with Respiratory-gated 4D Flow MR Imaging During the Expiratory and Inspiratory Phases.

A man in his 50s with Budd-Chiari syndrome diagnosed with the suprahepatic inferior vena cava (IVC) obstruction on CT was assessed using 4D Flow MRI before and after balloon angioplasty. 4D Flow MRI acquired in two respiratory phases, depicted complex hemodynamic and respiratory variability, and a jet stream at the narrowed channel of the membranous IVC. Post-interventional 4D Flow MRI showed that the IVC blood flow increased with corrected flow directions in the infrarenal IVC.

Percutaneous hepatic vein recanalization in pediatric Budd-Chiari syndrome - 10 years' experience from a tertiary center.

Budd - Chiari syndrome (BCS) due to hepatic venous outflow obstruction is a rare cause of liver disease with dismal outcome, often amenable to catheter intervention. This retrospective single-center study analyzed the clinical profile and medium-term outcome of interventional treatment with balloon angioplasty ± stenting in all pediatric BCS over a 10-year period. Clinical, laboratory, imaging, and interventional data were retrieved. Transhepatic (TH) access was utilized in the recent 3 years. We included a total of 27 patients. Acute and subacute BCS comprised 93% of subjects. Ascites was the most common symptom. COVID-19 infection and Takayasu arteritis were two novel etiologies in our study. There was isolated hepatic vein (HV) narrowing in 11 (41%), isolated inferior vena cava obstruction in 4, and combined occlusion in 12 (44%). Intervention was successful in 22 (82%) patients. Stenting was required in 14 (64%) patients and the rest underwent balloon angioplasty. The immediate outcome was better with stenting than balloon (91% vs. 64%). Transhepatic access in 6 patients allowed HV cannulation in all and achieved patency in five patients. Two patients from the balloon group (25%) and 9 from the stent group (64%) are alive with patent veins at a median follow-up of 60 months, indicating a high attrition rate. Catheter interventions restored physiological blood flow in pediatric BCS. TH route improved cannulation of occluded HV compared to other accesses. Immediate and medium-term outcomes were better after stenting with lower rates of reinterventions than balloon angioplasty. Life-long surveillance is required as mortality is high on follow-up.

Controversies in the management of proximal deep vein thrombosis.

Controversies in the management of proximal deep vein thrombosis.

P02] Inferior Vena Cava Reconstruction: A Single Centre Experience

<h3>Objective</h3> Inferior vena cava (IVC) stenting is carried out for symptomatic chronic IVC stenosis or occlusion, and for the treatment of malignant IVC obstruction. The patency of IVC stents placed for both acute on chronic and chronic venous occlusion was determined. <h3>Methods</h3> Retrospective analysis of prospectively collected data was completed on all patients who underwent technically successful IVC stenting for treatment of symptomatic venous outflow obstruction or stenosis between February 2015 and November 2021. All patients had standard pre-operative work up, including venography ± intravascular ultrasound for chronic cases, and followed standard anticoagulation and surveillance programmes post-procedure, unless there was malignant disease. <h3>Results</h3> Sixteen patients underwent IVC stenting. Seven cases (43%) presented acutely with deep vein thrombosis and chronic underlying IVC stenosis or occlusion. Five cases (31%) were for symptomatic malignant external IVC compression. In four cases (25%), kissing iliac stents were placed into the IVC to treat infrarenal IVC disease. The remainder required single stents in the IVC, or were combined with double barrelled iliac stents. Re-intervention occurred in four cases (25%) for in stent thrombosis. Primary patency was 75%, and primary assisted patency was 88%. Stenting the IVC in all cases for malignant obstruction gave symptomatic relief. <h3>Conclusion</h3> Stenting of the occluded/atretic IVC may require additional access from the right internal jugular vein. Stenting above and across the renal veins did not cause any additional complications in this series. Stenting of the IVC is safe, and can give significant improvement in symptoms in patients with limited alternative options for treatment.

Progressive Obstruction of Inferior Vena Cava by Ameroid Constrictor: The Canine Model of Revealing Hemodynamic and Compensatory Patterns of Tumor Thrombus Formation at the Renal Hilus Level.

Background: To develop an efficient and stable canine model of inferior vena cava (IVC) progressive obstruction at the renal hilus level. Methods: The model was established in two beagles by encircling an ameroid constrictor (AC) on the IVC at the renal hilus level. Abdominal wall varicosity and animal weight variations were observed weekly after operation. Ultrasound examination was performed weekly after surgery to observe the AC position, the diameter, and the velocity in the IVC. Six weeks after surgery, IVC angiography and CT scan were performed to observe the collateral circulation establishment and internal organ variation. Blood samples were taken regularly to monitor for variation in critical biochemical parameters. Renal biopsy was performed at 0, 2, 4, and 6 weeks after surgery. Results: Superficial varicose veins were observed on the abdominal wall at 2 weeks after surgery. Four weeks after operation, the IVC diameter increased by ∼30%, whereas the IVC velocity decreased by more than 50%. Collateral circulation was observed by IVC angiography at 6 weeks through multiple dilated veins along with neovascularization. CT scan showed congestive alteration in the kidney. The body weight, kidney, and liver function were not significantly affected. Chronic congestive renal injury was detected in the renal tubular epithelium by kidney biopsy after surgery. Conclusions: A canine model of IVC progressive obstruction at the renal hilus level was stably and safely established for the first time by using an AC, which may be helpful for preserving pivotal collateral circulation and nontumor-side kidney function in the IVC thrombus surgery.

Malignant obstruction of the inferior vena cava: clinical experience with the self-expanding Sinus-XL stent system

PurposeTo evaluate the technical and clinical outcome of Sinus-XL stent placement in patients with malignant obstruction syndrome of the inferior vena cava.MethodsBetween October 2010 and January 2021, 21 patients with different malignant primary disease causing inferior vena cava obstruction were treated with Sinus-XL stent implantation. Procedural data, technical and clinical outcome parameters were retrospectively analyzed.ResultsTechnical success was 100%. Analysis of available manometry data revealed a significant reduction of the mean translesional pressure gradient following the procedure (p = 0.008). Reintervention rate was 4.8% (1/21). The available follow-up imaging studies showed primary and primary-assisted stent patency rates of 93% (13/14) and 100% (14/14), respectively. Major complications did not occur. The clinical success regarding lower extremity edema was 82.4% (14/17) for the first and 85.7% (18/21) for the last follow-up. Longer lengths of IVC obstruction were associated with reduced clinical improvement after the procedure (p = 0.025). Improvement of intraprocedural manometry results and lower extremity edema revealed only minor correlation. Ascites and anasarca were not significantly positively affected by the procedure.ConclusionSinus-XL stent placement in patients with malignant inferior vena cava obstruction showed high technical success and low complication rates. Regarding the clinical outcome, significant symptom improvement could be achieved in lower extremity edema, whereas ascites and anasarca lacked satisfying symptom relief. Based on our results, this procedure should be considered as a suitable therapy in a palliative care setting for patients with advanced malignant disease.

Inferior vena cava obstruction due to complete thrombosis of the filtering device

Inferior vena cava obstruction due to complete thrombosis of the filtering device

PD56-08 EN BLOC RESECTION OF RIGHT RENAL CELL CARCINOMA AND INFERIOR VENA CAVA WITH TUMOR THROMBUS: IS IT SAFE TO DIVIDE THE LEFT RENAL VEIN?

You have accessJournal of UrologyCME1 May 2022PD56-08 EN BLOC RESECTION OF RIGHT RENAL CELL CARCINOMA AND INFERIOR VENA CAVA WITH TUMOR THROMBUS: IS IT SAFE TO DIVIDE THE LEFT RENAL VEIN? Laura Horodyski, Javier Gonzalez, Marina Tabbara, Jeffrey Gaynor, Maria Rodriguez-Cabero, Felipe Herranz-Amo, Carlos Hernández, Rushi Shah, and Gaetano Ciancio Laura HorodyskiLaura Horodyski More articles by this author , Javier GonzalezJavier Gonzalez More articles by this author , Marina TabbaraMarina Tabbara More articles by this author , Jeffrey GaynorJeffrey Gaynor More articles by this author , Maria Rodriguez-CaberoMaria Rodriguez-Cabero More articles by this author , Felipe Herranz-AmoFelipe Herranz-Amo More articles by this author , Carlos HernándezCarlos Hernández More articles by this author , Rushi ShahRushi Shah More articles by this author , and Gaetano CiancioGaetano Ciancio More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002636.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: When renal cell carcinoma extends into the inferior vena cava, obstruction leads to redistribution of venous flow through collaterals. A few case reports have found that resection of the obstructed inferior vena cava without reconstruction may be safe in the short term with regard to renal function, though a transient increase in creatinine can be seen. The objective was to assess whether resection of a right renal cell carcinoma and inferior vena cava with obstructing tumor thrombus is safe to perform without reconstructing the inferior vena cava with regard to long-term renal function. METHODS: A bi-institutional retrospective review was performed over an 18 year period, assessing patients with right renal cell carcinoma and obstructing level II-IV tumor thrombus. RESULTS: Twenty-two patients were included in the study. Average age was 62.5 (range 45-79) years old and 19 (86%) of the patients were male. One patient (5%) had a level II thrombus, 14 patients (64%) had a level III thrombus (IIIa n=3, IIIb n=6, IIIc n= 3, IIId n=2), and seven patients (32%) had a level IV thrombus. Intra-operatively, average estimated blood loss was 1.35 (range 0.2 – 25) L. The average length of hospital stay was 11 (range 5 – 50) days. Average preoperative creatinine was 1.20 (range 0.40 – 2.70) mg/dL and postoperatively, average creatinine was 1.3 (range 0.86 – 2.20) mg/dL. Mean creatinine at 6 month and 12 month follow-up was 1.10 (range 0.5 – 1.6) and mg/dL 1.34 (range 0.6 – 2.0), respectively. Eight patients were lost to follow-up, and two died (one in the hospital, and the other three months post-operatively). CONCLUSIONS: Resection of right renal cell carcinoma with inferior vena cava in the presence of an obstructing level II- IV tumor thrombus without reconstruction of the inferior vena cava appears not to have a significant adverse effect on long-term renal function. Source of Funding: N/A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e956 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Laura Horodyski More articles by this author Javier Gonzalez More articles by this author Marina Tabbara More articles by this author Jeffrey Gaynor More articles by this author Maria Rodriguez-Cabero More articles by this author Felipe Herranz-Amo More articles by this author Carlos Hernández More articles by this author Rushi Shah More articles by this author Gaetano Ciancio More articles by this author Expand All Advertisement PDF DownloadLoading ...

Evaluation of dangerous collateral vessels and thrombus in Budd-Chiari syndrome patients with inferior vena cava obstruction

Evaluation of dangerous collateral vessels and thrombus in Budd-Chiari syndrome patients with inferior vena cava obstruction

PHLEGMASIA CERULEA DOLENS ASSOCIATED WITH OBSTRUCTIVE SHOCK

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Phlegmasia cerulea dolens (PCD) is a rare, fulminant condition caused by massive venous thrombosis associated with a high morbidity (amputation rates 20-50%) and mortality (25-40%)1. PCD often presents as a triad of limb swelling, acute ischemic pain, and reddish purple to blue skin discoloration1. This case presents a patient who developed PCD involving complete obstruction of the inferior vena cava (IVC) leading to obstructive shock. CASE PRESENTATION: Shortly after admission a 67 year old female with a relevant past medical history of metastatic tonsillar cancer on chemotherapy, Sjogren's disease, and previous venous thromboembolism (no longer on anticoagulation) developed acute onset of abdominal pain and hypotension associated with significant mottling and edema in her bilateral lower extremities. Six months prior to presentation she had an IVC filter placed. She developed worsening shock, acute kidney injury, and metabolic academia. A CT abdomen/pelvis revealed an extensive clot burden distal to the IVC filter with extension down through the bilateral iliac veins (img 1). Bilateral lower extremity venous duplex ultrasound scans showed extensive bilateral acute deep vein thromboses (img 2). Vascular surgery took the patient to the operating room for mechanical thrombectomy of the IVC and left iliac vein (img 3) and right above-the-knee amputation due to the severity of injury to right lower extremity. After returning from the operating room she developed worsening shock despite continued resuscitative measures, and after discussion with the patient's family her goals of care were transitioned to comfort-focused. DISCUSSION: Similar to DVT risk, factors associated with the development of PCD include congestive heart failure, immobility post-operatively, and malignancy1,2. Chemotherapy may increase the risk by up to six to seven times3. Initial management of PCD includes elevation of affected limbs, judicious fluid resuscitation, and anticoagulation1. Definitive therapeutic interventions include catheter-directed thrombolysis and surgical thrombectomy1. IVC filter presence is also a rare but important risk factor for the development of PCD associated with up to 3.2% of cases in one review1. The presence of an IVC filter may lead to the development of inferior vena cava syndrome which is often mistaken for other conditions. Complications associated with IVC filter presence also highlights the value of bedside ultrasound which could help to identify non-collapsible femoral veins. CONCLUSIONS: The clinical triad of PCD includes limb swelling, acute ischemic pain, and reddish purple to blue skin discoloration. Early recognition and treatment is critical to improved outcomes.Risk factors for the development of PCD are the same as those associated with DVT or PE IVC filter presence can be a nidus for thrombus development which can progress to the point of filter occlusion REFERENCE #1: Chinsakchai K, Ten Duis K, Moll FL, de Borst GJ. Trends in management of phlegmasia cerulea dolens. Vasc Endovascular Surg. 2011;45(1):5-14. doi:10.1177/1538574410388309 REFERENCE #2: Mohammed, M., Elhamdani, S., Abusnina, W., Majdi, A., & Yousef, S. (2018). Inferior Vena Cava Obstruction and Shock. Journal of emergencies, trauma, and shock, 11(2), 146–148. https://doi.org/10.4103/JETS.JETS_22_17 REFERENCE #3: Söderman, M., & Grimm, P. (2020). Phlegmasia cerulea dolens in a patient treated with carboplatin. BMJ case reports, 13(4), e233760. https://doi.org/10.1136/bcr-2019-233760 DISCLOSURES: No relevant relationships by Avraham Cooper, source=Web Response No relevant relationships by Sarah MacDowell, source=Web Response

Reversal of cardiopulmonary exercise intolerance in patients with post-thrombotic obstruction of the inferior vena cava

BackgroundIt is unclear whether cardiopulmonary exercise intolerance in patients with chronic obstruction of the inferior vena cava (IVC) is reversible following endovascular IVC reconstruction. MethodsIn 17 patients (mean age 45 ± 15 years, 71% men) with post-thrombotic syndrome due to IVC obstruction and preserved left ventricular ejection fraction (mean 58 ± 3%), we performed cardiopulmonary exercise testing before and 3 months after IVC reconstruction (mean 4.1 ± 1.5 implanted stents). The median time from latest episode of deep vein thrombosis to intervention was 150 (interquartile range 102–820) days. ResultsAt baseline, 12 (71%) patients reported New York Heart Association (NYHA) class II or III symptoms, 76% did not achieve >85% of predicted oxygen uptake at peak exercise (mean 61.8 ± 13.7%). After IVC reconstruction, the following changes were observed at anaerobic threshold: work rate increased by 14.6 W, 95%CI (−0.7; 30.0), oxygen uptake increased by 1.8 ml/kg, 95%CI (0.3; 3.3). Oxygen pulse increased by 1.95 ml per beat, 95%CI (1.12; 2.78), corresponding to a mean relative increase of 22.5%, 95%CI (12.4; 32.7) (p < 0.001). The following changes were observed at peak exercise: work rate increased by 48.1 W, 95%CI (27.8; 68.4), oxygen uptake increased by 6.4 ml/kg, 95%CI (3.8; 9.1). Oxygen pulse increased by 2.68 ml per beat, 95%CI (1.60; 3.76), corresponding to a mean relative increase of 29.4%, 95%CI (17.7; 41.2) (p < 0.001). At follow-up, 5 (29%) patients remained in NYHA class II. ConclusionsIn patients with chronic IVC obstruction, cardiopulmonary exercise intolerance as a result of impaired cardiac filling is at least partially reversible following endovascular IVC reconstruction. Study registrationURL: https://clinicaltrials.gov. Unique identifier: NCT02433054.

Cauda equina syndrome secondary to portal vein thrombosis: case report of favorable outcome with conservative treatment

Epidural varicosis is a rare though well-known cause of cauda equina syndrome (CES). Although inferior vena cava (IVC) obstruction is the most common finding in such cases, portal vein hypertension can lead to epidural venous plexus engorgement by means of lumbar portocaval shunt activation. A 40-year-old woman presented with right-sided sciatica, which progressed to right foot drop and a 3-day history of vesical tenesmus and fecal retention. She was initially diagnosed with L4–5 lumbar disc protrusion. However, contrast-enhanced lumbar MRI scan showed the presence of epidural varices in the L3–S1 tract. Given the absence of vascular anomalies amenable to resection, etiological conservative treatment was addressed. Therefore, a complete diagnostic workup was performed and revealed deep vein thrombosis (DVT), pulmonary embolism, and portal vein thrombosis. Oral anticoagulant therapy was initiated and prompt resolution of CES was observed. To the authors’ knowledge, this is the first report of CES secondary to epidural varicosis in the setting of acute portal vein thrombosis and extrahepatic portal vein obstruction (EHPVO). In cases of epidural varicosis, conservative etiological treatment is the most appropriate choice as CES may be the epiphenomenon of underlying systemic pathophysiological processes.