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Case Sixty One - Pseudothrombosis of the Inferior Vena Cava

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Clinical History: Thin, 30 year old female on antibiotics (day 10) for a LLL pneumonia with new pleuritic chest pain. Ventilation-perfusion lung scan interpreted as indeterminate. The patient was sent to the interventional suite for pulmonary angiography. Initial inferior vena cavography demonstrated possible infrarenal thrombus or flow related phenomena. A second injection was performed with valsalva in an attempt to increase venous opacification. IVC occlusion and persistent areas of incomplete opacification led to an abdominal ultrasound which was normal. Subsequent pulmonary angiography was negative.

Findings: #1 IVC injection/DSA (films 1,2): Irregular, incomplete filling of the inferior vena cava compatible with thrombosis or flow related phenomena. #2 IVC injection/DSA (films 3,4) performed with patient valsalva: Persistent irregular, incomplete opacification and new occlusion of inferior vena cava with collateral filling of ascending lumbar veins. Abdominal ultrasound: Patent inferior vena cava without evidence for thrombosis.

Diagnosis: Pseudothrombosis of the inferior vena cava.

Discussion:We report a case of documented, flow related pseudothrombosis of the inferior vena cava. Retrocaval adenopathy, fluid in the lesser sac, hiatal hernia and flow related phenomena following peripheral venous contrast injection have been reported to mimic IVC thrombosis during CT examinations (2,3). In a similar fashion, catheter placement, injection rates, and extrinsic compressive processes are all important factors in vana cavography.

Heterogeneous opacification is a common finding during IVC injections, and is normally seen at the renal vein level secondary to unopacified flow. Similar inflow heterogeneity can occur from the contralateral iliac venous flow. Adequate catheter placement at the iliac venous confluence and injection rates on the order of 40-50 cc at 20/sec are essential, however, not foolproof, in eliminating the possible false positive angiographic examination(1).

References:

  1. Kadir, Saadoon. Diagnostic Angiography. Philadelphia,
    W. B. Saunders, 1986:544-545.

  2. Glazer GM, Callen PW, and Parker JJ. CT Diagnosis of Tumor
    Thrombus in the Inferior Vena Cava: Avoiding the False Positive Diagnosis.
    AJR 1981;137:1265-1267.

  3. Kesava P and Raval B. Intrathoracic Stoamch: Another Cause of IVC
    Pseudothrombosis. Clinical Imaging 1994;18:113-114.

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Submitted by:
M. E. Pfister, M.D.
Joseph P. LiPuma, M.D.