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December 23, 2005
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Jenny hawes, MD, Joann Lohr, MD, Barry Blum, MD, Anant Bhati, MD, Jayapandia Bhaskaran, MD, Amy Engel, MA.
Good Samaritan Hospital, Cincinnati, OH, USA.
OBJECTIVES:
A 35-year-old female, following a spontaneous abortion of a 20-week fetus, presented with severe left leg swelling and pain. Duplex ultrasound confirmed venous thrombosis of the left iliac, common femoral, superficial femoral, deep femoral, greater saphenous, posterior tibial, and popliteal, peroneal and soleal veins.
METHODS:
The patient was initially anticoagulated with a heparin drip. Venography was performed further identifying thrombosis of the distal inferior vena cava, bilateral common iliac and external iliac veins. Venous thrombolysis (retavase) in combination with mechanical angiojet was used, which initially recanalized the vessels. On reimaging following 24 hours of continued thrombolysis all involved vessels had rethrombosed. Angiojet was repeated and patency regained. A CT scan of the abdomen and pelvis was done to evaluate for possible mechanical obstruction of the venous system, leading to recurrent distal thrombosis in spite of adequate lytic therapy. The scan showed large uterine fibroids measuring 25 cm at maximum diameter, this mass was completely compressing the distal inferior vena cava and both ureters, with associated hydronephrosis. A MRI was done to evaluate the IVC proximal to the mechanical obstruction, this was found to be free of thrombosis however dilated at 27mm in the suprarenal location. In addition, she was found to have heparin induced antibodies and lupus anticoagulant hypercoagulability mutation. Anticoagulation was changed to argatroban.
RESULTS:
The plan for surgical intervention with a hysterectomy was made with the intension of relieving the mechanical obstruction on the IVC and thus preventing further thrombosis of the lower extremity venous system. During surgery the patient’s cardiac function was monitored with a transesophageal echocardiogram. The hysterectomy was performed removing an eight-pound uterus. Intraoperative ultrasound of the IVC showed a patent crescent shaped vein with no thrombus and adequate venous blood flow. The heart function was unchanged and no embolic material was visualized during surgery. Pathology of the uterus showed a large leiomyoma with necrosis. Her lower extremity symptoms resolved. She was continued on coumadin anticoagulation.
CONCLUSIONS:
Fibroid uterus is an unusual cause of external vena caval obstruction.
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Large Uterine Fibroids Causing Mechanical Obstruction of the Inferior Vena Cava and Subsequent Thrombosis
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Jenny hawes, MD, Joann Lohr, MD, Barry Blum, MD, Anant Bhati, MD, Jayapandia Bhaskaran, MD, Amy Engel, MA.
Good Samaritan Hospital, Cincinnati, OH, USA.
OBJECTIVES:
A 35-year-old female, following a spontaneous abortion of a 20-week fetus, presented with severe left leg swelling and pain. Duplex ultrasound confirmed venous thrombosis of the left iliac, common femoral, superficial femoral, deep femoral, greater saphenous, posterior tibial, and popliteal, peroneal and soleal veins.
METHODS:
The patient was initially anticoagulated with a heparin drip. Venography was performed further identifying thrombosis of the distal inferior vena cava, bilateral common iliac and external iliac veins. Venous thrombolysis (retavase) in combination with mechanical angiojet was used, which initially recanalized the vessels. On reimaging following 24 hours of continued thrombolysis all involved vessels had rethrombosed. Angiojet was repeated and patency regained. A CT scan of the abdomen and pelvis was done to evaluate for possible mechanical obstruction of the venous system, leading to recurrent distal thrombosis in spite of adequate lytic therapy. The scan showed large uterine fibroids measuring 25 cm at maximum diameter, this mass was completely compressing the distal inferior vena cava and both ureters, with associated hydronephrosis. A MRI was done to evaluate the IVC proximal to the mechanical obstruction, this was found to be free of thrombosis however dilated at 27mm in the suprarenal location. In addition, she was found to have heparin induced antibodies and lupus anticoagulant hypercoagulability mutation. Anticoagulation was changed to argatroban.
RESULTS:
The plan for surgical intervention with a hysterectomy was made with the intension of relieving the mechanical obstruction on the IVC and thus preventing further thrombosis of the lower extremity venous system. During surgery the patient’s cardiac function was monitored with a transesophageal echocardiogram. The hysterectomy was performed removing an eight-pound uterus. Intraoperative ultrasound of the IVC showed a patent crescent shaped vein with no thrombus and adequate venous blood flow. The heart function was unchanged and no embolic material was visualized during surgery. Pathology of the uterus showed a large leiomyoma with necrosis. Her lower extremity symptoms resolved. She was continued on coumadin anticoagulation.
CONCLUSIONS:
Fibroid uterus is an unusual cause of external vena caval obstruction.
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