Catherine Chen, MD
Assistant Professor of Medicine
Rutgers Robert Wood Johnson Medical School, United States
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Title: A Case of IVC Syndrome as a Mimic of PE
Case Report Body:
Introduction: While SVC Syndrome is a well-recognized issue, IVC Syndrome (IVCS) is underrecognized despite having similarly deleterious effects. Its diagnosis can be difficult as it presents similarly to more common conditions like PE and DVT.
Description: A 67-year-old male with history of DM, HTN, multiple myeloma (remission since 2018), and DVTs with IVC filter in-place, was admitted for sudden onset dyspnea associated with chest tightness, pain in his calves, diaphoresis, nausea, and exertional erections. On arrival his HR was 101, RR was 20, and SpO2 was 96% on room air. EKG, CXR, and lab tests, including CBC, CMP, coagulation studies, and troponins were unremarkable. A CTA chest and CT Abdomen/Pelvis were negative for PE or Aortic Dissection but did show bony lesions concerning for MM recurrence. Further workup included Echocardiogram, HR-CT, perfusion scan, left and right heart catheterization, and cardiac MRI. All of these were unremarkable.
He developed left leg swelling and duplex ultrasound showed a left DVT. Despite adequate heparin dosing, swelling remained and began in the right leg as well. This raised suspicion for proximal venous obstruction. A CT Venogram showed extensive thrombosis. Vascular surgery was consulted, and endovascular venography revealed DVT extending from the IVC Filter through bilateral iliac veins and down to the left femoral and popliteal veins. Thus, the diagnosis of IVCS was made. Mechanical thrombectomy and thrombolysis was performed with retrieval of IVC filter. Post procedure the patient noted symptom improvement with increased exercise tolerance. He stayed for a total of 21 days and was discharged to home with cardiopulmonary rehab and anticoagulation with Eliquis.
Discussion: Incidence of IVCS has been estimated to be as high as 4-15% for patient presenting with a DVT. Signs, symptoms, and complications of IVCS result primarily from reduced return to the heart and venous congestion. Risk factors include any elements contributing to Virchow's triad of hypercoagulability, stasis of flow, and endothelial injury. When suspected, venous imaging should be pursued followed by therapeutic thrombectomy or thrombolysis. In patients at risk, index of suspicion for IVCS should remain high, especially if patients remain symptomatic despite appropriate anticoagulation for DVT.