Inferior vena cava and renal vein thrombosis: a rare cause of acute kidney injury in tuberculosis.

Recent studies show active tuberculosis induces a prothrombotic state and increases the risk of venous thromboembolism. We report a recently diagnosed case of tuberculosis who presented to our hospital with painful bilateral lower limb swelling and several episodes of vomiting with abdominal pain for 2 weeks. Investigations by a hospital elsewhere 2 weeks ago showed abnormal renal function, misdiagnosed as antitubercular therapy-induced acute kidney injury. D-dimer levels were increased on admission with us, with still deranged renal function. Imaging revealed thrombus at the origin of left renal vein, inferior vena cava and bilateral lower limbs. We started treatment with anticoagulants, which gradually improved kidney function. This case highlights that early diagnosis of renal vein thrombosis and prompt treatment are associated with good clinical outcomes. It also highlights the importance of further studies for risk assessment, prevention strategies and reduction of the burden of venous thromboembolism in patients with tuberculosis.

Post-Acute COVID-19 syndrome (PACS) right atrioventricular and vena cava thrombus on top of a myxoma. A Case report.

Post-Acute COVID-19 syndrome (PACS) is considered to be one of the least understood post-infectious syndromes. We report a case of a 21-year-old female who had a history of SARS-CoV-2 infection and presented with a right atrioventricular thrombus associated with pulmonary embolism and thrombocytopenia. At the time of admission, she was not vaccinated against SARS-CoV-2, and her serological tests for IgG and IgM antibodies against SARS-CoV-2 were positive. The size of the thrombus measured approximately 6 × 8 × 4 cm, which also led to tricuspid valve insufficiency due to mechanical dilatation of the valve's ring. The right atrioventricular thrombus also extended up to the inferior vena cava, leading to mild congestive hepatomegaly. Moreover, during thrombectomy, the mass of the thrombus was attached to the interseptal right atrial wall. The histopathological assessment of the core mass revealed that it was a right atrial myxoma hidden inside that large thrombus. We suspect that the formation and propagation of the thrombus to that size occurs as a part of Post-Acute COVID-19 syndrome (PACS). This study reviews and discusses coronavirus disease 2019-relate to thrombus formation inside cardiac chambers in case of a cardiac tumor, like myxoma in the setting of post-acute phase COVID-19 syndrome.

Rarely Described Renal Malignancies Associated With Venous Tumor Thrombus.

BACKGROUND/AIM: Collecting duct carcinoma, epithelioid angiosarcoma and neuroendocrine/carcinoid tumor are uncommon renal malignancies, and their association with tumor thrombus extending into the inferior vena cava is extremely rare. Owing to the rarity of the above-mentioned malignancies and short follow-up of the cases published in the literature, the prognosis and clinical behavior of these tumors remains unclear. Up to date, the culprit of treatment is surgical management with radical nephrectomy, lymph node dissection, thrombectomy and vascular reconstruction if necessary. PATIENTS AND METHODS: We herein describe in detail the first cases published of the above-mentioned renal malignancies associated with extensive inferior vena cava (IVC) thrombus, in which complex vascular reconstruction was performed. RESULTS: Three male patients were identified as having collecting duct carcinoma, epithelioid angiosarcoma and neuroendocrine/carcinoid tumor with IVC involvement. Tumor thrombus levels were II, I and IIIc respectively. Patient ages were 42, 60 and 47 years and tumor sizes were 9.2, 10.9 and 3.7 cm correspondingly. Patient 2 underwent cavectomy, IVC replacement using polytetrafluoroethylene (Gore-Tex®) vascular graft and IVC filter deployment inside the graft. None of the patients developed any pulmonary emboli postoperatively. At the last follow-up, IVC graft for patient 2 remained patent. CONCLUSION: Owing to the rarity of the aforementioned malignancies and short follow-up of cases published in the literature, the prognosis and clinical behavior of these tumors remains unclear. Up to date, the culprit of treatment is surgical management with radical nephrectomy, lymph node dissection, thrombectomy and vascular reconstruction if necessary. Polytetrafluoroethylene (Gore-Tex) vascular grafts are an excellent and safe option for complex vascular reconstructions in patients with evidence of IVC invasion.

Successful IVC thrombus extraction with the AngioVac device following five vessel coronary artery bypass graft: a case report.

BACKGROUND: Inferior vena cava thrombosis is cited to be a complication of inferior vena cava filter placement and post coronary artery bypass surgery. Often only mild symptoms arise from these thrombi; however, due to the chronic nature of some thrombi and the recanalization process, more serious complications can arise. Although anticoagulation remains the gold standard of treatment, some patients are unable to be anticoagulated. In this case, we present a 65-year-old male who underwent IVC filter placement and open-heart surgery who later developed extensive femoral and iliocaval thrombosis leading to right heart failure, which required thrombus extraction with an AngioVac suction device. CASE PRESENTATION: We present a 65-year-old male who presented with bilateral pulmonary emboli with extensive right lower extremity deep vein thrombosis. Upon investigation he had ischemic heart disease and underwent a five-vessel coronary artery bypass for which he had an IVC filter placed preoperatively. On post operative day 3 to 4, he was decompensated and was diagnosed with an IVC thrombus. He progressed to right heart failure and worsening cardiogenic shock despite therapeutic anticoagulation and was taken for a suction thrombectomy using the AngioVac (AngioDynamics, Latham, NY) aspiration thrombectomy device. The thrombectomy was successful and he was able to recover and was discharged from the hospital. CONCLUSION: Despite being a rare complication, IVC thrombosis can have detrimental effects. This case is an example of how IVC thrombus in the post-operative setting can lead to mortality. The gold standard is therapeutic anticoagulation but despite that, this patient continued to have worsening cardiogenic shock. Other therapies have been described but because of its rarity, they are only described in case reports. This case shows that the AngioVac device is a successful treatment option for IVC thrombus and can have the possibility of future use.

Extensive thrombosis after COVID-19 vaccine: cause or coincidence?

A 62-year-old Caucasian female patient presented with abdominal pain, vomiting and fever 1 day after administration of COVID-19 vaccine. Bloodwork revealed anaemia and thrombocytosis. Abdominal CT angiography showed a mural thrombus at the emergence of the coeliac trunk, hepatic and splenic arteries, and extensive thrombosis of the superior and inferior mesenteric veins, splenic and portal veins, and the inferior vena cava, extending to the left common iliac vein. The spleen displayed extensive areas of infarction. Aetiological investigation included assessment of congenital coagulation disorders and acquired causes with no relevant findings. Administration of COVID-19 vaccine was considered a possible cause of the extensive multifocal thrombosis. After reviewing relevant literature, it was considered that other causes of this event should be further investigated. Thrombosis associated with COVID-19 vaccine is rare and an aetiological relationship should only be considered in the appropriate context and after investigation of other, more frequent, causes.

Ovarian vein thrombosis in the postnatal period.

Although ovarian vein thrombosis (OVT) is classically considered a puerperal pathology, it can also occur in nonpuerperal settings such as endometritis, pelvic inflammatory disease, Crohn's disease, pelvic or gynaecological surgeries and thrombophilia. Hypercoagulation conditions such as antiphospholipid syndrome, systemic lupus erythematosus, factor V Leiden and protein C and S deficiency are all recognised risk factors. It is also a known complication during pregnancy often presenting with fever and lower abdominal pain within weeks after delivery. Its incidence is exceedingly rare, occurring in 0.05% of all pregnancies that result in live births and peaking around 2-6 days after delivery. Its preferential involvement of the right ovarian vein may be explained by the compression of the inferior vena cava and the right ovarian vein due to dextrorotation of the uterus during pregnancy. Furthermore, antegrade flow of blood and multiple incompetent valves in the right ovarian vein favours bacterial infection. Complications may include sepsis and thrombus extension to the inferior vena cava or left renal vein and rarely, pulmonary embolism. The authors present the case of a 27-year-old woman with lower abdominal pain 5 weeks after an elective caesarean section. Although the diagnosis of postpartum endometritis was initially considered, a CT suggested a right OVT. She commenced treatment with low-molecular weight heparin. A high index of clinical suspicion is required in order to establish the diagnosis of this rare cause of abdominal pain, which can mimic an acute abdomen.

Leiomyosarcoma of the inferior vena cava posing as an adrenal incidentaloma.

Adrenal incidentalomas are incidentally detected adrenal lesions on imaging, which have a variety of differential diagnoses, the most common being a non-functioning adenoma. Surgical intervention for these lesions is needed when there is hypersecretion, for lesions larger than 4 cm and smaller lesions with suspicious characteristics. Here we present a young woman who was incidentally found to have a right suprarenal mass with loss of fat planes with the inferior vena cava (IVC). She underwent resection of the tumour along with the posterior wall of IVC, which was primarily repaired. Her postoperative biopsy was suggestive of leiomyosarcoma arising from the IVC. In the absence of distant metastasis, the sole prognostic factor for this tumour is achieving negative margins through radical resection of the tumour with IVC resection. Retroperitoneal leiomyosarcomas should be considered as a differential diagnosis for larger lesions, especially those more than 10 cm.

Current Controversies in Inferior Vena Cava Filter Placement: AJR Expert Panel Narrative Review.

Despite inferior vena cava (IVC) filter practice spanning over 50 years, interventionalists face many controversies in proper utilization and management. This article reviews recent literature and offers opinions on filter practices. IVC filtration is most likely to benefit patients at high risk of iatrogenic pulmonary embolus during endovenous intervention. Filters should be used selectively in patients with acute trauma or who are undergoing bariatric surgery. Retrieval should be attempted for perforating filter and fractured filter fragments when imaging suggests feasibility and favorable risk-to-benefit ratio. Antibiotic prophylaxis should be considered when removing filters with confirmed gastrointestinal penetration. Anticoagulation solely because of filter presence is not recommended except in patients with active malignancy. Anticoagulation while filters remain in place may decrease long-term filter complications in these patients. Patients with a filter and symptomatic IVC occlusion should be offered filter removal and IVC reconstruction. Physicians implanting filters may maximize retrieval by maintaining physician-patient relationships and scheduling follow-up at time of placement. Annual follow-up allows continued evaluation for removal or replacement as appropriate. Advanced retrieval techniques increase retrieval rates but require caution. Certain cases may require referral to experienced centers with additional retrieval resources. The views expressed should help guide clinical practice, future innovation, and research.

Echocardiographic assessment of the right ventricle in COVID -related acute respiratory syndrome.

In patients with the novel coronavirus (COVID-19) infection, the echocardiographic assessment of the right ventricle (RV) represents a pivotal element in the understanding of current disease status and in monitoring disease progression. The present manuscript is aimed at specifically describing the echocardiographic assessment of the right ventricle, mainly focusing on the most useful parameters and the time of examination. The RV direct involvement happens quite often due to preferential lung tropism of COVID-19 infection, which is responsible for an interstitial pneumonia characterized also by pulmonary hypoxic vasoconstriction (and thus an RV afterload increase), often evolving in acute respiratory distress syndrome (ARDS). The indirect RV involvement may be due to the systemic inflammatory activation, caused by COVID-19, which may affect the overall cardiovascular system mainly by inducing an increase in troponin values and in the sympathetic tone and altering the volemic status (mainly by affecting renal function). Echocardiographic parameters, specifically focused on RV (dimensions and function) and pulmonary circulation (systolic pulmonary arterial pressures, RV wall thickness), are to be measured in a COVID-19 patient with respiratory failure and ARDS. They have been selected on the basis of their feasibility (that is easy to be measured, even in short time) and usefulness for clinical monitoring. It is advisable to measure the same parameters in the single patient (based also on the availability of valid acoustic windows) which are identified in the first examination and repeated in the following ones, to guarantee a reliable monitoring. Information gained from a clinically-guided echocardiographic assessment holds a clinical utility in the single patients when integrated with biohumoral data (indicating systemic activation), blood gas analysis (reflecting COVID-19-induced lung damage) and data on ongoing therapies (in primis ventilatory settings).