Unprovoked Deep Venous Thrombosis in Young Adult Associated with Membranous Obstruction of Inferior Vena Cava

Abstract

INTRODUCTION: Unprovoked deep venous thrombosis in young adults is unusual phenomena. Developmental anomalies of inferior vena cava (IVC) should be considered as a possible etiological factor. We report a case of spontaneous thrombosis of inferior vena cava and bilateral iliac venous system in a young man associated with membranous obstruction of IVC. CASE PRESENTATION: 20 years old healthy male carpenter presented with complains on swelling and pain in bilateral lower extremities of one week duration. His family history was negative for any hypercoagulable disorders. On physical examination, lower extremities were swollen and tender from the ankles to the groin. Doppler ultrasound of lower extremities showed thrombosis of bilateral common, external and internal iliac veins. Computer tomography of the abdomen and pelvis revealed thrombosis of iliac venous system and infrarenal IVC with significant stenosis, dilated azygous vein with retroperitoneal collaterals. Venography confirmed the above findings. Catheter- induced thrombolytic therapy and systemic anticoagulation were initiated. In addition, patient required mechanical thrombectomy and balloon angioplasty of IVC stenosis. Control venography demonstrated restored blood flow. A hypercoagulable workup revealed elevated factor VIII level and heterozygous mutation of prothrombin G20210A. He was discharge home on warfarin for lifetime. DISCUSSION: Anomalies of IVC have been recognized as a possible risk factor for deep vein thrombosis, particularly in young adults. Fusion error in embryogenesis may lead to membranous obstruction due to true membrane or fibrous cord. The pathophysiology of thrombosis can be explained by inadequate blood return that increases the blood pressure in the veins of the lower extremities, leading to venous stasis. Anomalies of the IVC are also linked to thrombophilia disorders. Doppler ultrasonography is the first imaging modality that may occasionally fail to identify IVC. Computer tomography of the abdomen and pelvis should be used to access extension of thrombosis and detect anomalies of IVC. Treatment options include anticoagulation, systemic or trans catheter regional thrombolytic therapy and mechanical thrombectomy. If membrane presents, balloon angioplasty can be performed. In a case of fibrous cord, stent placement or graft surgery may be necessary. The duration of anticoagulation therapy should be individualized. CONCLUSIONS: Physician should be aware about association deep venous thrombosis with congenital anomalies of the inferior vena cava. Appropriate diagnostic tests should be done that may influence treatment option.