History

Patients with inferior vena caval (IVC) thrombosis (IVCT) may present with a spectrum of signs and symptoms. Patients may be asymptomatic, or they may present only after complications occur.

This variability is a significant part of the challenge of diagnosis. Using a classification system may help the clinician make the correct diagnosis. Thus, patients may present with symptoms that are predominantly thrombotic in origin or predominantly embolic in nature. Additionally, the thrombotic findings are dependent on the degree of occlusion of the IVC and on the location between the iliac confluence and the right atrium.

Patients who have IVCT may present only after having pulmonary embolism (PE). The lack of uniform symptoms and the significant number of asymptomatic patients contribute to this feature of IVCT. In one retrospective review of all patients who had cavography to document IVC thrombus, 20% had angiographically proven PE with no symptoms of deep vein thrombosis (DVT). Thus, PE may be the first sign of IVCT.

In patients with complete absence of the IVC, symptoms associated with severe venous hypertension (eg, bilateral lower-extremity edema, varicose veins, nonhealing venous ulcers, caput medusae, or other manifestations of collateral venous system hypertension/dilatation) may be varied in their manifestation and, in some cases, may not be apparent until later in life.

Physical Examination

The classic presentation of IVCT includes bilateral lower-extremity edema with dilated, visible superficial abdominal veins. Intuitively, this constellation makes sense, though it is not universally found. In one study, almost 60% of patients did not have bilateral leg edema. In addition, if the thrombus is confined to the cava and does not involve the iliac or femoral system, the collateral pathways form along the posterior abdominal wall. This scenario may have significant impact on surgical procedures involving this anatomic region.

Occlusive thrombus of the IVC at the juxtarenal level can affect renal function by altering renal perfusion.

It is hypothesized that blood return with an absent IVC is inadequate, despite adequate collaterals, resulting in chronic venous hypertension in the lower extremities and causing venous stasis that precipitates thrombosis.

Budd-Chiari syndrome

Budd-Chiari syndrome merits specific attention, though a discussion of the entire syndrome is beyond the scope of this article. The essentials of this condition as they relate to IVCT are important. Patients typically have significant ascites, portal hypertension, hepatomegaly, collateral vein enlargement, and hepatic fibrosis. The pathophysiology of this syndrome centers on either IVC or hepatic venous thrombosis. If it is at the hepatic venous level, two or three of the major hepatic veins must be occluded before the syndrome can develop. Both hypercoagulable states and membranous venous webs have been postulated as the etiologic agents of Budd-Chiari syndrome.

Differential Diagnoses

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Media Gallery

Virchow triad/venous thromboembolism (VTE) risk factors.
Photo showing dilated superficial abdominal veins (upper quadrant), with bruising and thrombosed large abdominal veins (lower quadrant).
Abdominal CT scan shows absent inferior vena cava with thrombosis of very prominent collateral veins in the abdominal wall, corresponding to right side of abdomen as seen in earlier photo.
Veins of abdomen and thorax. Unless stated otherwise, lithograph plate is from Gray's Anatomy (online edition of the 20th US edition of Gray's Anatomy of the Human Body, originally published in 1918).

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Author

Luis G Fernández, MD, KHS, KCOEG, FACS, FASAS, FCCP, FCCM, FICS Professor of Surgery, Department of Surgery, Division of Trauma Surgery/Surgical Critical Care, University of Texas Health Science Center; Clinical Assistant Professor of Surgery, Department of Surgery, University of Texas Medical Branch; Adjunct Clinical Professor of Medicine and Nursing, University of Texas; Adjunct Clinical Assistant Professor, Department of Medical Education Health Science Center, Adjunct Clinical Assistant Professor, Department of Physician Assistant Studies, School of Health Professions, University of North Texas; Medical Director, Trauma Wound Care, UT Health East; Member, ACS National Committee on Trauma; Vice Chairman, State Guard Association of the United States (SGAUS) Medical Academy; Commander Emeritus, Texas Commandery, MOFW; Brigadier General (Ret/HR), Past Commanding General, TXSG Medical Brigade/Medical Rangers

Luis G Fernández, MD, KHS, KCOEG, FACS, FASAS, FCCP, FCCM, FICS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Legal Medicine, American College of Surgeons, American Society of Abdominal Surgeons, American Society of General Surgeons, American Society of Law, Medicine & Ethics, American Trauma Society, Association for Surgical Education, Association of Military Surgeons of the US, Chicago Medical Society, Illinois State Medical Society, International College of Surgeons, New York Academy of Sciences, Pan-American Trauma Society, Society of Critical Care Medicine, Society of Laparoendoscopic Surgeons, Southeastern Surgical Congress, Texas Medical Association, Undersea and Hyperbaric Medical Society

Disclosure: Received honoraria from KCI for speaking and teaching; Received honoraria from PACIRA for speaking and teaching; Speaker / teaching honoraria for URGO -Stedmed North America.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine

John Geibel, MD, MSc, DSc, AGAF is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Acknowledgements

Douglas M Geehan, MD Associate Professor, Department of Surgery, University of Missouri-Kansas City School of Medicine

Disclosure: Nothing to disclose.

Michael A Grosso, MD Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital

Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons

Disclosure: Nothing to disclose.