(1699) From Incidental to Urgent: Inferior Vena Cava Thrombus in a Lung Transplant Recipient

Introduction: The clinical presentation of inferior vena cava (IVC) thrombosis can range from asymptomatic (ie, incidental radiological finding) to severe hemodynamic compromise and cardiovascular collapse. It is often under-recognized given its relative rarity and atypical presentation. We present a case of an incidental IVC thrombus found during routine posttransplant imaging.

Description: A 73-year-old man with a medical history of bilateral lung transplantation (LT) for pulmonary fibrosis, secondary sclerosing cholangitis, diabetes, and hypertension received an outpatient abdominal MRI to monitor his liver disease. This led to the incidental discovery of a large IVC thrombus at the infrarenal level extending to the iliac bifurcation. The patient denied chest pain, dyspnea, or syncope and reported no pain or paresthesia in his extremities. His lower extremities were warm to the touch with strong pulses without edema. He was hemodynamically stable and not in respiratory distress. His blood pressure was 136/88 mmHg with a heart rate of 69 BPM. Abdominal/pelvic CT with contrast revealed thrombus throughout the infrarenal IVC extending through the left common and internal iliac veins. Further workup was negative for deep vein thrombosis in the extremities and pulmonary embolism. A heparin drip was initiated, and mechanical thrombectomy of the IVC and left common iliac vein via the right internal jugular vein with infrarenal IVC filter placement was performed for VTE prophylaxis. The IVC filter was retrieved after 3 months, and the patient will remain on life-long apixaban prophylaxis. Of interest, our patient had a remarkable recovery from chronic thrombocytopenia once the IVC clot was addressed.

Discussion: IVC thrombosis carries a high risk of morbidity and mortality due to its unusual presentation, delayed diagnosis, and late interventions, leading to complications including pulmonary emboli and renal ischemia as the thrombus extends. Overall prognosis hinges on the underlying cause of the thrombus. Complete hypercoagulable work-up as well as underlying causes need to be to pursued. Our patient had multiple risk factors including post-LT immunosuppressive medications that can cause clots and underlying liver disease. Our patient received adequate treatment in time and continues to progress well.