IMAGES IN PULMONARY, CRITICAL CARE, SLEEP MEDICINE AND THE SCIENCES A Giant Clot Raghav Gupta1, Aditi Jindal2, John Fratinni1, and Hope Cranston-D’Amato3 1 Department of Internal Medicine, Pulmonary and Critical Care Medicine, and 3Department of Critical Care Medicine and Infectious Disease, St Luke’s Hospital, Chesterfield, Missouri; and 2Department of Pediatric Dentistry, Tufts University School of Dental Medicine, Boston, Massachusetts
Figure 1. Echogenic filling defect in inferior vena cava consistent with a clot.
Figure 2. Computed tomography of the abdomen and pelvis with coronal reconstruction showing long strand of thrombus within the inferior vena cava extending from the superior aspect of the filter.
Figure 3. Follow-up echocardiogram revealed complete resolution of clot status post tissue plasminogen activator (tPA).
A 44-year-old man with a history of renal cell carcinoma status post nephrectomy, pulmonary emboli, and deep venous thrombosis of bilateral lower extremities status post inferior vena cava filter was admitted to the intensive care unit with complaints of chest pain and shortness of breath. One year earlier, the patient’s warfarin had been discontinued due to repeated negative Doppler’s of bilateral lower extremities. On admission, laboratory tests showed troponin of 1.48 ng/ml and D-dimer of over 20 mg/ml, followed with an electrocardiogram that noted sinus tachycardia. Surface echocardiogram revealed a 5-cm-long, 1-cm-wide thrombus extending from inferior vena cava to superior vena cava and right atrium (Figure 1). Computed tomography of the abdomen and pelvis confirmed a long strand of thrombus within the inferior vena cava, extending from the superior aspect of the filter to the right atrium (Figure 2, arrow). Alteplase, the tissue plasminogen activator (tPA), was administered with an intravenous bolus dose of 0.6 mg/kg over 2 minutes, and heparin drip and warfarin was started. Within 24 hours of the clot, a follow-up echocardiogram showed complete resolution of the clot (Figure 3). After 7 days, he showed remarkable clinical and radiographic improvement, and was discharged to home on warfarin. n Author disclosures are available with the text of this article at www. atsjournals.org.
Am J Respir Crit Care Med Vol 189, Iss 11, p e68, Jun 1, 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1164/rccm.201305-0998IM Internet address: www.atsjournals.org
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American Journal of Respiratory and Critical Care Medicine Volume 189 Number 11 | June 1 2014
Figure 1. Echogenic filling defect in inferior vena cava consistent with a clot.
Figure 2. Computed tomography of the abdomen and pelvis with coronal reconstruction showing long strand of thrombus within the inferior vena cava extending from the superior aspect of the filter.
Figure 3. Follow-up echocardiogram revealed complete resolution of clot status post tissue plasminogen activator (tPA).
A 44-year-old man with a history of renal cell carcinoma status post nephrectomy, pulmonary emboli, and deep venous thrombosis of bilateral lower extremities status post inferior vena cava filter was admitted to the intensive care unit with complaints of chest pain and shortness of breath. One year earlier, the patient’s warfarin had been discontinued due to repeated negative Doppler’s of bilateral lower extremities. On admission, laboratory tests showed troponin of 1.48 ng/ml and D-dimer of over 20 mg/ml, followed with an electrocardiogram that noted sinus tachycardia. Surface echocardiogram revealed a 5-cm-long, 1-cm-wide thrombus extending from inferior vena cava to superior vena cava and right atrium (Figure 1). Computed tomography of the abdomen and pelvis confirmed a long strand of thrombus within the inferior vena cava, extending from the superior aspect of the filter to the right atrium (Figure 2, arrow). Alteplase, the tissue plasminogen activator (tPA), was administered with an intravenous bolus dose of 0.6 mg/kg over 2 minutes, and heparin drip and warfarin was started. Within 24 hours of the clot, a follow-up echocardiogram showed complete resolution of the clot (Figure 3). After 7 days, he showed remarkable clinical and radiographic improvement, and was discharged to home on warfarin. n Author disclosures are available with the text of this article at www. atsjournals.org.
Am J Respir Crit Care Med Vol 189, Iss 11, p e68, Jun 1, 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1164/rccm.201305-0998IM Internet address: www.atsjournals.org
e68
American Journal of Respiratory and Critical Care Medicine Volume 189 Number 11 | June 1 2014
