524615 research-article2014
VMJ0010.1177/1358863X14524615Vascular MedicineProvias et al.
Images in Vascular Medicine Inferior vena cava compression by a hematoma
Vascular Medicine 2014, Vol. 19(2) 146–147 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1358863X14524615 vmj.sagepub.com
Tim Provias, Ido Weinberg, Robert Schainfeld and Michael Jaff
A 72-year-old woman underwent L3-L4 laminectomy for lower back and right leg pain caused by severe L3 radiculopathy. In the immediate postoperative period, upon extubation, the patient became hypotensive to 46/28 mmHg. She was re-intubated, resuscitated with fluids and blood products, and started on phenylephrine and vasopressin. An emergent contrast-enhanced computed tomography (CT) of the abdomen and pelvis revealed extravasation of contrast from the distal abdominal aorta into the retroperitoneum, forming an 8 × 12 cm hemorrhagic collection posteriorly. She returned to the operating room, where control of the bleeding was achieved with balloon occlusion of the aorta. The injury was repaired with a Gore stent graft (Gore, Flagstaff, AZ, USA). The remainder of her hospital course was unremarkable, and she was discharged 7 days later. She returned 1 month after discharge with progressive, significant right-greater-than-left lower extremity swelling to the thighs. Duplex ultrasound revealed extensive thrombus in the right femoral vein (Panel A1) extending proximally into the iliac vein with an abnormal Doppler flow pattern bilaterally (Panel A2) suggestive of an occlusion in the bilateral proximal iliac veins or inferior vena cava. A repeat CT scan showed a large, multiloculated retroperitoneal hematoma compressing the inferior vena cava (Panel B, arrow) and thrombosed iliac veins (Panel C, arrowheads). This case illustrates a unique example of a massive retroperitoneal hematoma resulting in inferior vena cava compression and thrombosis. The patient was treated with heparin and warfarin, ultimately with conversion to rivaroxaban for a planned 6-month course.
Panel B
Panel C
Division of Cardiology, Institute for Heart, Vascular, and Stroke Care, The Massachusetts General Hospital, Boston, MA, USA
Panel A
Corresponding author: Tim Provias Massachusetts General Hospital 55 Fruit St Boston, MA 02114 USA Email: [email protected]
Downloaded from vmj.sagepub.com at NANYANG TECH UNIV LIBRARY on June 9, 2015
147
Provias et al. Declaration of conflicting interest
Funding
None declared.
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
‘Images in vascular medicine’ is a regular feature of Vascular Medicine. Readers may submit original, unpublished images related to clinical vascular medicine. Submissions may be sent to: Heather L Gornik, Editor in Chief, Vascular Medicine, via the web-based submission system at http://mc.manuscriptcentral.com/vascular-medicine
Downloaded from vmj.sagepub.com at NANYANG TECH UNIV LIBRARY on June 9, 2015
VMJ0010.1177/1358863X14524615Vascular MedicineProvias et al.
Images in Vascular Medicine Inferior vena cava compression by a hematoma
Vascular Medicine 2014, Vol. 19(2) 146–147 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1358863X14524615 vmj.sagepub.com
Tim Provias, Ido Weinberg, Robert Schainfeld and Michael Jaff
A 72-year-old woman underwent L3-L4 laminectomy for lower back and right leg pain caused by severe L3 radiculopathy. In the immediate postoperative period, upon extubation, the patient became hypotensive to 46/28 mmHg. She was re-intubated, resuscitated with fluids and blood products, and started on phenylephrine and vasopressin. An emergent contrast-enhanced computed tomography (CT) of the abdomen and pelvis revealed extravasation of contrast from the distal abdominal aorta into the retroperitoneum, forming an 8 × 12 cm hemorrhagic collection posteriorly. She returned to the operating room, where control of the bleeding was achieved with balloon occlusion of the aorta. The injury was repaired with a Gore stent graft (Gore, Flagstaff, AZ, USA). The remainder of her hospital course was unremarkable, and she was discharged 7 days later. She returned 1 month after discharge with progressive, significant right-greater-than-left lower extremity swelling to the thighs. Duplex ultrasound revealed extensive thrombus in the right femoral vein (Panel A1) extending proximally into the iliac vein with an abnormal Doppler flow pattern bilaterally (Panel A2) suggestive of an occlusion in the bilateral proximal iliac veins or inferior vena cava. A repeat CT scan showed a large, multiloculated retroperitoneal hematoma compressing the inferior vena cava (Panel B, arrow) and thrombosed iliac veins (Panel C, arrowheads). This case illustrates a unique example of a massive retroperitoneal hematoma resulting in inferior vena cava compression and thrombosis. The patient was treated with heparin and warfarin, ultimately with conversion to rivaroxaban for a planned 6-month course.
Panel B
Panel C
Division of Cardiology, Institute for Heart, Vascular, and Stroke Care, The Massachusetts General Hospital, Boston, MA, USA
Panel A
Corresponding author: Tim Provias Massachusetts General Hospital 55 Fruit St Boston, MA 02114 USA Email: [email protected]
Downloaded from vmj.sagepub.com at NANYANG TECH UNIV LIBRARY on June 9, 2015
147
Provias et al. Declaration of conflicting interest
Funding
None declared.
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
‘Images in vascular medicine’ is a regular feature of Vascular Medicine. Readers may submit original, unpublished images related to clinical vascular medicine. Submissions may be sent to: Heather L Gornik, Editor in Chief, Vascular Medicine, via the web-based submission system at http://mc.manuscriptcentral.com/vascular-medicine
Downloaded from vmj.sagepub.com at NANYANG TECH UNIV LIBRARY on June 9, 2015
