Simple hepatic cyst causing inferior vena cava thrombus

Thrombosis of the inferior vena cava (IVC) is governed by Virchow's triad of stasis of blood flow, endothelial damage and hypercoagulability. Causes may be secondary to malignancy, congenital anomalies or other infrequent events such as external compression. We present a case of external compression of the IVC leading to extensive thrombus burden secondary to a benign hepatic cyst.

A 72 year old African American female presented to the emergency department with new onset shortness of breath, right lower extremity weakness and swelling. CT imaging demonstrated multiple hepatic cysts compressing the IVC, leading to extensive clot burden. Treatment with heparin drip was initiated without resolution of her symptoms. Transcatheter mechanical thrombectomy and tPA infusion was performed. After 24h, swelling and weakness were nearly resolved. The patient was bridged to therapeutic low molecular weight heparin in preparation for surgery.

Management of IVC thrombosis has typically been with a heparin drip and transition to oral anticoagulants. Thrombolysis has been shown to promote complete clot lysis more often than compared to standard anticoagulant therapy. In addition, venous patency was better maintained.

We feel that the added benefit of short term effects of improved venous patency and long term benefits of less post thrombotic syndrome, catheter based tPA administration and mechanical thrombectomy for thrombus offers an adjuvant treatment in the setting of large clot burden refractory to standard treatment.