Clinical Aspects Of Iliocaval Obstruction

The clinical presentation of inferior vena cava occlusion comprises a wide spectrum of signs and symptoms of venous hypertension. The recruitment of collateral pathways may be adequate, as well as occult, and some individuals will remain symptom free. Symptomatic individuals present with edema and a variety of signs and symptoms of venous hypertension. The severity of symptoms implies inadequate collateral inflow in the face of poorly recanalized, multisegmental obstruction. Although not as common as isolated iliofemoral thrombosis, patients with iliocaval involvement represented between 1 and 10% in the reported series.15

Acute caval thrombosis commonly presents with bilateral lower limb edema, unexplained recent weight gain, and in some, back pain. The lack of collateral flow causes lower limb edema, discoloration, and discomfort. Patients have no difficulty recognizing the seriousness of this condition, even though it may have been a gradual change. Once the critical mass of thrombus interrupts caval flow, acute venous hypertension progresses rapidly. Alternatively, chronic caval occlusion is sometimes difficult to diagnose. Occult central venous problems can be indicated in duplex waveform analysis, where the loss of phasicity can provide a clue to more proximal obstruction. (See Figure 61.4)

IVC occlusion often results in bilateral lower limb edema, but occasionally, a single limb is most affected and the discovery of caval occlusion is a surprise. Prominent collateral veins may be seen on the lower anterior abdominal wall or in the region of the pubic symphysis (see Figure 61.1). Unilateral or bilateral lower limb varicosities may be present. Advanced skin changes including hyperpigmentation, lipo-dermatosclerosis, and ulceration are common with IVC syndrome (see Figure 61.2). In two of our patients, venous stasis changes led to below-the-knee amputation years before the caval obstruction was identified. Patients often report that leg elevation does little to alleviate edema. Prolonged sitting can cause a vague inguinal ache often described as a constant sensation of fullness in the groin area, which becomes

Ivc Obstruction Collaterals
FIGURE 61.1 Prominent lower anterior abdominal wall veins seen on a young woman with iliocaval obstruction for 2 years are a pathopneumonic sign of IVC obstruction. The collateral veins become unapparent after endovenous correction of caval occlusion.
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FIGURE 61.2 Twenty-two-year-old male with long-standing iliocaval obstruction, suspected to have occurred shortly after birth. Within two years of his initial episode left femoral-popliteal thrombosis, at age 20, he had a recurrent DVT and developed a stasis ulcer on the medial anterior calf. Evidence of varicosities in his teenage years was an additional sign suspicious for central venous obstruction.

FIGURE 61.2 Twenty-two-year-old male with long-standing iliocaval obstruction, suspected to have occurred shortly after birth. Within two years of his initial episode left femoral-popliteal thrombosis, at age 20, he had a recurrent DVT and developed a stasis ulcer on the medial anterior calf. Evidence of varicosities in his teenage years was an additional sign suspicious for central venous obstruction.

worse with stair climbing. Patients frequently report dyspnea on exertion, even in the absence of any history of pulmonary embolus or respiratory ailments. They may have been told they have asthma. One patient presented with hematuria due to bladder varicosities. In two young patients, presenting at age 17 and 21 years, caval occlusion probably occurred near birth, since each had a single left kidney with compensatory hypertrophy. The common use of central lines in premature and young infants has created a juvenile population with the sequela of central venous thrombosis. The incidence of catheter-related deep vein thrombosis is estimated to be 3.5 per 10,000 hospital admissions, whereas the IVC is affected in approximately 10% of pediatric DVT cases.43 In a longitudinal study, 40 children, diagnosed with IVC thrombosis between birth and 13 years of age, were followed for up to 20 years after recognition of an early thrombotic event.44 Among the patients, 21 were identified with extensive IVC thrombosis. During follow-up, complete resolution was seen in four cases; one underwent thrombolysis, two surgeries, and one spontaneous lysis. Obstructive IVC thrombus persisted in the iliocaval segments in 17 children, including six who received thrombolytic therapy. Varicose veins were present in 12/17 (71%) and post-thrombotic syndrome in 7/17 (41%). Analysis suggested that 30% of children with unresolved caval obstruction will develop post-thrombotic syndrome within 10 years of the initial thrombosis. In the young patients we treated, they were asymptomatic until the acute thrombosis of the left iliofemoral segments at ages 21 and 17, respectively. In one patient, this happened after sliding into base playing softball and in the other, after a summer job where he leaned over a large bin husking corn. As in many patients, the investigation of an acute lower limb deep vein thrombosis led to the discovery of previously compensated underlying caval obstruction of indeterminate age.

The majority of patients with long-standing venous insufficiency, secondary to obstruction, are seen by primary care physicians long before they are referred to a vascular specialist. Patients commonly report that they have been told there is not much available for treatment of PTS other than compression. They may have a remote history of iliofemoral DVT and no suspicion of central venous obstruction. Alternatively, they may have a prior diagnosis of iliocaval occlusion, or have been told that the IVC is absent after phlebography or if cross-sectional imaging with CT or MRV have been performed. Large collaterals, seen on computed tomography (CT), have even been interpreted as lymphade-nopathy and led to a search for malignancy.

Blood Pressure Health

Blood Pressure Health

Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

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