Duplicate Inferior Vena Cava As A Potential Pathway For Recurrent Pulmonary Embolism

SESSION TITLE: Medical Student/Resident Pulmonary Vascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: A duplicate inferior vena cava (dIVC) is a rare congenital abnormality with a reported incidence rate of 0.3 to 3.0%. It occurs when there is failure of regression of the left subcardinal vein during embryogenesis. Although rare, clinical implications can be life-threatening. Herein we present a case of a young adult female with recurrent pulmonary embolism (PE) after inferior vena cava (IVC) filter placement who was ultimately found to have a dIVC. CASE PRESENTATION: A 33-year-old woman with recent surgical repair of a right ankle fracture presented to our institution in cardiac arrest. Prior to her arrest she complained of dyspnea and was found to be hypoxemic. Enroute she developed bradycardia and lost pulses. She was ultimately treated with alteplase for suspected PE with return of spontaneous circulation. Further work-up confirmed large right-sided PE and right lower extremity DVT. She later developed large hemoperitoneum. Her anticoagulation was discontinued and an IVC filter was placed. Her condition improved and she was discharged on hospital day 9. One month later routine follow-up chest CT-angiogram revealed bilateral PE with a large saddle embolus. She was urgently transferred to our facility. Further imaging revealed an intact IVC filter, complete resolution of her prior hemoperitoneum and incidentally a dIVC splitting from the non-aberrant IVC distally at the level of the right common iliac artery, crossing the abdominal aorta anteriorly, and ultimately rejoining the non-aberrant IVC proximal to her IVC filter (Image 1). Areas of low attenuation likely representing clot were noted both below the IVC filter and within the dIVC. Posteriorly the left renal vein can be seen draining into the duplicate IVC (Figure 2). With interval resolution her hemoperitoneum the decision was made to start anticoagulation with heparin. She was transitioned to apixiban and discharged on hospital day 6. Her IVC filter was retrieved one month later. DISCUSSION: In the past 100 years, the number of cases published involving dIVC in association with thromboembolism is less than 10. A dIVC may be in found in association with horseshoe kidney and other ureteropelvic junctional anomalies. Other rare pathologies that have been reported include venous compression syndromes on the dIVC due to anatomic entrapment resembling Nutcracker syndrome and May-Thurner syndrome. A DVT originating in the lower extremities could have traveled into the dIVC and entered the primary IVC proximal to the filter. Had this aberration been known it would have likely changed the approach to IVC filter placement. CONCLUSIONS: In the setting of DVT/PE a dIVC provides an alternative pathway for embolization of a DVT. In patients with DVT/PE where IVC filter placement is indicated, the potential presence of this anatomic aberrancy should be considered. Reference #1: Coco, Danilo, Sara Cecchini, Silvana Leanza, Massimo Viola, Stefano Ricci, and Roberto Campagnacci. 2016. “Inferior Vena Cava Duplication: Incidental Case in a Young Woman.” Case Reports in Radiology 2016 (April): 3071873. Reference #2: Tamizifar, Babak. 2013. “Duplication of the inferior vena cava and thrombosis: a rare case.” Journal of Research and Medical Sciences. 2013; 18(10): 911-913. Reference #3: Mukai, Yuichi, Shuhei, Nozawa, Suzuki, Toshiro. “Double venous compression due to duplicated inferior vena cava-induced right common iliac vein thrombosis.” BMJ Case Reports. 2018 DISCLOSURES: No relevant relationships by Daniel Condit, source=Web Response No relevant relationships by Brian Covello, source=Web Response No relevant relationships by Antarpreet Kaur, source=Web Response No relevant relationships by Anantha Sriharsha Madgula, source=Web Response