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An Oscillating Thrombus Inside the Inferior Vena Cava

(A) Inferior vena cava-right atrium thrombus. (B) Right atrium thrombus. (C) Right atrium thrombus.

Thrombosis of the inferior vena cava is an under-recognized entity that is associated with significant morbidity and mortality.1 It is estimated that 2.6%-4% of patients with deep vein thrombosis of the lower extremities have inferior vena cava thrombosis. The most common cause of inferior vena cava thrombosis is the presence of an unretrieved inferior vena cava filter in absence of a congenital anomaly. The mortality rate of inferior vena cava thrombosis is twice as high as that of deep vein thrombosis confined to the lower extremities.2 Untreated patients with inferior vena cava thrombosis suffer from significant morbidities, such as postthrombotic syndrome in up to 90%, disabling venous claudication in 45%, pulmonary embolism in 30%, and venous ulceration in 15%.

A 68-year-old woman was admitted to our hospital with a recent ischemic stroke. Her history revealed a previous hospitalization of 1 week in another hospital because of the ischemic stroke. The physical examination revealed acute respiratory distress syndrome (peripheral capillary oxygen saturation, SpO2: 88%). The patient was taking warfarin because she was suffering from chronic atrial fibrillation.

During the time that she was in our hospital, a thorough evaluation was done. Computed tomography of the brain revealed areas of hypoattenuation in the left basal ganglia. Transthoracic echocardiography demonstrated a large oscillating thrombus at the confluence of the inferior vena cava and the right atrium. Eventually, the thrombus was located in the right atrium (Figure and Video, available online). Pulmonary computed tomography angiography showed various intraluminal filling defects in both the main and the segmental and subsegmental pulmonary arteries (pulmonary embolism). Ultrasound evaluation of the lower extremity veins diagnosed deep vein thrombosis of the right lower extremity. The treatment was conservative. The patient left the hospital after several days.

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-Christos Tourmousoglou, MD, Gerasimos Gogas, MD, Dimitrios Siskos, MD, Dimitrios Zioutas, MD

This article originally appeared in the December issue of The American Journal of Medicine.

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