Inferior vena cava obstruction, also known as inferior vena cava syndrome, refers to the clinical manifestations occurring as a result of any blockage in the inferior vena cava. It can occur due to external compression, thrombosis of inferior vena cava or iatrogenic placement of filters 1. Certain congenital malformations of inferior vena cava have also been implicated. Primary malignancy of inferior vena cava is very rare but metastatic tumors can invade the vessel resulting in obstruction 2.
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Epidemiology
Associations
Between 4-15% of the cases of inferior vena cava syndrome are associated with deep vein thrombosis 1. Treatment of deep vein thrombosis with inferior vena cava filters, especially without timely retrieval, can also lead to inferior vena cava syndrome.
Primary malignancies of inferior vena cava constitute less than 1% of all malignancies with inferior vena cava leiomyosarcoma being the most common type 2. Secondary malignancies with involvement of inferior vena cava include renal cell carcinoma with 4-10% having vascular spread and hepatocellular carcinoma with 4-5.9% having vascular spread 2.
Other associations include
pregnancy 1
obesity 1
lymphadenopathy 3
liver transplantation 4
Diagnosis
The underlying cause of inferior vena cava obstruction needs to be diagnosed and various imaging modalities are used for this purpose. When obstruction of inferior vena cava is suspected, duplex ultrasound, CT or MRI of abdomen and pelvis are used to arrive at a diagnosis 2,3.
Clinical presentation
The clinical presentation depends on whether the obstruction is sudden or gradual. Slowly developing occlusion results in formation of collaterals and thus, often a less florid clinical presentation 3.
Patient may present with 1,6:
hypotension
edema of lower limbs
tachycardia
tachypnea
abdominal distention
anasarca
constitutional and other symptoms in the case of underlying malignancy
Pathology
Blockage of the inferior vena cava results in decreased venous return to the heart and signs and symptoms of hypovolemia. Stasis of blood activates the coagulation cascade and results in thrombosis. Further congestion is responsible for localized signs such as pedal edema 1.
Radiographic features
Ultrasound, CT and MRI show features suggesting the etiology of occlusion as discussed in the articles inferior vena cava thrombosis and inferior vena cava leiomyosarcoma.
Treatment and prognosis
Malignancy requires chemotherapy or radiotherapy along with surgical resection, whereas in case of thrombosis, anticoagulants form the mainstay of treatment 1,3. Other options include endovascular procedures and stent placement 5.
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