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A 48-year old welder presented to the emergency department with a 3 day history of a swollen left leg. He has enalapril and nifedipine for hypertension and does not smoke. This has never occurred in the past. Examination revealed a tense, erythematous and swollen left leg with a normal asymptomatic contralateral lower limb. Peripheral pulses were present. Blood results were within normal limits. Deep vein thrombosis (DVT) was suspected and this was confirmed by ultrasonography. The patient was anticoagulated and discharged a few days later on warfarin. His international normalised ratio (INR) was 1.72, with an activated partial thromboplastin time (APTT) ratio of 0.91. He returned 3 days later with a swollen right leg, an INR of 1.9 and symptoms identical to his previous presentation. Ultrasonography revealed a right DVT. Thrombophilia screen was normal. CT abdomen demonstrated the presence of thrombus extending from the femoral veins to the distal segment of the inferior vena cava (IVC). Proximal to the level of the renal arteries, a rudimentary IVC measuring <5 mm in diameter (fig 1) was noted up to where it enters the right atrium. A well-established venous circulation was seen at the para-aortic region (fig 2). In the absence of other risk factors, this IVC malformation is thought to cause decreased venous return with subsequent venous stasis leading to DVT. He was managed on lifelong anticoagulation and graduated compression stockings.
The incidence of IVC anomalies in patients between the ages of 20 and 40 years with idiopathic DVT is about 5%.1 These anatomical variations can be divided into prerenal, renal or postrenal. Our case demonstrates hypoplasia of the entire prerenal segment of the IVC. This rare risk factor should be considered in young patients presenting with spontaneous bilateral DVT.
Mr T Walker, Consultant in General and Vascular Surgery
Competing interests: none.
Patient consent: Patient/guardian consent was obtained for publication.
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