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A 43-year-old man with a medical history of multiple deep vein thrombosis and right inferior vena cava (IVC) filter placement, was evaluated for shortness of breath and venous claudication. Vital signs showed an O2 saturation of 90% on room air and a respiratory rate of 24 breaths/min. Physical examination revealed grossly dilated veins of the abdomen, chest wall and inguinal areas (figure 1), as well as dilated veins in the patient's legs. Lung examination was notable for crackles in the left lower lobe. Given the elevated Wells’ score, and clinical findings of shortness of breath and history …