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(a) Hypodense filling defect in the IVC on CT and (b) free-floating echodensity at the level of the hepatic veins, both consistent with intracaval thrombus.
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fig1
The thrombus extended from the right external iliac vein to the level of the hepatic veins (Figure 1).
PMC4689968_02
(a) Right and left pulmonary artery filling defects on CTPA and (b) TOE demonstrating the head of the mass protruding from the IVC into the RA. The TV was not damaged although the mass protruded through the TV into the RV during diastole. IVC: inferior vena cava; RA: right atrium; TV: tricuspid valve; RV: right ventricle.
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fig2
A 62-year-old female was found to have bilateral pulmonary emboli on computed tomography pulmonary angiography (CTPA) following two episodes of syncope (Figure 2(a)). She underwent transthoracic echocardiography (TTE) and a large, mobile thrombus was reported in her right atrium (RA) and IVC (Figure 2(b)).
(a) A thin, white mass in the RA with its attachment extending down the IVC and (b) the gross specimen of the intracardiac tumor. (c) Smooth muscle actin antibody stain positive in the tumor specimen.
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fig3
She underwent emergency removal of the intracardiac mass and a large, white tumor mass protruded through the atriotomy when the right atrium was opened for venous cannulation for cardiopulmonary bypass (Figure 3(a)). The right atriotomy was extended and the mass was well visualized and divided at its apparent attachment to the IVC (Figure 3(b)). Immunostaining was positive for smooth muscle actin and desmin, confirming the diagnosis of IVL (Figure 3(c)).
(a) CT axial and (b) coronal views of the IVL in the right common iliac vein (red arrows). (c) Axial and (d) coronal views of the pelvic component of the tumor (red arrows), abutting the dilated common iliac vein (yellow arrow). (e) Axial T2-weighted sequence on MRI identifying the intraluminal caval tumor with (f) associated pelvic mass on coronal image.
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fig4
Further abdominal imaging with CT identified a distended IVC, right common iliac vein, and right internal iliac vein, filled with low-density intraluminal material and a soft tissue density mass in the pelvis (Figure 4).
(a) Gross specimen of the tumor resected from the IVC venotomy during second-stage procedure and (b) pelvic mass with venous attachment site (yellow arrow) with (c) strongly positive staining of IVC tumor specimen for estrogen receptors.
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fig5
Redo-sternotomy and laparotomy were performed, the IVC was opened after gaining control of the proximal and distal vessels, and a white, firm, rubbery tumor nearly 30 cm long was excised with gentle traction (Figure 5(a)). The pelvic mass was identified abutting but not invading the sigmoid colon and was excised (Figure 5(b)). Histopathology identified identical material to the original specimen with strong estrogen and progesterone receptor positivity on immunostaining (Figure 5(c)).