Surgical treatment of floating thrombosis of the inferior vena cava

Inferior vena cava (IVC) thrombosis is a serious complication of deep vein thrombosis (DVT). Floating IVC thrombosis have an increased risk of pulmonary embolism (PE). To date, there is a lack of sufficient data on the treatment of floating IVC thrombosis. There is no information in any guidelines and recommendations regarding the tactics of treatment of floating IVC thrombosis. In this case report, the patient was admitted to the Clinic on the 3rd day from the onset of symptoms - shortness of breath, disturbing at the slightest exercise, cyanosis, hemoptysis, pain, edema of right lower extremity. These symptoms appeared suddenly and increased in the following days, forcing the patient to go to the clinic. In the previous month, the patient suffered from acute femoral-popliteal DVT of the right lower limb, for which he received anticoagulant therapy. Thrombophilia test showed Leidens mutation (V factor). Echocardiography revealed pulmonary hypertension I degree (pulmonary artery pressure 37 mmHg), dilatation of the right heart. No pathology was detected during duplex vein scanning of both lower extremities. Duplex scanning of the veins of both lower extremities revealed floating thrombosis of the IVC, extending from the right common iliac vein for 8 cm. Distal thrombotic masses spread to the level of the tibial veins, the great saphenous vein was compacted. The thrombus mixed echogenicity. Deep and superficial veins of the left lower extremity were passable. The valve apparatus was preserved, no signs of Mayo-Turner Syndrome were found. To confirm pulmonary embolism, spiral computed tomography (CT) with intravenous pulmonary artery contrast was used. Spiral CT with intravenous contrast of the pulmonary artery revealed thrombotic masses in the trunk and lobular branches of the right and left pulmonary artery, infarction-pneumonia of D8, 9, 10 and S9 segments of lungs. CT cavography showed floating thrombosis of IVC for 8 mm, extending from the right common iliac vein. Considering the presence of PE and hemoptysis in the patient, because of infarction-pneumonia, thrombolytic therapy in this patient was dangerous due to the risk of bleeding and migration of the floating part of the thrombus in the proximal direction as a result of lysis of the base of the floating part. Given that recurrent PE with massive thrombotic masses (floating part length 8 cm) could lead to fatal PE, we decided to surgically remove the floating part of the thrombus from the IVC. In the postoperative period, pain, cyanosis and edema of the right lower extremity regressed, and the patient’s condition improved significantly. Control duplex scan on day 1, 5, 17 after surgery showed no thrombotic masses in the IVC. Floating IVC thrombosis is a dangerous disease and can lead to PE with a high risk of death. Thrombophilic conditions are one of the reasons for the propagation of thrombotic masses in the IVC. Open thrombectomy is an effective method of treatment for floating IVC thrombosis.