The IVC Clot

74 y.o. male with a 90 pack year smoking history who presented to the LLUMC ED w/ SOB for 2 days duration associated with a productive cough and palpitations. He initially presented to the Barstow ED with hypoxia (90% on RA) which improved with oxygen administration. Chest X-ray at the outside hospital showed a right pleural effusion, while a CT scan showed a large pleural effusion with bilateral lung nodules. He had a thoracentesis which drained 200mL of serosanguinous fluid. After the procedure he developed hypertensive emergency and was thus transferred to LLUMC ED for further care.

The patient was admitted for hypertensive emergency, pleural effusion, and possible pneumonia

A bedside cardiac ultrasound was ordered which I performed. Below are my findings

Cardiac
– Mild Left Ventricular Hypertrophy
– EF WNL
– Negative for Effusion, IVC >50% collapsible

Lung
– Significant Bilateral Effusion

IVC
– Large filling defect extending from Rt. Renal Vein into IVC
– No vascularity identified on defect via color doppler

My main concern was to understand how to differentiate between a mass being a tumor or a thrombus. I then looked up various papers regarding masses in the IVC found via ultrasound and only found case studies related to tumour thrombuses of cancer and did not find any information regarding diagnosing via ultrasound. The definitive diagnoses is via biopsy, but ultrasound is definitely a great screening tool. Nevertheless, there is no protocol for screening IVC clots available seeing as oftentimes when they occur a patient is already severely clinically ill.

Isaiah Horton, MS4