No abstract

We present a case of a 67-year-old man with T4aN3bM0 gastric adenocarcinoma who developed refractory hypotension 24 hours postinferior vena cave filter (IVCF) insertion for a new finding of pulmonary embolism (PE) and ongoing melena stool. After 18 hours of aggressive 20 L intravenous fluid resuscitation in the ICU followed by vasopressors and intravenous antibiotics, a point-of-care echocardiography did not reveal right ventricular strain and a non-contrast CT scan of the abdominal and pelvis was reported as not remarkable. But his lower limbs became progressively edematous and swollen while his upper limb maintained its normal circumference. At 24 hours post-ICU admission, his lower limbs had worsened with severe pain and pallor. The compartmental pressure measurements were in the high normal ranges. At morning rounds, the complete occlusion of the IVCF causing severe hypovolemic shock was considered and re-review of the non-contrast CT abdomen and pelvis showed complete collapsed IVC above the IVCF. The IVC below the IVCF was distended, as were the common and external iliac veins bilaterally concerning for extensive venous thrombosis and early phlegmasia cerulea dolens (PCD). The patient was treated with local catheterdirected thrombolysis with thrombus maceration and aspiration followed by localized direct tissue plasminogen activator (tPA) infusion and systemic heparin infusion. The patient's refractory hypotension resolved quickly and had surgery to remove his gastric tumor 8 days post-IVCF insertion. The placement of IVCF in a patient with known malignancy can greatly increase the risk for additional thrombus formation. But in our patient the speed is unprecedented, in which complete vena cava thrombosis (VCT) occurred at the site of the IVCF and below and its mechanism of causing refractory hypotension is rare. The consideration of PCD in a patient with refractory hypovolemic shock post-IVCF insertion followed by aggressive fluid resuscitation and worsening lower limb pain and discoloration remains a rare but important differential diagnosis.