Thrombosis of the inferior vena cava secondary to incidental portal vein aneurysm

Abstract

Aneurysm of the portal vein is a rare type of visceral aneurysm that is largely asymptomatic although some patients may develop symptoms or secondary complications. In this report, we present the first case in the literature of inferior vena cava (IVC) thrombosis arising as a consequence of portal vein aneurysm. A 95-year-old male with past medical history significant for hypertension, hypercholesterolemia, type II diabetes mellitus, benign prostatic hyperplasia, and gastroesophageal reflux presented to the emergency department with several days of altered mental status, disorganized behavior, visual hallucinations, and weight loss. Contrast-enhanced computed tomography of the patient's abdomen and pelvis was performed to assess for infection or malignancy. The study revealed a large saccular aneurysm of the proximal portal vein arising near the portal confluence. Compression of the adjacent IVC was also seen which contained a hypoattenuating filling defect, probably representing thrombus. Incidental large hepatic cysts were seen, and a 6 mm pancreatic cyst was also identified which likely represented an intra-ductal papillary mucinous neoplasm . He was determined not to be a surgical candidate due to age, comorbidities, and absence secondary symptoms. The patient was discharged on quetiapine and enoxaparin for management of agitation and IVC thrombosis, respectively. This case demonstrates the increasing rates of detection of portal vein aneurysm and the range of complications that may arise as a result.

Keywords: Aneurysm; Inferior vena cava; Portal vein; Thrombosis.

Fig. 1

Contrast-enhanced axial computed tomography imaging sections illustrate a 3.5 × 3.0 × 3.5 cm saccular aneurysm of the portal vein arising near the portal confluence (blue and red star). Compression of the IVC is also seen posteriorly (orange arrows) with hypoattenuating intra-luminal material (red circles). This is most consistent with thrombus within the IVC. A 6 mm hypoattenuating lesion is seen within the pancreatic body (red arrow) which likely represents an intra-ductal papillary mucinous neoplasm.

Fig. 2

Contrast-enhanced coronal CT imaging again shows saccular aneurysm of the portal vein (blue circle). Also present in this image are large hepatic cysts (maroon arrows). This study was slightly degraded by motion artifact.