Post-traumatic giant thrombosis of inferior vena cava induced right-sided blunt traumatic diaphragmatic injury: a case report

Abstract

Background: Inferior vena cava thrombosis is a severe disease as it carries a higher risk of developing pulmonary embolism associated with a high mortality rate. The incidence of inferior vena cava thrombosis is extremely low and is commonly associated with outflow obstruction of the inferior vena cava. The frequency of traumatic diaphragmatic injuries is less than 1% of all traumatic injuries. In addition, it was not a typical cause of inferior vena cava obstruction. We report the case of the patient who presented with giant thrombosis of the inferior vena cava, which required surgical treatment-induced right-sided blunt traumatic diaphragmatic injury.

Case presentation: A 60-year-old male presented to the emergency department with pelvic and lower leg pain. He was working on a dump truck with the bed raised position. Suddenly, the bed came down, and his body was crushed and injured. Primary CT showed a right lung contusion and elevation of the right diaphragm but no apparent liver injury. The right pleural effusion gradually worsened after admission, as the traumatic diaphragmatic injury was highly suspected. Repeat CT showed aggravation of elevation of the right-sided diaphragm, narrowing of the inferior hepatic vena cava due to left cephalic deviation of the liver, and formation of a giant thrombus in the inferior vena cava. No adverse hemodynamic effects were observed due to thrombus formation, and we performed thrombolytic therapy. The day after starting thrombolytic therapy, the patient developed pulmonary embolism due to a dropped in SpO₂ needed oxygen, and dyspnea triggered by coughing. Thrombolytic therapy was continued after the diagnosis of pulmonary embolism. However, thrombolytic therapy was ineffective, so we decided on surgical thrombectomy and inferior vena cava filter placement. The postoperative course was not eventful, and an anticoagulant was started. The patient was transferred to the hospital on the 62nd day for rehabilitation.

Conclusions: When a diaphragmatic hernia is suspected of causing hepatic hernia and narrowing of the inferior vena cava, it may be necessary to consider emergency surgical treatment to prevent secondary inferior vena cava thrombosis and fatal pulmonary embolism.

Keywords: Blunt trauma; Diaphragmatic injury; Inferior vena cava thrombosis; Pulmonary thromboembolism.

Fig. 1

Chest X-ray and CT scan findings on the day of admission. The enhanced CT scan and chest X-ray shows right diaphragm elevation and pulmonary contusion

Fig. 2

Follow-up enhanced CT scan findings on the ninth day of admission. Compared to the CT scan on the admission, the liver was more elevated, and a diagnosis of traumatic diaphragmatic injury was made. The diaphragmatic hernia caused severe narrowing of the inferior hepatic vena cava and formed a 13 cm × 3 cm giant thrombus in the inferior vena cava

Fig. 3

Enhanced CT scan findings after sudden dyspnea and dropped SpO₂. The enhanced CT scan showed Pulmonary thromboembolism due to thrombus in the left main pulmonary artery