Abstract
A 72-year-old woman underwent L3-L4 laminectomy for lower back and right leg pain caused by severe L3 radiculopathy. In the immediate postoperative period, upon extubation, the patient became hypotensive to 46/28 mmHg. She was re-intubated, resuscitated with fluids and blood products, and started on phenylephrine and vasopressin. An emergent contrast-enhanced computed tomography (CT) of the abdomen and pelvis revealed extravasation of contrast from the distal abdominal aorta into the retroperitoneum, forming an 8 × 12 cm hemorrhagic collection posteriorly. She returned to the operating room, where control of the bleeding was achieved with balloon occlusion of the aorta. The injury was repaired with a Gore stent graft (Gore, Flagstaff, AZ, USA). The remainder of her hospital course was unremarkable, and she was discharged 7 days later. She returned 1 month after discharge with progressive, significant right-greater-than-left lower extremity swelling to the thighs. Duplex ultrasound revealed extensive thrombus in the right femoral vein (Panel A1) extending proximally into the iliac vein with an abnormal Doppler flow pattern bilaterally (Panel A2) suggestive of an occlusion in the bilateral proximal iliac veins or inferior vena cava. A repeat CT scan showed a large, multiloculated retroperitoneal hematoma compressing the inferior vena cava (Panel B, arrow) and thrombosed iliac veins (Panel C, arrowheads). This case illustrates a unique example of a massive retroperitoneal hematoma resulting in inferior vena cava compression and thrombosis. The patient was treated with heparin and warfarin, ultimately with conversion to rivaroxaban for a planned 6-month course.
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Footnotes
Declaration of conflicting interest
None declared.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.