Case report
A 31-year-old male was referred to our hospital for further evaluation
of a retroperitoneal cyst which was found incidentally by abdominal
ultrasonography during evaluation of abdominal pain and diarrhea about
two years ago.
The patient presented with mild lower limbs swelling and venous
insufficiency. Duplex ultrasonography displayed bilateral deep femoral
vein thrombosis. Thoracic CT angiography was performed but did not find
any abnormalities. The retroperitoneal cyst was further explored by MRI
which displayed a huge (9x7x7.5cm) aneurysm of infrarenal IVC (figure
1). Laboratory examinations including coagulation profile were normal.
Due to the risk of aneurysmal thrombosis and rupture, surgical
intervention was indicated. The operation was started by median
laparotomy using mesenteric root approach, infrarenal aorta was freed.
Dissection continued, the proximal and distal control of vena cava at
infrarenal and iliac veins junction level was obtained. The aneurysm,
which was located posterior to the right kidney, was also dissected free
from adjacent tissues. The patient was heparinized and the aorta was
clamped to decrease venous return to IVC. The IVC proximally at
infrarenal level and distally at the junction of iliac veins excluding
the aneurysmal area was clamped (figure 2 upper).
The IVC was opened longitudinally and a huge aneurysm was found while
the walls of vena cava were normal (figure 2 under). Afterwards the
aneurysm was resected and two specimens sent for bacteriology and
histopathology respectively. IVC was closed by continuous non absorbable
sutures and after de-airing clamps were also released, no leakage was
seen. An active drain was left in the aneurysmal lodge (and was latterly
removed on second post-operative day). Peritoneum and abdominal wall
were closed.
Histopathological examination found no sign of inflammation but slight
modifications of venous wall with a miner interstitial fibrosis
otherwise containing endothelium and a regular tunica muscularis which
was surrounded by adventitia. Bacteriologic examination was also sterile
after two weeks of incubation period.
Post operatively the patient recovered without any complications and was
discharged on 8th postoperative day with only aspirin. Doppler
ultrasonography was performed on 45th postoperative day and showed good
flow in IVC and in femoral veins.