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.