ACUTE VENOUS THROMBOSIS IS VERY COMMON IN INDIAN SCENARIO.

WE AS DOCTORS COME ACROSS SUCH PATIENTS IN OUR DAILY ROUTINE.THERE CAN BE DIFFERENT CAUSES FOR ACUTE THROMBOSIS.IT CAN EITHER BE DUE TO INBORN ERRORS IN THE BLOOD OR ELSE IT CAN BE ACQUIRED.GENERALLY IT INVOLVES THE LOWER LIMB VENOUS SYSTEM BUT UPPER LIMB DVT IS NOT UNCOMMON.INFERIOR VENA CAVA THROMBOSIS PER SE IS NOT VERY COMMON TO COME ACROSS IN DAILY PRACTICE.GENERALLY IT IS ASSOCIATED WITH THROMBUS  ANYWHERE ELSE WHICH GETS PROPAGATED TO INVOLVE THE IVC.THE OTHER USUAL CAUSE IS RENAL CELL CARCINOMA WHICH  PROGRESSES TO INVOLVE THE IVC. THE TREATMENT OF IVC THROMBOSIS IS ALL THE MORE CONTROVERSIAL BECAUSE OF ITS RARITY.WHETHER TO GO AHEAD WITH INTERVENSION OR TO FOLLOW CONSERVATIVE MANAGEMENT IN PATIENTS WITH ACUTE PRESENTATION IS STILL UNCLEAR. 

       I REMEMBER A PHRASE FROM A REPUTED VASCULAR SURGEON WHICH SAYS”ITS CHALLENGING TO DO SOMETHING NEW IN AN INSTITUTION WHERE  EVERYONE HAS AN OPINION BUT NO ONE THE EXPERIENCE”.

  THIS PATIENT 50 YEARS OLD A CASE OF NEPHROTIC SYNDROME CAME WITH ACUTE RENAL FAILURE TO OUR HOSPITAL.HE HAD MASSIVE SWELLING OF BOTH  HIS LEGS AND SCROTUM AND HAD GENERALISED ANASARCA..SUBSEQUENTLY HE WAS FOUND TO HAVE BILATERAL RENAL VEIN THROMBOSIS AND ACUTE THROMBOSIS OF BILATERAL LOWER LIMB VENOUS SYSTEM INVOLVONG THE IVC TILL THE HEPATIC VEINS.THE LIKELY CAUSE FOR ACUTE THROMBOSIS IN THIS PATIENT WAS PROTEIN LOSSING NEPHROPATHY. THE EXCESSIVE URINARY PROTEIN LOSS IS ASSOCIATED WITH DECREASED ANTITHROMBIN III, A RELATIVE EXCESS OF FIBRINOGEN, AND CHANGES IN OTHER CLOTTING FACTORS; ALL LEAD TO PROPENSITY TO CLOT. NUMEROUS STUDIES DEMONSTRATED A DIRECT RELATIONSHIP BETWEEN NEPHROTIC SYNDROME AND BOTH ARTERIAL AND VENOUS THROMBOSIS.THIS CLOT CAN DAMAGE THE KIDNEYS,CAN BREAK AND TRAVEL THROUGH THE BLOOD STREAM TO THE LUNGS A CONDITION CALLED AS PULMONARY THROMBOEMBOLISM WHICH MAY PROVE TO BE FATAL. THIS PATIENT WAS SUBJECTED TO DIALYSIS.AND DIFFERENT OPTIONS WERE THOUGHT OF REGARDING THE FURTHER COURSE OF TREATMENT.CONSERVATIVE TREATMENT WAS VIRTUALLY RULED OUT AS THIS WOULD HAVE LED TO SEVERE MORBIDITY  HAD THE PATIENT SURVIVED.THROMBOLYSIS WAS ALSO RULED OUT BECAUSE OF  THE EXTENSIVE THROMBUS LOAD.IT WAS AGREED UNANIMOUSLY BETWEEN THE NEPHROLOGY TEAM AND MYSELF TO GO AHEAD WITH IVC THROMBECTOMY THINKING THAT IT WOULD REVERT HIS RENAL STATUS TO NORMAL,WOULD PREVENT THROMBOEMBOLISM,PREVENT LIMB LOSS FROM VENOUS IMPEDIMENT AND  PREVENTCHRONIC VENOUS INSUFFICIENCY IN THE LONG RUN.IVC THROMBECTOMY THROUGH MIDLINE LAPROTOMY INCISION WAS DONE .TOTAL IVC CLEARANCE WITH BILATERAL COMMON FEMORAL VEIN THROMBECTOMY WAS DONE. THIS PATIENT HAD MIDGUT MALROTATION WHICH WAS FOUND INTRAOPERATIVELY MAKING IT ALL THE MORE UNIQUE.POSTOPERATIVELY PATIENT DID FINE AND WAS DISCHARGED FROM THE HOSPITAL ON ORAL ANTICOAGULANTS ON THE TENTH POSTOPERATIVE DAY.PRESENTLY HE IS  OFF DIALYSIS AS HIS RENAL PARAMETERS HAVE COME TO NORMAL.

             THE IMPORTANCE OF THIS CASE LIES IN THE SPEEDY RECOVERY THE  PATIENT MADE WHEN IT SEEMED HE IS A HIGH RISK CASE FOR SURGERY. HE IS NOW LEADING A NEAR NORMAL LIFE.HIS  LOWER LIMB SWELLING  HAS DECREASED REMARKABLY. HIS RENAL PARAMETERS ARE WITHIN NORMAL RANGE..THIS PATIENT NEEDS TO BE IN REGULAR FOLLOWUP OF HIS NEPHROLOGIST AND MY OWNSELF.