Unusual Coexistence: Inferior Vena Cava Agenesis, a Free-Floating Right Atrial Thrombus, and Severe Pulmonary Embolism Successfully Treated with Tenecteplase
Ghita Bennis *
Cardiology Department, Cheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences, Casablanca, Morocco.
Malak Alaoui Yazidi
Cardiology Department, Cheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences, Casablanca, Morocco.
Youssef Daoudi
Cardiology Department, Cheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences, Casablanca, Morocco.
Mohamed El Ghali Benouna
Cardiology Department, Cheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences, Casablanca, Morocco.
Fatima Zahra Merzouk
Cardiology Department, Mohammed VI International University Hospital Mohammed VI University of Health Sciences, Casablanca, Morocco.
*Author to whom correspondence should be addressed.
Abstract
Background: Inferior vena cava agenesis (IVCA) is rare, and its association with severe pulmonary embolism (PE) is exceptional.
Case Presentation: A 56-year-old man with insulin-dependent diabetes but no major venous thromboembolic risk factors presented with repeated syncope and hemodynamic shock. He was tachycardic, hypoxemic, and hypotensive. Echocardiography showed a free-floating right atrial thrombus with severe right ventricular dysfunction. CT confirmed massive bilateral PE and revealed IVCA with azygos continuation.
Management and Outcome: Because of persistent instability and the unavailability of alteplase, weight-adjusted tenecteplase was administered, followed by unfractionated heparin. The patient improved rapidly. Echocardiography at 24 hours showed complete disappearance of the thrombus and recovery of right ventricular function. Follow-up CT demonstrated reduced clot burden. Workup for thrombophilia was negative. The patient was discharged on oral anticoagulation and remained asymptomatic at follow-up.
Conclusion: This case illustrates a rare presentation of IVCA revealed by life-threatening PE and supports considering off-label tenecteplase when no approved fibrinolytic agent is available.
Keywords: Inferior vena cava agenesis, thrombolysis, tenecteplase, pulmonary embolism