Case series of seven women with uterine fibroids associated with venous thromboembolism and chronic thromboembolic disease

Successful thrombectomy for inferior vena cava thrombosis associated with an ovarian tumor: a case report

A 51-year-old female patient presented with abdominal distension. Computed tomography revealed a right ovarian tumor suspicious for clinical stage IC ovarian cancer, along with a considerable inferior vena cava (IVC) thrombus extending to the Th2 level, accompanied by a deep vein thrombus and a peripheral left pulmonary embolism (PE). Preoperative IVC filter placement was deemed unfavorable due to the short distance between the renal vein and the thrombus. On the second day of hospitalization, ovarian tumor extraction, thrombectomy, and IVC filter placement were performed. Pathology of the excised tumor revealed endometrioid carcinoma. Postoperatively, anticoagulation therapy with edoxaban 30 mg/day resulted in improvement of the deep vein thrombus and PE. The concomitant adnexal resection and thrombectomy rendered the safe placement of an IVC filter feasible despite the preoperative placement being unfeasible. Open thrombectomy remains a valid treatment strategy despite advances in endovascular therapy.

Large uterine fibroid causing DVT and PE: Successful management with mechanical aspiration thrombectomy and hysterectomy: A case report and literature review

RATIONALE

Uterine leiomyomas, though commonly benign, can occasionally lead to serious complications, including deep vein thrombosis (DVT) and pulmonary embolism (PE). This study aims to highlight the uncommon yet serious association between large uterine leiomyomas and thromboembolism, which is often overlooked in patients without traditional risk factors. It emphasizes the need for awareness, early diagnosis, and timely intervention to prevent complications in patients presenting with unexplained symptoms and pelvic masses.

PATIENT CONCERN

A 38-year-old gravida 5, para 2 woman presented to the emergency room with left lower extremity swelling, pain, and discoloration, accompanied by dyspnea. She had no prior history of DVT or PE and did not have any known risk factors for venous thromboembolism.

DIAGNOSIS

The patient was diagnosed with DVT and PE, confirmed by venous duplex ultrasound and abdominal and pelvic computed tomography, which revealed thrombus extension to the left iliac vein. Chest computed tomography angiography confirmed a partially occlusive thrombus in the pulmonary arteries.

INTERVENTION

The patient underwent mechanical aspiration thrombectomy, followed by placement of a left iliac stent. Anticoagulation therapy with heparin was initiated post-thrombectomy. On the third day, a right supracervical hysterectomy was successfully performed. After surgery, anticoagulation was continued with heparin, and the patient was later discharged on apixaban for ongoing therapy.

OUTCOMES

The patient made full recovery with no recurrence of thromboembolic events at 11 months posttreatment.

LESSONS

This case highlights the rare but serious complication of DVT and PE in patients with uterine leiomyomas. Timely intervention with thrombectomy, stent placement, and hysterectomy was effective in resolving the thromboembolic events.

Uterine Fibroid-Associated Massive Pulmonary Embolism: A Report of Two Cases

This report details cases of uterine fibroid-associated deep vein thrombosis leading to massive pulmonary embolism, as well as the likely associated physiology. Two women, aged 33 and 37, presented with fibroid-associated pulmonary embolism. They both had large uterine sizes and no underlying thrombophilia. Case 1 had an uncomplicated course, whereas Case 2 had a course complicated by cardiac arrest and prolonged recovery. The presence of fibroids enhances coagulation and platelet adhesion. Mechanical compression also plays a role in predisposing to thrombosis. There may be a role for preoperative screening, especially in those with an elevated estimated uterine weight.

Diagnosis and Management of Pulmonary Hypertension and Right Ventricular Failure in the Cardiovascular Intensive Care Unit

Pulmonary hypertension (PH) encompasses a broad range of conditions, including pulmonary artery hypertension, left-sided heart disease, and pulmonary and thromboembolic disorders. Successful diagnosis and management rely on an integrated clinical assessment of the patient's physiology and right heart function. Right ventricular (RV) heart failure is often a result of PH, but may result from varying abnormalities in preload, afterload, and intrinsic myocardial dysfunction, which require distinct management strategies. Consideration of an individual's hemodynamic phenotype and physiologic circumstances is paramount in management of PH and RV failure, particularly when there is clinical instability in the intensive care setting.

Uterine Fibroid-Induced Compressive Neuropathy of Lumbar Plexus and Obturator Nerve

Introduction

Uterine fibroids are the most common gynecologic tumors in reproductive-aged women with a prevalence of up to 80%. Symptoms can range from heavy vaginal bleeding and bulk symptoms to, less frequently, deep vein thrombosis and bowel obstruction.

Case Description

A 32-year-old female patient presented with acute-onset of right groin and knee pain, and difficulty ambulating. A large posterior uterine fibroid was found to be compressing branches of the lumbar plexus, including the obturator nerve. The patient underwent gynecologic evaluation and an urgent laparoscopic myomectomy. Postoperatively, she had significant improvement in neurologic symptoms. She continued physical therapy for residual mild paresthesia and pain with prolonged ambulation.

Discussion

Large pelvic masses such as uterine fibroids should be considered on the differential diagnosis for acute-onset non-gynecologic symptoms such as compressive neuropathy, which require urgent evaluation and possible surgical management.

Pulmonary Embolism after Liposuction Totally by Tumescent Local Anesthesia in a Patient with Large Uterine Fibroids

A fatal pulmonary embolism occurred in a 43-year-old black woman after tumescent liposuction totally by local anesthesia. An autopsy revealed large uterine fibroids, peri-uterine vascular thrombi, and a large saddle pulmonary embolism. Large uterine fibroids are a risk factor for postsurgical venous thromboembolism. Fatal outcomes after tumescent liposuction totally by local anesthesia are exceedingly rare.

Distinguishing exercise intolerance in early-stage pulmonary hypertension with invasive exercise hemodynamics: Rest VE /VCO2 and ETCO2 identify pulmonary vascular disease

BACKGROUND

Among subjects with exercise intolerance and suspected early-stage pulmonary hypertension (PH), early identification of pulmonary vascular disease (PVD) with noninvasive methods is essential for prompt PH management.

HYPOTHESIS

Rest gas exchange parameters (minute ventilation to carbon dioxide production ratio: VE /VCO2 and end-tidal carbon dioxide: ETCO2 ) can identify PVD in early-stage PH.

METHODS

We conducted a retrospective review of 55 subjects with early-stage PH (per echocardiogram), undergoing invasive exercise hemodynamics with cardiopulmonary exercise test to distinguish exercise intolerance mechanisms. Based on the rest and exercise hemodynamics, three distinct phenotypes were defined: (1) PVD, (2) pulmonary venous hypertension, and (3) noncardiac dyspnea (no rest or exercise PH). For all tests, *p < .05 was considered statistically significant.

RESULTS

The mean age was 63.3 ± 13.4 years (53% female). In the overall cohort, higher rest VE /VCO2 and lower rest ETCO2 (mm Hg) correlated with high rest and exercise pulmonary vascular resistance (PVR) (r ~ 0.5-0.6*). On receiver-operating characteristic analysis to predict PVD (vs. non-PVD) subjects with noninvasive metrics, area under the curve for pulmonary artery systolic pressure (echocardiogram) = 0.53, rest VE /VCO2  = 0.70* and ETCO2  = 0.73*. Based on this, optimal thresholds of rest VE /VCO2  > 40 mm Hg and rest ETCO2  < 30 mm Hg were applied to the overall cohort. Subjects with both abnormal gas exchange parameters (n = 12, vs. both normal parameters, n = 19) had an exercise PVR 5.2 ± 2.6* (vs. 1.9 ± 1.2), mPAP/CO slope with exercise 10.2 ± 6.0* (vs. 2.9 ± 2.0), and none included subjects from the noncardiac dyspnea group.

CONCLUSIONS

In a broad cohort of subjects with suspected early-stage PH, referred for invasive exercise testing to distinguish mechanisms of exercise intolerance, rest gas exchange parameters (VE /VCO2  > 40 mm Hg and ETCO2  < 30 mm Hg) identify PVD.

Vena cava balloon occlusion for pulmonary embolism prevention during resection of giant uterus fibroids

We report the case of a single 46-year-old woman presenting with huge uterine fibroids growing for the last 12 years, resulting in a recent common iliac vein thrombosis. Due to the high risk for pulmonary embolism, an occluding balloon was inserted through the right jugular vein before the abdominal incision and occluded the vena cava just inferior to the renal veins. The tumor was easily mobilized, and the vena cava bifurcation was exposed and controlled until the uterus with the masses was resected. We recommend this method for oncovascular surgeries involving deep vein thrombosis and vein thromboembolism.

Effects of total laparoscopic hysterectomy on the clinical outcomes of patients with uterine fibroids

OBJECTIVE

To clarify the effects of total laparoscopic hysterectomy (TLH) on sex hormone levels, quality of life (QOL) and complications such as lower-extremity deep vein thrombosis (DVT) in patients with uterine fibroids (UFs).

METHODS

In this retrospective study, 136 patients with UFs treated in Hainan General Hospital from March 2018 to December 2020 were collected as research participants, of which 65 patients received total abdominal hysterectomy (TAH) were included in the control group and 71 patients who received TLH were assigned to the research group. The two groups were compared regarding the following items: response rate, surgical indexes, rehabilitation indicators, changes in sex hormone levels and QOL, and the occurrence of lower-extremity DVT.

RESULTS

The research group showed a significantly higher response rate, and better indicators of surgical treatment and rehabilitation than the control group (P<0.05). The sex hormones in the research group were more stable than that in the control group. The QOL was also significantly better and the incidence of total complications was statistically lower in the research group compared with the control group (both P<0.05).

CONCLUSIONS

TLH is a feasible and safe alternative than traditional TAH for UFs, as it can effectively improve patients' sex hormone levels and QOL, and reduce the incidence of complications, which is worthy of clinical promotion.

May-Thurner Anatomy in Patients With Chronic Thromboembolic Pulmonary Hypertension: An Important Clinical Association

OBJECTIVES

The aim of this study was to investigate the incidence of May-Thurner anatomy (MTA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) and identify its predictors.

BACKGROUND

MTA is an anatomical variant characterized by compression of left common iliac vein by the overlying right iliac artery. Over time, this leads to venous intimal scarring, blood flow stasis, and the development of deep vein thrombosis (DVT). DVT is a known risk factor for the development of CTEPH. The prevalence of this anatomical variation in patients with CTEPH is unknown.

METHODS

A retrospective chart review was conducted in patients referred to Temple University Hospital's cardiac catheterization laboratory for the evaluation of CTEPH between January 2016 and June 2020. Among these patients, those who underwent invasive venography were evaluated for the presence of angiographic MTA. Multivariate regression was used to identify factors associated with presence of MTA.

RESULTS

A total of 193 patients with CTEPH were referred for pulmonary angiography, of whom 148 patients underwent invasive venography. MTA was identified in 44 patients (29.7%). Factors associated with the presence of MTA were lower extremity DVT (odds ratio: 3.5; 95% confidence interval: 1.58-7.8; P = 0.002), and left lower extremity post-thrombotic syndrome (odds ratio: 2.0; 95% confidence interval: 0.98-4.1; P = 0.05). Patients with MTA were more likely to undergo pulmonary thromboendarterectomy than patients without MTA (79.5% vs 58.7%; P = 0.015).

CONCLUSIONS

MTA is very common in patients with CTEPH. History of lower extremity DVT and or left lower extremity post-thrombotic syndrome was associated with the presence of MTA.

Venous thromboembolism in a patient with an uncommon etiology of May-Thurner syndrome

May-Thurner syndrome (MTS) consists of common iliac vein compression from an extrinsic source. Patients with MTS can present with a variety of symptoms, potentially making the diagnosis difficult. Classically, MTS will result in left iliac vein compression from the right iliac artery. In rare cases, it can be secondarily caused by compression from other anatomic structures in the pelvis. We present the case of a 43-year-old woman with MTS with iliofemoral deep vein thrombosis and pulmonary embolism caused by a large uterine leiomyoma. Our findings underscore the need to consider various etiologies of venous compression in patients with extensive unilateral venous thromboembolism.

Vascular biology of uterine fibroids: connecting fibroids and vascular disorders

Fibroids are benign tumors caused by the proliferation of myometrial smooth muscle cells in the uterus that can lead to symptoms such as abdominal pain, constipation, urinary retention, and infertility. While traditionally thought of as a disease process intrinsic to the uterus, accumulating evidence suggests that fibroid growth may be linked with the systemic vasculature system, although cell-intrinsic factors are certainly of principal importance in their inception. Fibroids are associated with essential hypertension and preeclampsia, as well as atherosclerosis, for reasons that are becoming increasingly elucidated. Factors such as the renin-angiotensin-aldosterone system, estrogen, and endothelial dysfunction all likely play a role in fibroid pathogenesis. In this review, we lay out a framework for reconceptualizing fibroids as a systemic vascular disorder, and discuss how pharmaceutical agents and other interventions targeting the vasculature may aid in the novel treatment of fibroids.

Real-time ultrasound-guided epidural anesthesia for cesarean section in a parturient with achondroplasia

Achondroplasia is a type of disproportionate dwarfism with short limbs and a normal-sized torso. This condition results in a potential spinal abnormality and a difficult airway may increase the anesthetic risk, not only in neuraxial anesthesia, but also in general anesthesia. We report a 25-year-old primigravida with achondroplasia who underwent cesarean section under epidural anesthesia with the assistance of real-time ultrasound guidance. A total dose of 17 mL 2% lidocaine with 7.5 μg sufentanil was administered via epidural catheter intermittently. The level of anesthesia reached T4. No other anesthetic was administered during the operation and the procedure was uneventful. The mother and her newborn were routinely discharged without any adverse events. During the follow-up at 10 months postoperatively, the patient did not have any discomfort. We suggest that titrated epidural anesthesia at the time of real-time ultrasound-guidance is a safe and effective epidural anesthesia for patients with achondroplasia.

Iliocaval Venous Obstruction, Cardiac Preload Reserve and Exercise Limitation

Cardiac output during exercise increases by as much as fivefold in the untrained man, and by as much as eightfold in the elite athlete. Increasing venous return is a critical but much overlooked component of the physiological response to exercise. Cardiac disorders such as constrictive pericarditis, restrictive cardiomyopathy and pulmonary hypertension are recognised to impair preload and cause exercise limitation; however, the effects of peripheral venous obstruction on cardiac function have not been well described. This manuscript will discuss how obstruction of the iliocaval venous outflow can lead to impairment in exercise tolerance, how such obstructions may be diagnosed, the potential implications of chronic obstructions on sympathetic nervous system activation, and relevance of venous compression syndromes in heart failure with preserved ejection fraction.

Bilateral abdominopelvic lymphoceles secondary to huge uterine leiomyomas: A case report

Pelvic lymphocele secondary to uterine leiomyoma has not been previously reported. We report a case of abdominopelvic lymphocele associated with huge uterine fibroids which was managed conservatively. A 39-year-old unmarried lady presented with pressure symptoms in pelvis was diagnosed to have a huge uterine leiomyomas occupying the entire abdomen. Magnetic resonance imaging of pelvis and abdomen demonstrated multiple uterine fibroids. In addition, bilateral cystic structures were seen in the pelvis with extension to the para-colic gutters. During myomectomy, bilateral abdominopelvic lymphoceles were noted which required only fine-needle aspiration. Follow up abdominal ultrasound at 6 weeks, demonstrated spontaneous resolution of these lesions. The pressure exerted by these huge uterine leiomyomas might have possibly obstructed the lymphatic drainage leading to bilateral abdominopelvic lymphoceles. These secondary lymphoceles resolve spontaneously and does not need any further diagnostic procedures or surgical interventions.

Laparoscopic hysterectomy as optimal approach for 5400 grams uterus with associated polycythemia: A case report

BACKGROUND

Uterine myomas are the most common benign gynecological soft tissue tumors in women but polycythemia associated with these tumors is rare. Polycythemia is significantly associated with risk of venous thromboembolism (VTE), which is further increased in case of a large pelvic mass and obesity. Here we report the surgical challenges in the case of an obese patient with a giant fibromatous uterus and associated polycythemia.

CASE SUMMARY

A 42-year-old obese woman was referred to our department for treatment for a huge fibromatous uterus. She suffered of pelvic pressure and abdominal distension and reported severe dyspnea from several months. Laboratory analyses including hemoglobin (Hb) 19.2 g/dL and hematocrit (Hct) 59.7% were indicative of polycythemia. Arterial blood gas analysis showed arterial oxygen pressure (pO2) of 81.5 mmHg. Abdominal computed tomography confirmed a giant fibromatous uterus measuring 28.2 cm × 17 cm × 25 cm. To reduce the thromboembolic risk, the patient underwent low molecular weight heparin, phlebotomy twice before surgery, and we opted for a laparoscopic hysterectomy. The uterus weighed 5400 g and the histology confirmed a diagnosis of leiomyoma. We did not find increased erythropoietin levels in the supernatant of the myomatous uterine tissue. There were no complications. On postoperative day 1, the Hb and the Hct levels normalized to 13.3 g/dL and 41.7%, respectively. Arterial blood gas analysis after surgery showed a pO2 of 144.7 mmHg. These results suggested the diagnosis of myomatous erythrocytosis syndrome. The patient was discharged on the second postoperative day in very good condition with no symptoms.

CONCLUSION

We believe this is the first reported laparoscopic hysterectomy in a patient with a giant uterus, polycythemia and obesity. Multiple VTE risk factors warranted a laparoscopic approach.