Concomitant DVT and RPH has proven to be difficult to diagnose in the acute setting,
in our case series none of the patients were correctly diagnosed at presentation.
All three patients presented with left iliac fossa pain and hypotension,
but varibility of other symptoms delayed diagnosis significantly.
One patient was started on anti-coagulation which could have had severe consequences.
The radiologist should consider an ileo-femoral DVT in the context of SRPH; it is particularly relevant if there is evidence of May-Thurner syndrome on CT,
this has shown in previous case studies to be strongly linked to left ileo-femoral DVTs.1 Moreover,
an ileo-femoral DVT can be easily missed on CT,
this happened in one patient in our case series which delayed treatment.
There are several speculations which came first,
the DVT or the SRH.
It is likely mutiple factors are involved simultaneously.
1.
SRH may be secondary to a large DVT.
Previous cases series have described venous rupture due to localised thrombophlebitis or bleeding from engorged collaterals due to a pre-exisiting DVT (which have a tendency to bleed).1,2 Additionally,
previous case series have shown a strong link between spontaneous rupture of the left common iliac vein and May-Thurner syndrome. 1
2.
DVT may be a complication of retroperitoneal bleeding.
DVT may result from a mixture of hypovolaemia,
compression of the haematoma or local trauma.
It is also possible that DVTs and SRH are not directly related,
but they are simply precipitated by the same aetiology: e.g.
malignancy,
vascular malformation,
tumour,
drugs or coagulopathies.3,5
In our case series there were no clear aetiology.
One patient was shown to have preexisting perivesical varices,
these may have ruptured when a large ileofemoral DVT formed (causing by increased venous pressure). The other two cases did not have a clear cause identified.
All three patients had a temporary IVC filter inserted and received anticoagulation (once haemodynamically stable),
although anticoagulation regimes varied from case to case and was frequently reviewed by the Haematologists.
Ultimately,
management decisions were complex and were made within a multidisciplinary setting.
Previously published studies shows that in most cases patients can be managed succesfully with a conservative approach.
However,
persistent haemodynamic instability is the main indicator for arterial catheter angiogram or surgery (as happened in one case).4,5 There was no mortality in this case series,
all patients were discharged home.
One patient developed post-thrombotic syndrome at 6 months follow-up.
The causative relationship between spontaneous retroperitoneal haemorrhage and ileofemoral DVT is not clear,
it is likely they may both be the chicken and the egg,
depending on the context.