Kaufman et al.

T h o r a c o a b d o m i n a l I m ag i n g • P i c t o r i a l E s s ay
Inferior Vena Cava Filling
Defects on CT and MRI
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Inferior Vena Cava Filling

Defects on CT and MRI
Lauren B. Kaufman1 OBJECTIVE. The purpose of this article is to describe the appearance and causes of infe-
Benjamin M. Yeh rior vena cava (IVC) filling defects, how such findings may be accurately characterized, and
Richard S. Breiman the clinical significance of IVC filling defects. Filling defects in the IVC observed at MDCT
Bonnie N. Joe and MRI may be a result of flow artifacts, anatomic variants, or bland or malignant thrombus.
Aliya Qayyum CONCLUSION. Familiarity with anatomy and flow effects is critical for distinguishing
true from false filling defects in the IVC. Delayed imaging after administration of IV contrast
Fergus V. Coakley
material and dedicated MRI sequences may be helpful for further characterization of such find-
Kaufman LB, Yeh BM, Breiman RS, Joe BN, ings. Once a true filling defect of the IVC is established, identification of the cause, whether
Qayyum A, Coakley FV benign or malignant, and extent will guide clinical treatment.

illing defects in the inferior vena reflux of opacified blood from the heart into

F cava (IVC) are a frequent finding

Received November 21, 2004; accepted after revision
January 28, 2005.
1All authors:Department of Radiology, University of
California San Francisco, Box 0628, C-324C, 505 Parnassus
Ave., San Francisco, CA 94143-0628. Address
correspondence to B. M. Yeh (benyeh@itsa.ucsf.edu).
AJR 2005; 185:717–726
0361–803X/05/1853–717
© American Roentgen Ray Society
on CT and MRI. Many of these de-
fects are artifactual and require dis-
tinction from real defects that are of critical im-
portance to clinical management. The
objective of this pictorial essay is to review the
spectrum of IVC filling defects, with an em-
phasis on the distinction of apparent from true
filling defects and the identification of under-
lying disease. The clinical features and thera-
peutic implications of IVC filling defects are
also discussed. This topic is timely because of
the introduction of MDCT, which allows rapid
and high resolution multiplanar vascular refor-
mation, and the recognition of several new
causes of IVC filling defects over the last de-
cade, such as pseudolipoma and previously un-
described coagulopathies. MRI is useful to
evaluate ambiguous CT findings. For purposes
of description, we have classified IVC filling
defects as artifactual, benign, or malignant.
Artifactual Filling Defects
The most common IVC filling defect seen
on CT is pseudothrombosis caused by lami-
nar flow of enhanced blood from the renal
veins streaming parallel to the column of
unopacified blood returning from the lower
body [1] (Fig. 1). The appearance is usually
characteristic. Artifactual filling defects may
also result from poorly enhanced blood, such
as from an accessory hepatic vein, flowing
into an opacified IVC (Fig. 2) or from laminar
the IVC, usually in the setting of right heart
disease or a high injection rate (Fig. 3). De-
layed images to show resolution of the filling
defect are usually sufficient to confirm the ar-
tifactual nature of such pseudolesions, but oc-
casionally, problematic cases may require
further evaluation with flow-sensitive [1]
(Fig. 4) or delayed contrast-enhanced MRI
sequences. The so-called pseudolipoma is a
rarer and more recently described pseudole-
sion of the IVC and represents a partial vol-
ume artifact of pericaval fat above the caudate
lobe rather than a true intraluminal lesion [2]
(Fig. 5). This artifact is common in patients
with chronic liver disease in whom prominent
pericaval fat collections commonly develop
[2]. Coronal MRI or reformatted CT images
help to confirm the true nature of this finding.
Benign Filling Defects
The most common true filling defect of the
IVC is bland thrombus, which may be idio-
pathic or reflect a hypercoagulable state,
venous stasis, or the presence of a foreign
body. Hypercoagulable states include oral con-
traceptive use, antiphospholipid syndrome [3],
paroxysmal nocturnal hemoglobinuria, vascu-
lar injury, paraneoplastic syndromes, and var-
ious coagulopathies, such as factor V Leiden
deficiency and protein C resistance. Antian-
giogenesis agents are also known to cause
vascular thrombosis. Venous stasis, which
can occur from immobility, heart failure,

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Kaufman et al.

A B
Fig. 1—64-year-old man with incidental CT finding of pseudothrombus caused by opacified blood from renal veins streaming into unopacified inferior vena cava (IVC).
A, Axial enhanced CT image shows filling defect (arrow) caused by inflow of opacified blood from renal veins mixing with poorly opacified blood in IVC.
B, Curved multiplanar image reveals opacified blood from renal veins streaming into IVC (arrows). This case illustrates how axial image can show IVC filling defect.

Fig. 2—54-year-old man with pseudothrombus in intra-

hepatic inferior vena cava (IVC) resulting from flow
artifact.
A, Axial enhanced CT image obtained in portal venous
phase shows filling defect (arrow) in intrahepatic IVC.
B, Axial enhanced CT image, delayed venous phase,
reveals accessory right hepatic vein inflow (arrow)
that accounts for filling defect seen on earlier phase
images.
A B

and external compression, can also facilitate
the formation of thrombus. External compres-
sion is most commonly due to retroperitoneal
adenopathy, but other sources include hepatic
masses and hepatomegaly; renal, adrenal, and
pancreatic masses; abdominal aortic aneu-
rysms; and retroperitoneal hematomas, neo-
plasms, and fibrosis [4]. Foreign bodies, such
as IVC filters or venous catheters (Fig. 6), may
promote thrombus formation. Intracaval
thrombosis has been reported to develop in
2.7% of patients after placement of an IVC fil-
ter [5] due to new local thrombus formation,
trapped embolus of a thrombus from a more
distant site, or cephalad extension of a more
distally located deep venous thrombus from
the pelvis or lower extremities. Bland throm-
bus can extend superiorly past the level of an
IVC filter. Thrombus occurring at the site of a
venous catheter can persist in the form of a fi-
brin sheath even after removal of the catheter

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Inferior Vena Cava Filling Defects on CT and MRI

Fig. 3—78-year-old man with pseudothrombus in inferior vena cava (IVC) caused by
high contrast-injection rate. Axial enhanced CT image, early arterial phase, shows
IVC filling defect (arrowhead) due to laminar flow of refluxed contrast from hepatic
veins. Bright enhancement in hepatic veins (arrows) is seen because of reflux of
contrast from heart.

A B
Fig. 4—50-year-old woman with renal cell carcinoma and acquired cystic kidney disease.
A, Axial enhanced CT image shows heterogenous enhancement of inferior vena cava (IVC) (arrow), suggesting tumor invasion.
B, Axial gadolinium-enhanced T1-weighted MR image shows filling defect (arrow) of intrahepatic IVC, also suggesting tumor invasion.
(Fig. 4 continues on next page)

(Fig. 7). Benign tumor thrombus in the IVC Malignant Filling Defects rare in malignant involvement of the IVC
may be a result of vascular invasion by renal A malignant cause should be considered and the existence of tumor thrombus is often
angiomyolipoma [6], IV leiomyomatosis (Fig. for all true IVC filling defects, particularly first recognized at imaging. Cancers can ex-
8), or adrenal pheochromocytoma [7]. because pathognomonic symptomatology is tend directly into the IVC from adjacent or-

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Kaufman et al.

Fig. 4 (continued)—50-year-old woman with renal cell carcinoma and acquired cys-
tic kidney disease.
C, Axial steady-state gradient-echo flow-sensitive MR image shows patency of IVC
(arrow) and absence of true filling defect. Low venous return from failed kidneys may
have contributed to apparent intracaval defect.

A B
Fig. 5—73-year-old man with incidental CT finding of pseudolipoma.
A, Axial enhanced CT image shows apparent inferior vena cava filling defect (arrow) of fat density.
B, Coronal T2-weighted MR image shows shelf of pericaval fat (arrow) above caudate lobe. Fat collection may appear intraluminal on axial images.

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Inferior Vena Cava Filling Defects on CT and MRI

A B
Fig. 6—50-year-old man with bland thrombus in inferior vena cava (IVC) and left renal vein that extends proximally after filter placement.
A, Axial enhanced CT image before IVC filter placement shows bland thrombus (arrow) in IVC.
B, Coronal multiplanar image reconstructed from CT data after IVC filter placement shows extension of bland thrombus into both renal veins (arrowheads) and intrahepatic
IVC. Note IVC filter (arrow) and decreased enhancement of right kidney due to hypoperfusion.

Fig. 7—36-year-old man with previously removed IV catheter. Axial enhanced CT

image shows circular filling defect (arrows) within infrahepatic inferior vena cava
consistent with fibrin sheath.

gans or occasionally arise as primary malig-
nancies of the IVC. Malignancies that
commonly extend directly into the IVC in-
clude renal cell, hepatocellular, and adreno-
cortical carcinoma (Fig. 9), but invasion
from other adjacent cancers such as me-
tastases to the lung (Fig. 10) and kidney [8]
can occur. Pancreatic carcinoma, Wilms’ tu-
mor, and metastases in retroperitoneal
lymph nodes can occasionally extend into
the IVC [4]. Features that distinguish malig-
nant from bland thrombus include presence
of a contiguous adjacent mass and
enhancement of the filling defect (Figs. 11
and 12). However, it should be remembered
that malignancy predisposes to thrombosis
due to hypercoagulability and that bland
downstream thrombus may coexist with ma-

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Kaufman et al.

A B
Fig. 8—45-year-old woman with uterine leiomyomatosis.
A, Axial enhanced CT image obtained at level of pelvis shows heterogenous hyper-
enhancing lesion (arrowheads) in uterus consistent with uterine leiomyoma.
B, Axial enhanced CT image obtained below inferior vena cava (IVC) bifurcation
shows IV leiomyomatosis (arrow) within right common iliac vein.
C, Axial enhanced CT image obtained at level of gallbladder reveals filling defect
(arrow) of IVC due to cephalad extension of IV leiomyomatosis.

Fig. 9—66-year-old woman with adrenocortical carcinoma. Coronal T2-weighted

MR image shows large adrenal mass (arrowheads) with tumor thrombus extending
into infrahepatic inferior vena cava (arrow).

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Inferior Vena Cava Filling Defects on CT and MRI

A B
Fig. 10—46-year-old woman with metastatic colon carcinoma to lung.
A, Axial steady-state gradient-echo flow-sensitive MR image shows direct extension of lung mass (arrowheads) into inferior vena cava (IVC) (arrow).
B, Coronal T1-weighted MR image shows lung metastasis (white arrow) invading supradiaphragmatic IVC (black arrow) and another metastasis (arrowheads) invading right
pulmonary artery.

A B
Fig. 11—47-year-old man with hepatocellular carcinoma.
A, Axial enhanced CT image, early arterial phase, shows hypervascular hepatocellular carcinoma (arrows) in liver.
B, Axial enhanced CT image obtained at higher level than A reveals similarly enhancing tumor thrombus (arrow) in inferior vena cava.

lignant thrombus more superiorly in the IVC
(Fig. 12). If an adjacent tumor is not identi-
fied, an enhancing IVC mass may be the re-
sult of primary intraluminal sarcoma (Fig.
13).
Clinical Features and Therapeutic
Implications
Obstruction of the IVC can be clinically
silent or result in bilateral lower extremity
edema, Budd-Chiari syndrome (Fig. 14), or
venous collateral formation. Embolization
of bland and tumor thrombus to the pulmo-
nary circulation is another potential compli-
cation and can be assessed by CT pulmonary
angiography (Fig. 15), although it is often

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Kaufman et al.

A B
Fig. 12—46-year-old man with renal cell carcinoma.
A, Axial unenhanced T1-weighted MR image shows tumor thrombus (arrowheads)
extending into right renal vein, abutting bland thrombus (arrow) of higher signal
intensity in inferior vena cava (IVC). Note large lesion (asterisk) in upper pole of right
kidney consistent with renal cell carcinoma.
B, Axial gadolinium-enhanced T1-weighted MR image shows enhancing renal mass
with tumor thrombus (arrowheads) extending into right renal vein adjacent to non-
enhancing bland thrombus in IVC (arrow).
C, Coronal unenhanced T1-weighted MR image reveals bland thrombus (arrow-
heads) that formed inferior in relation to tumor thrombus (arrows) seen in infrahe-
patic IVC. Lesion of low signal intensity is present in right kidney (asterisk), repre-
senting renal cell carcinoma.

impossible to distinguish bland and tumor
emboli. In cases of IVC extension of renal
cell carcinoma and other tumors, curative
treatment may still be possible with aggres-
sive resection. The superior extent of the tu-
mor thrombus has surgical implications;
thrombus extension into the supradiaphrag-
matic IVC or right atrium requires resection
accompanied by cardiopulmonary bypass
and is associated with increased morbidity
and mortality.
Familiarity with anatomy and flow effects
is critical for distinguishing true from false
filling defects in the IVC. Delayed imaging
after administration of IV contrast material
and dedicated MRI sequences may be helpful
for further characterization of such findings.
Once a true filling defect of the IVC is estab-
lished, identification of the cause, whether
benign or malignant, and extent will guide
clinical treatment.

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Inferior Vena Cava Filling Defects on CT and MRI

A B
Fig. 13—66-year-old woman with leiomyosarcoma arising in inferior vena cava (IVC).
A, Axial enhanced CT image obtained at level of pancreas shows heterogeneously enhancing mass (arrow) in IVC.
B, Pathologic specimen of leiomyosarcoma in IVC.

Fig. 14—47-year-old man with Budd-Chiari syndrome 1 year after nephrectomy was
performed for right-sided renal cell carcinoma. Axial enhanced CT image shows
tumor thrombus in inferior vena cava lumen (large arrow) and adjacent surgical clips
(small arrow) from previous nephrectomy. Heterogenous enhancement of liver and
ascites (arrowheads) is seen, consistent with hepatic outflow obstruction.
A
Fig. 15—54-year-old woman with renal cell carcinoma invading inferior vena cava
(IVC) and pulmonary emboli.
A, Axial T2-weighted MR image with fat saturation shows right-sided renal mass
(arrowheads) with heterogeneous high signal consistent with renal cell carcinoma.
Tumor thrombus is present in adjacent IVC (arrow).
(Fig. 15 continues on next page)

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Kaufman et al.

Fig. 15 (continued)—54-year-old woman with renal cell carcinoma invading inferior

vena cava (IVC) and pulmonary emboli.
B, Axial T1-weighted MR image reveals large IVC tumor thrombus (arrows).
C, Axial enhanced CT image shows large thrombus in right main pulmonary artery
(arrowheads) and left lower lobe pulmonary artery (arrow).

B C

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