Shock Circulatory Collapse and the IVC and Hepatic Veins

IVC level sign


  • Diagnosis
    • clinical
      • altered mental status,
      • cool extremities and/or
      • low urinary output.
      • persistent hypotension
        • systolic blood pressure < 80-90 mm Hg or
        • mean arterial pressure 30 mm Hg lower than baseline
        • reduction in cardiac index
          • <1.8 L • min−1 • m−2 without support or
          • <2.0 to 2.2 L • min−1 • m−2 with support
      •  echocardiography,
        • deceleration time of early left ventricular filling has been shown to correlate inversely with pulmonary capillary wedge pressure,
      • CT
        • incidental radiographic findings
          • dependent layering of contrast within the IVC and its tributaries
          • creating a blood-contrast level.
          •  = IVC level sign
• 68 year old male in cardiogenic shock manifesting as an IVC level sign (aka IVC niveau sign ) characterized by dependent layering of contrast within the IVC and its tributaries in the liver (hepatic veins) creating a blood-contrast level.(middle and bottom images) In this patient there was also blood contrast level in the SVC.
(top image)
Ashley Davidoff MD



An incidental Finding an a CTPA patient who was an outpatient who presented with elevated d dimer but was  hemodynamically stable.

CT scan shows reflux into the azygous vein (top right), with normal to small right sided chambers, enlarged left atrium and left ventricle, bulging of the septum primum to the right indicating that left atrial pressures are higher than the right and enlarged IVC and coronary sinus.(second row)
There is significant stasis of systemic venous inflow into the right
atrium and right ventricle characterized by almost complete stasis of the
contrast column in the IVC and extension of the contrast into the smallest
hepatic veins in the dependent portion of the liver posteriorly. (3rd and 4th row) The blood contrast level in the IVC is called the “IVC level sign” (aka IVC niveau sign) Since this patient was completely well the explanation may relate to an unusually robust breath hold and [possible Valsalva maneuver during the study
Ashley Davidoff MD See 82H
65 year old male s/p MVA presents in shock. Scout film (top left) shows left sided tension pneumothorax with rightward mediastinal shift. Axial CT through the liver (top right) shows expanded pneumothorax at the left lung base with reflux of contrast into the IVC.. Contrast also refluxes into the right renal vein (bottom left) and into the internal iliac veins (bottom right) Associated pneumatosis intestinalis in the sigmoid colon is present as well and likely secondary to the tension pneumothorax
Ashley Davidoff MD




  • Links and References

  • 8. Tsai P.P., Chen J.H., Huang J.L., Shen W.C. Dependent pooling: a contrast-enhanced sign of cardiac arrest during CT. AJR Am J Roentgenol. 2002;178(5):1095–1099. [PubMed[] [Ref list]
  • 9. Ko S.F., Ng S.H., Chen M.C., Lee T.Y., Huang C.C., Wan Y.L. Sudden cardiac arrest during computed tomography examination: clinical findings and “dense abdominal veins” on computed tomography. Cardiovasc Comput Tomogr2003;27(1):93–97. [PubMed[] [Ref list]
  • 10. Yeh B.M., Kurzman P., Foster E., Qayyum A., Joe B., Coakley F. Clinical relevance of retrograde inferior vena cava or hepatic vein opacification during contrast-enhanced CT. AJR Am J Roentgenol. 2004;183(5):1227–1232. [PubMed[] [Ref list]
  • 11. Roth C., Sneider M., Bogot N., Todd M., Cronin P. Dependent venous contrast pooling and layering: a sign of imminent cardiogenic shock. Am J Roentgenol. 2006;186(4):1116–1119. [PubMed[] [Ref list]
  • 12. Sueyoshi E., Imamura T., Sakamoto I., Uetani M., Matsuoka Y. Contrast-fluid level in the inferior vena cava (IVC niveau sign) in patients with acute type A aortic dissection: computed tomography findings during acute cardiac tamponade. Jpn J Radiol. 2010;28(4):278–282. [PubMed[] [Ref list]
  •  Bagheri S.M., Taheri M.S., Pourghorban R., Shabani M. Computed tomographic imaging features of sudden cardiac arrest and impending cardiogenic shock. J Comput Assist Tomogr. 2012;36(3):291–294. [PubMed[] [Ref list]
  • 14. Wong H.Y., Lee K.H. The IVC contrast level sign. Abdom Radiol. 2017;42(12):2962–2963. [PubMed[] [Ref list]
  • 15. Shiotani S., Kohno M., Ohashi N., Yamazaki K., Itai Y. Postmortem intravascular high-density fluid level (hypostasis): CT findings. J Comput Assist Tomogr. 2002;26(6):892–893. [PubMed[] [Ref list]
  • TCV