We describe the value of live/real time three-dimensional transthoracic echocardiography (3DTTE) over two-dimensional transthoracic echocardiography (2DTTE) in the assessment of inferior vena cava (IVC) and hepatic vein (HV) obstruction in a patient with sickle cell disease. 3DTTE provided additional information when compared to 2DTTE by (1) identifying the obstructing lesion as a likely thrombus, (2) by providing assessment of anatomical severity of IVC lumen obstruction since the thrombus could be visualized en face also, and (3) identifying an area of increased mobility of a portion of the thrombus suggesting greater risk of embolization. (Echocardiography 2010;27:594-596).