Alternative techniques, such as transvenous biopsy, can aid in cases with these constraints, particularly in patients with thrombocytopenia.<h4>Case presentation</h4>A 32-year-old male with PIK3CA related overgrowth syndrome presenting as Congenital, Lipomatous, Overgrowth, Vascular malformations, Epidermal nevi, Spinal/skeletal anomalies and/or scoliosis (CLOVES) syndrome, was admitted to the emergency department with bleeding cystic lesions and severe thrombocytopenia. The gene discussed is PIK3CA; the disease is Thrombocytopenia.