Abstract
Inferior vena cava (IVC) filters are recommended for patients with proximal deep vein thrombosis (DVT) who are not eligible for anticoagulation. Long-dwelling filters are well-known to be associated with the development of IVC thrombosis. Chronic caval occlusion can lead to a severe post-thrombotic syndrome (PTS), with manifestations of chronic venous insufficiency in the lower extremities. Animal studies have shown that post-thrombotic inflammation can trigger the development of an arteriovenous fistula (AVF), however, there is limited evidence for this phenomenon in patients with PTS. We describe the case of a spontaneous AVF in a patient with long-standing IVC thrombosis. It was postulated that the AVF could be compounding the venous hypertension and severe swelling of his lower extremities. The case additionally demonstrates the successful results of endovascular recanalisation for an occluded filter in the presence of an AVF.
Highlights
Complication rates tend to rise in line with the duration of filter implantation, and NICE guidelines recommend retrieval of the Inferior vena cava (IVC) filter as soon as pharmacological anticoagulation is appropriate.[5]
In our patient, IVC thrombosis was discovered within a month of insertion, and the presence of thrombus was a contraindication to removing the filter
Once the patient had been appropriately anticoagulated, he should have been reviewed with a view to removing the filter as soon as possible, as this may have prevented the development of his severe post-thrombotic syndrome (PTS) 2 years later
Summary
A rare case of arteriovenous fistula formation in a patient with inferior vena cava thrombosis, successfully managed with endovascular recanalisation. The patient was lost to follow up He re-presented 18 months later with features of PTS including extensive swelling and oedema of his right leg extending up to his groin, pigmentation changes, venous eczema and active ulceration affecting his right lower calf and lateral thigh (Figure 1). He scored 20/30 points using the Revised Venous Clinical Severity Score.[2] Examination further revealed prominent dilated tortuous superficial abdominal veins The swelling of his right leg caused him excruciating pain, which compounded his residual mobility issues post-stroke, and rendered him wheelchair bound. At 2 months’ post-procedure, his right thigh circumference had dramatically reduced and his mobility had improved His superficial abdominal varicosities clinically resolved, and the skin changes over his right thigh and calf had settled (Figure 6). He has been seen regularly by the cardiology team to monitor for signs of right heart failure following the sudden increase in venous return, he has not shown any signs of cardiac compromise to date
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