Abstract No. 511 - Minimally invasive management of post-operative chylous ascites

Abstract

No. 512 Pharmacomechanical recanalization of caval thrombosis in patients with vena cava filter associated phlegmasia cerulea dolens R. Florek, E.K. Lang, Dr, R. Batson, F. Alessi, E. LaNassa, C. Sheehan; Radiology, Lourdes Regional Medical Center, Lafayette, LA; Radiology, West Jefferson Medical Center, Marrero, LA; Radiology, SUNY Downstate, New York, NY; Vascular Surgery, LSU Medical Center, New Orleans, LA Purpose: Occlusion of the inferior vena cava (IVC) occurs in 1-2.5% of chronically indwelling caval filters (1). IVC thrombosis results in impaired venous drainage from the lower extremities, and can present clinically as phlegmasia cerulea dolens (PCD) in chronic cases. Caval filter associated IVC thrombosis can be recanalized by mechanical clot disruption, aided by multi-day TPA thrombolysis with restoration of caval flow and resolution of PCD symptoms of swelling and discoloration. Materials and Methods: Six patients (ages 48-72, avg. 63) were reviewed who presented with chronic (more than 1 week) symptoms of PCD of the lower extremities after placement of a caval filter (6-49 mos. prior, avg. 25 mos; two placed by the primary author, four referred from outside institutions). All showed complete caval thrombosis with an indwelling caval filter. Mechanical disruption with balloon catheters and Trellis device thrombus disruption was used, in combination with TPA infusion (10 mg. loading dose, followed by overnight infusion of 1 mg/hr, followed by repeat mechanical disruption, over an average of three days). Results: Five of the six patients were recanalized and discharged after therapy. All showed resolution of lower extremity swelling and discoloration. One patient who was admitted with ongoing sepsis continued to worsen into multiorgan failure (MOF) and expired. Overall success rate was 83%, with one treatment failure due to ongoing sepsis resistant to multiple antibiotics, suggesting the IVC thrombus may have been superinfected. Conclusion: PCD secondary to caval filter occlusion is difficult to recanalize and both mechanical and thrombolytic therapy may be necessary over several days. Success rate in this series was 5 of 6 (83%).2. Sepsis in addition to caval thrombosis carries a higher risk of fatality due to resistant sepsis progressing to MOF, suggesting the presence of infected thrombus.