Cava Thrombosis Research Articles

Tratamiento de la trombosis de vena cava inferior asociada a los tumores renales

IntroductionRenal carcinoma represents 3% of all solid tumors and is associated with renal or inferior caval vein (IVC) thrombosis between 2-10% of patients, extending to right atrial in 1% of cases. MethodsThis is a retrospective study that comprises 5 patients who underwent nephrectomy and thrombectomy by laparotomy because of renal tumor with IVC thrombosis level iii. ResultsFour patients were males and one was female, and the mean age was 57,2 years (range: 32-72). Most important clinical findings were hematuria, weight loss, weakness, anorexia, and pulmonary embolism. Diagnostic confirmation was performed by CT scanner. Metastatic disease was diagnosed before surgery in 3 patients. Suprahepatic caval vein and hepatic hilium (Pringle's maneouver) were clamped in 4 patients, and ligation of infrarrenal caval vein was carry out in one patient.Five patients developed mild complications (Clavien I/II). No patient died and the mean hospital stay was 8,6 days. All patients were treated with chemotherapy, and 3 died because distant metastasis, but 2 are alive, without recurrence, at 5 and 60 months, respectively. ConclusionsNephrectomy and thrombectomy in renal tumors with caval thrombosis can be curative in absence of metastasis or, at less, can increase survival or quality of live. Then these patients must be treated in liver transplant units because major surgical and anesthesiologic expertise. Adjuvant treatment with tyrosin kinase inhibitors must be validate in the future with wider experiences.

INFERIOR VENA CAVA SUPRARENAL FILTER IMPLANTATION

The paper analyzes indications for, frequency, safety, and efficiency of inferior vena cava (IVC) suprarenal filter implantation. The study based on the Medline database has indicated that an IVC suprarenal filter should be implanted following very strict indications, such as extensive caval thrombosis; renal vein thrombosis with a thrombus in the IVC; some vascular anomalies; a renal tumor process with a tumor thrombus in the IVC; prevention of pulmonary embolism in pregnant women with deep vein thrombosis; and prior to surgery. IVC suprarenal implantation done as clinically indicated is an effective and safe method to prevent pulmonary embolism.

腹部の鈍的外傷後に生じた下大静脈血栓の1例

腹部の鈍的外傷後に生じた下大静脈血栓の1例

Inferior vena cava filter retrievals, standard and novel techniques.

The placement of an inferior vena cava (IVC) filter is a well-established management strategy for patients with venous thromboembolism (VTE) disease in whom anticoagulant therapy is either contraindicated or has failed. IVC filters may also be placed for VTE prophylaxis in certain circumstances. There has been a tremendous growth in placement of retrievable IVC filters in the past decade yet the majority of the devices are not removed. Unretrieved IVC filters have several well-known complications that increase in frequency as the filter dwell time increases. These complications include caval wall penetration, filter fracture or migration, caval thrombosis and an increased risk for lower extremity deep vein thrombosis (DVT). Difficulty is sometimes encountered when attempting to retrieve indwelling filters, mainly because of either abnormal filter positioning or endothelization of filter components that are in contact with the IVC wall, thereby causing the filter to become embedded. The length of time that a filter remains indwelling also impacts the retrieval rate, as increased dwell times are associated with more difficult retrievals. Several techniques for difficult retrievals have been described in the medical literature. These techniques range from modifications of standard retrieval techniques to much more complex interventions. Complications related to complex retrievals are more common than those associated with standard retrieval techniques. The risks of complex filter retrievals should be compared with those of life-long anticoagulation associated with an unretrieved filter, and should be individualized. This article summarizes current techniques for IVC filter retrieval from a clinical point of view, with an emphasis on advanced retrieval techniques.

Severe ulcerative colitis complicated by Budd Chiari syndrome, inferior vena cava and cerebral venous thrombosis

Severe ulcerative colitis complicated by Budd Chiari syndrome, inferior vena cava and cerebral venous thrombosis

A Strategy for Achieving Early Reperfusion and Complete Clot Removal Using Endovascular Techniques for Management of Phlegmasia Cerulea Dolens

Phlegmasia cerulea dolens occurs when occluding caval or lower extremity deep venous thrombosis produces venous swelling sufficient to occlude arterial inflow. Ideal treatment should reduce swelling quickly, restore arterial perfusion, and eliminate all venous thrombus, preserving valvular function. Treatment options include any combination of open balloon thrombectomy, catheter-directed thrombolysis (CDT), and mechanical or aspiration thrombectomy. Open thrombectomy can be performed expeditiously but may leave thrombus or damage valves. Endovascular techniques may require time to resolve swelling and to restore perfusion but allow better clot removal, preserving valvular function. We describe a strategy of a combination of endovascular techniques that provide both rapid improvement and complete clot lysis. A 54-year-old woman with stage IV lung cancer developed bilateral deep venous thrombosis and pulmonary emboli. She was treated with intravenous tissue plasminogen activator, inferior vena cava filter, and oral anticoagulation. She presented 2 months later with worsening and painful swollen lower extremities. Physical examination showed bilateral swelling, mottling, and no palpable pulses. Doppler signals were present in both dorsalis pedis arteries. Venography showed occluding thrombus from the inferior vena cava filter to the popliteal veins bilaterally (Fig 1, A). Arteriography showed slow flow distal to the midcalf. AngioJet Power Pulse (Boston Scientific, Natick, Mass) pharmacomechanical thrombectomy (PMT) with tissue plasminogen activator was used to re-establish iliac vein outflow immediately. CDT using two infusion catheters and a bilateral up-and-over technique was performed during 72 hours with daily venography. We used a combination of early iliac clot debulking with caval protection, PMT, and up-and-over thrombolysis infusion catheters to achieve early improvement in perfusion followed by complete clot resolution (Fig 1, B). Phlegmasia cerulea dolens requires aggressive treatment. Early restoration of arterial perfusion is essential. Complete clot removal with maintenance of valvular competence may prevent post-thrombotic syndrome. Initial PMT combined with ongoing CDT can provide these outcomes. Up-and-over infusion catheters are a useful alternative to prograde popliteal access, reducing the likelihood of access site complications from compression in the popliteal veins after treatment.

Runtime and aPTT predict venous thrombosis and thromboembolism in patients on extracorporeal membrane oxygenation: a retrospective analysis.

Background Even though bleeding and thromboembolic events are major complications of extracorporeal membrane oxygenation (ECMO), data on the incidence of venous thrombosis (VT) and thromboembolism (VTE) under ECMO are scarce. This study analyzes the incidence and predictors of VTE in patients treated with ECMO due to respiratory failure.MethodsRetrospective analysis of patients treated on ECMO in our center from 04/2010 to 11/2015. Patients with thromboembolic events prior to admission were excluded. Diagnosis was made by imaging in survivors and postmortem examination in deceased patients.ResultsOut of 102 screened cases, 42 survivors and 21 autopsy cases [mean age 46.0 ± 14.4 years; 37 (58.7 %) males] fulfilling the above-mentioned criteria were included. Thirty-four patients (54.0 %) underwent ECMO therapy due to ARDS, and 29 patients (46.0 %) with chronic organ failure were bridged to lung transplantation. Despite systemic anticoagulation at a mean PTT of 50.6 ± 12.8 s, [VT/VTE 47.0 ± 12.3 s and no VT/VTE 53.63 ± 12.51 s (p = 0.037)], VT and/or VTE was observed in 29 cases (46.1 %). The rate of V. cava thrombosis was 15/29 (51.7 %). Diagnosis of pulmonary embolism prevailed in deceased patients [5/21 (23.8 %) vs. 2/42 (4.8 %) (p = 0.036)]. In a multivariable analysis, only aPTT and time on ECMO predicted VT/VTE. There was no difference in the incidence of clinically diagnosed VT in ECMO survivors and autopsy findings.ConclusionsVenous thrombosis and thromboembolism following ECMO therapy are frequent. Quality of anticoagulation and ECMO runtime predicted thromboembolic events.

Acute pyelonephritis with renal vein and inferior vena cava thrombosis and pulmonary emboli in poorly controlled type 2 diabetes and HHS

AbstractRenal vein thrombosis is a rare complication of acute pyelonephritis. We report a case of a 56‐year‐old woman with poorly controlled type 2 diabetes mellitus who presented with acute pyelonephritis and hyperglycaemic hyperosmolar state (HHS), complicated by thrombosis of the renal vein extending into the inferior vena cava. She was managed with intravenous antibiotics, intravenous fluids and insulin and with therapeutic low molecular weight heparin, despite which she developed pulmonary emboli two days after the diagnosis of renal vein and inferior vena caval thrombosis. Following optimisation of the dalteparin dose with factor Xa monitoring and a prolonged course of antibiotics, she made a full recovery. Two months post‐treatment there was resolution of the renal vein thrombosis and pulmonary emboli with improvement of inflammation of the right kidney on repeat computer tomography scanning.This case highlights the need to recognise renal vein thrombosis and pulmonary emboli as complications of acute pyelonephritis, especially in combination with poorly controlled diabetes mellitus, which further increases the hypercoaguable state. Copyright © 2016 John Wiley & Sons.

A 16-F Sheath with Endobronchial Forceps Improves Reported Retrieval Success of Long-Dwelling “Closed Cell” Inferior Vena Cava Filter Designs

PurposeTo report results of a 16-F sheath/endobronchial forceps combination in retrieval of “closed cell” inferior vena cava (IVC) filter designs with prolonged dwell times of ≥ 60 days. Materials and MethodsForceps retrieval of selected IVC filters using a 16-F 45-cm sheath was performed in 35 patients (25 women and 10 men). Patients presented with filters that were no longer needed without (n = 10) or with (n = 21) prior failed retrieval, caval thrombosis before lysis (n = 3), and back pain (n = 1). Filter designs included 19 Günther Tulip (54%), 10 Option (29%), and six OptEase (17%). Mean dwell time was 977 days. Imaging characteristics, technical success, fluoroscopy time, and complications were recorded. ResultsFilters included 20 tip-embedded, 6 tip-adherent, 4 fractured, and 6 containing thrombus. All were strut and wall-embedded. Initial snare failures occurred in 8 filters because of hook straightening (n = 4), adherent material (n = 2), snare breakage (n = 1), and filter tilt (n = 1). The 16-F sheath/forceps combination was 100% successful in removing filters. In 1 patient, 2 extravascular fragments could not be retrieved. Median fluoroscopy time, excluding 3 extended lysis procedures, was 8 minutes. Minor caval abnormalities, including caval spasm and caval defects, were noted in 17 patients, and filter fracture occurred in 2 patients. No major complications occurred. ConclusionsA high rate of retrieval for closed cell long-dwelling strut and wall-embedded filters may be achieved using a 16-F sheath/endobronchial forceps combination.

The Mesenteric-Caval Fistula: First Results of a New Technique in a Transperitoneal Reconstruction of the Caval Vein by Fulminant Thrombosis of the Inferior Vena Cava Based on Homozygous Antithrombin III-Deficiency

Recurrent thrombotic occlusions are one major problem in patients with thrombosis of the inferior vena cava. Due to this, we report a new surgical strategy for the construction of aorto-caval (mesenteric-caval) fistula in a patient with homozygous Antithrombin III (ATIII)-Deficiency. The patient survived postoperatively and only surgical complications grade I and II (Clavien-Dindo classification) were reported after short-term and one year follow-up. After one year, the CT-angiography did not show any caval thrombosis or stenosis and no restriction or occlusion of the fistula. Thus, the mesenteric-caval fistula could be safely performed and resulted in a satisfactory patency.

Fatal acute complete inferior vena cava thrombosis after inferior vena cava filter placement: Role of autopsy in elucidating the diagnosis

Introduction: On rare occasions patients’ develop unexpected complications following medical interventions from which they succumb. It is important to learn from these unfortunate events and an autopsy is invaluable in revealing the underlying anatomy of fatal pathophysiology. Case Report: We describe the catastrophic hospital course in a 58-year-old male who underwent a relatively minor surgical procedure which was complicated by deep venous thrombosis, pulmonary embolism and a paradoxical cerebral embolus. He suffered numerous complications related to placement of a vena caval filter, including complete inferior vena caval thrombosis with hemodynamic collapse. Conclusion: This case report provides the treating residents perspective of the patients’ complex medical course and the value of an autopsy.

Clinical Experience with Vena Cava Filter for Superior Vena Caval Thrombosis due to Indwelling Central Venous Catheter

Clinical Experience with Vena Cava Filter for Superior Vena Caval Thrombosis due to Indwelling Central Venous Catheter

Inferior Vena Caval Thrombosis in Elderly Patients with Active Pulmonary Tuberculosis: A Case Series with Implications for Therapy

Introduction: Prevalence of tuberculosis continues to remain high worldwide According to 2010 Global Burden of Disease estimates, majority of tuberculosis related deaths occurred in people older than 50. Tuberculosis (TB) is associated with a hypercoagulable state and hence VTE. These can be extensive and potentially life threatening. A variety of factors have been postulated to predispose patients with tuberculosis to venous thrombosis that include local stasis due to venous compression by lymph nodes and relative immobility caused by respiratory dysfunction, alteration in coagulation factors and reactive thrombocytosis. Case series presentation: We report 2 cases of extensive venous thromboembolism associated with pulmonary tuberculosis in the elderly. A 65 year-old Asian female with recently diagnosed tuberculosis presented with a new long deep vein thrombus extending from tibial vein up to right heart chamber and 67 year old Asian male in whom VTE was a presenting feature of tuberculosis (CFV thrombus extending up to IVC). Inferior vena caval thrombosis has been reported only rarely in active pulmonary tuberculosis and only 3 reports exist in English literature Conclusion: Our two cases highlight the risk of deep venous thrombosis in elderly patients with pulmonary tuberculosis even in the absence of any other risk factors for VTE. TB should be considered as a risk factor for VTE and included in thromboembolism risk evaluation especially in first few months of treatment. VTE might be the first presentation of underlying tuberculosis. Also, VTE associated with tuberculosis might be extensive and involve proximal veins hence, may be life threatening due to a higher risk of pulmonary embolism. Physicians must be aware of this for prompt diagnosis and treatment to prevent fatality. Patients on tubercular therapy might require high doses of anticoagulation due to known interaction

Inferior vena caval thrombosis complicating pyogenic liver abscess after pancreatoduodenectomy: a case report.

Pyogenic liver abscess (PLA) complicated by inferior vena caval (IVC) thrombosis is rare but life-threatening. We experienced a case of PLA complicated by an IVC thrombus close to the right atrium after pancreatoduodenectomy. A 75-year-old man had undergone pancreatoduodenectomy with modified-Child reconstruction for pancreatic cancer 3 years prior, and no recurrence was noted on follow-up. He was admitted to our hospital owing to fever and general fatigue. PLA and septic shock were diagnosed, and conservative therapy with antibiotics was initiated. His general condition gradually improved, but a thrombus in the middle hepatic vein and IVC was noted on follow-up computed tomography on hospital day 8. Although anticoagulant therapy using heparin was started, the thrombus size increase and extended to the right atrium. Considering the risk of pulmonary embolism, we planned a surgical intervention with a cardiovascular surgeon to remove the thrombus. During surgery, we made an incision in the right atrium and removed the thrombus using extracorporeal circulation. After removal, we dissected the middle hepatic vein using an automated suturing device to prevent the thrombus from extending into the IVC. The patient was discharged 10 weeks after surgery. Eighteen months post-intervention, there was no recurrence of either PLA or thrombi. Our experience suggests that physicians should consider the existence of a middle hepatic vein and IVC thrombi when examining PLA patients and that surgical intervention can be applied successfully in such cases.

Evaluation of different radiological interventional treatments of Budd–Chiari syndrome

AimTo evaluate the efficacy of various interventional techniques in treatment of Budd–Chiari syndrome (BCS). Patients methods103 patients with BCS were included in the study. There were 9/103 (8.7%) patients with obstruction of inferior vena cava (IVC) (type I), 17/103 (16.6%) patients with hepatic vein obstruction (type II), 71/103 (68.9%) patients with veno-occlusive diseases (type III) and 6/103 (5.8%) patients with veno-occlusive disease combined with caval thrombosis (type IV). Recanalization techniques of hepatic veins and IVC, and TIPS were used. ResultsOf all the subjects, 101 successfully underwent their procedures, with a technical success rate of 98.06%; only 2 failed to do TIPS. After treatments, 2 patients died after operation because of severe intra-abdominal hemorrhage. One hundred and one patients were followed up for 1–94months. The mean follow-up of a BCS patient treated with PTA was 52.1months, with an overall primary patent rate of 69.2% (18/26). The mean follow-up of BCS treated with TIPS was 33.5months, with an overall primary patent rate of 72.7% (56/77). Eight patients died 7–64months after the interventions. ConclusionsRecanalization of IVC/hepatic vein and TIPS can be regarded as safe and effective interventional invasive methods in the treatment of BCS.

Comparative Outcomes of Catheter-Directed Thrombolysis Plus Anticoagulation Versus Anticoagulation Alone in the Treatment of Inferior Vena Caval Thrombosis

While there has been a steady increase in the use of catheter-directed thrombolytic therapy in treatment of patients with inferior vena cava (IVC) thrombosis, there has been no significant difference in mortality between CDT vs anticoagulation alone, but bleeding events and resource utilization are higher in the CDT group.

Retrievable inferior vena cava filters can always be removed using "fall-back" techniques.

Retrievable inferior vena cava filters (IVCFs) left in place for a prolonged period can lead to complications including filter migration, fracture, and caval thrombosis. "Fall-back" techniques for IVCF retrieval that can be used when standard snaring is unsuccessful have been recently described. The purpose of this study was to analyze how incorporation of these new techniques affected the outcomes of IVCF retrievals at our institution during the past 5 years. Data were collected of all patients undergoing IVCF removal by vascular surgeons at a tertiary academic medical center between 2009 and 2013, including demographics and procedural and filter characteristics. A standard technique of snaring the retrieval hook was attempted first in all cases; if this was unsuccessful, a number of fall-back techniques were employed, including the use of endoscopic graspers, 18F sheaths, and snaring a second wire below the collar of the filter to collapse it into the sheath. IVCF retrieval was attempted in 275 patients; 3 were excluded intraoperatively because of thrombus in the filter. Most filters (97%) were Günther Tulips (Cook Medical, Bloomington, Ind); 70% had been placed prophylactically before bariatric surgery. A total of 268 filters (98.5%) were retrieved successfully, 213 (79%) by standard snaring and 55 (21%) with fall-back techniques. In patients undergoing fall-back techniques, technical success was achieved 100% of the time. The median time since insertion was significantly longer in the fall-back group (173 days vs 83 days; P < .0001). Four intraoperative complications occurred; fractured wires embolized to the right atrium or pulmonary artery and were successfully removed endovascularly. The majority of the procedures (80%) were performed under sedation in both groups. Incorporation of fall-back techniques may allow 100% technically successful and safe removal of retrievable IVCFs and is especially useful in removing filters with prolonged dwell time.

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

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.

3:39 PM, Abstract No. 127 - Conductive IVC filter retrieval following optimized radiofrequency ablation in an ex vivo model

encounters) in whom inferior vena cavography was performed before and after IVC filter retrieval were reviewed from a 12year period ending 3/2014. Retrieval was considered complex if it required forceps or other adjuncts. The cavograms were assessed for abnormalities including stenosis, filling defects, dissection, and extravasation of contrast. Stenosis was measured with electronic calipers and graded by quartiles. Change in stenosis in a given location greater than or equal to one quartile after removal was considered spasm. Results: Of the original 250 encounters, 2 were excluded because they were removed immediately after being placed, 16 due to missing records, and 4 due to extensive baseline caval thrombosis precluding analysis. Dwell time could not be determined for 15 encounters due to missing records. Filling defects and stenosis were significantly more frequent after retrieval, p o 0.05, but they did not change patient management (Table). The only major abnormality after retrieval was extravasation, which occurred only in the complex group and was treated with balloon tamponade and observation. No dissection was observed. There were no cases of 76% or greater stenosis. Dwell time was not correlated with the presence of abnormalities after retrieval (r 1⁄4 0.002, p 1⁄4 0.977). Conclusion: Caval stenosis is the primary abnormality found by cavography after IVC filter retrieval. The lack of cavographic abnormalities requiring treatment following routine IVC filter retrieval may justify omitting the post-retrieval cavogram irrespective of dwell time. While uncommon, extravasation requiring treatment may be seen after complex retrieval, thus cavography remains warranted in this setting.

3:30 PM, Abstract No. 126 - Is a cavogram necessary after IVC filter retrieval?

To evaluate the utility of inferior vena cavography after temporary IVC filter retrieval using routine and complex techniques. 245 patients (250 consecutive encounters) in whom inferior vena cavography was performed before and after IVC filter retrieval were reviewed from a 12-year period ending 3/2014. Retrieval was considered complex if it required forceps or other adjuncts. The cavograms were assessed for abnormalities including stenosis, filling defects, dissection, and extravasation of contrast. Stenosis was measured with electronic calipers and graded by quartiles. Change in stenosis in a given location greater than or equal to one quartile after removal was considered spasm. Of the original 250 encounters, 2 were excluded because they were removed immediately after being placed, 16 due to missing records, and 4 due to extensive baseline caval thrombosis precluding analysis. Dwell time could not be determined for 15 encounters due to missing records. Filling defects and stenosis were significantly more frequent after retrieval, p < 0.05, but they did not change patient management (Table). The only major abnormality after retrieval was extravasation, which occurred only in the complex group and was treated with balloon tamponade and observation. No dissection was observed. There were no cases of 76% or greater stenosis. Dwell time was not correlated with the presence of abnormalities after retrieval (r = 0.002, p = 0.977). Caval stenosis is the primary abnormality found by cavography after IVC filter retrieval. The lack of cavographic abnormalities requiring treatment following routine IVC filter retrieval may justify omitting the post-retrieval cavogram irrespective of dwell time. While uncommon, extravasation requiring treatment may be seen after complex retrieval, thus cavography remains warranted in this setting.