Chronic Inferior Vena Cava Occlusion Research Articles

Abstract 18056: Transhepatic and Trans-Patent Foramen Ovale Ablation of Atrial Fibrillation in the Setting of Chronic Inferior Vena Cava Occlusion: Addressing Complex Anatomic Hurdles and Achieving Therapeutic Success

Background: Rhythm control for atrial fibrillation (AF) is the preferred approach for symptomatic patients, particularly those with reduced ejection fraction. Catheter ablation primarily consists of pulmonary vein isolation via a transseptal approach. In patients with chronic occlusion of inferior vena cava (IVC), surgical ligation of IVC, or congenital venous system abnormalities, conventional femoral venous access may not feasible. Case Report: A 78-year-old male with history of Hypertension, diabetes, coronary artery disease, bilateral DVTs s/p thrombectomy, prior IVC stenting, presented with persistent, symptomatic AF on apixaban. Given a moderately reduced EF of 40-45%, amiodarone intolerance, and contraindication to other AADs, he was referred for catheter ablation. CT venogram showed chronically occluded IVC with patent hepatic veins, therefore transhepatic access to the right atrium was obtained. Transesophageal echocardiography (TEE) was planned for transseptal puncture; however, this showed an incidental PFO. This PFO was easily engaged using a manual modification of a VersaCross transseptal sheath and after entering the left atrium, the sheath was exchanged with a bi-directional sheath (Vizigo). Using this single left atrial access, pulmonary vein isolation and posterior wall isolation were performed. The transhepatic access site was closed with coil embolization to prevent track bleeding (figure 1). Conclusion: We present a case where successful AF ablation was achieved via percutaneous transhepatic approach, with improvised utilization of a conveniently located PFO. This was guided by pre-operative CT, and intra-operative TEE which allowed us to minimize any transseptal puncture related complications. The utilization of a multidisciplinary team comprising electrophysiologists, advanced imaging cardiologists and interventional radiologists is invaluable in executing complex procedures of this nature.

Lower Limb Weakness due to Spinal Venous Congestion in Chronic Inferior Vena Cava Occlusion: A Case Report.

A 31 year-old male presented with a long history of reduced sensation and motor function in his lower limbs upon waking every morning, lasting 30-50 minutes during which he was unable to ambulate. He was involved in a severe road traffic accident as a child, and was born prematurely requiring prolonged neonatal hospitalisation. Both duplex ultrasonography and magnetic resonance venography identified an occlusion of the IVC, with patent common femoral and iliac veins draining into large spinal collaterals. No other cause was identified for his symptoms. After appropriate multidisciplinary team discussion and patient counselling, the patient proceeded to have endovenous recanalization of his IVC and common iliac veins with dedicated venous stents. Post-operatively, the patient reported an immediate resolution of neurological symptoms, with an improvement in quality of life questionnaire scores and with stent patency at 9-month follow up. IVC occlusion with symptomatic spinal venous congestion is a rare condition which may be successfully treated with endovascular iliocaval recanalization, although long-term outcomes of this treatment are still unknown.

Radiofrequency wire \u2018power wire\u2019 recanalization of calcified chronically occluded inferior vena cava

BackgroundRadiofrequency (RF) wire recanalization of short segments of central venous obstruction has been considered safe; however its use for recanalization of long segments of inferior vena cava (IVC) has not been reported.Case presentationA 55-year-old female with recurrent massive hematemesis was found to have systemic venous upper esophageal varices on endoscopy and an extensive chronic IVC occlusion on CT. Using both a percutaneous transhepatic and transfemoral approach IVC recanalization was performed. A snare was advanced to the cavo-atrial junction via transhepatic venous access. From the groin utilizing RF wire steerable guide sheaths, endovascular reconstruction of the IVC was performed. Post recanalization venography demonstrated patent stented IVC and marked decrease in the intraabdominal-pelvic collaterals. No recurrence of hematemesis was noted. After 6 months, patient remained asymptomatic and had functioning right femoral arteriovenous hemodialysis graft.ConclusionsUsing appropriate techniques, Power wire recanalization of long occlusive segments of IVC can be safe and effective.

Long term follow-up of endo-vascular recanalization of chronic inferior vena cava occlusion secondary to inferior vena cava filters.

The long term efficacy of endovascular recanalization for chronic iliocaval occlusion secondary to inferior vena cava (IVC) filters is unknown. The purpose of this study was to evaluate the effectiveness of endovascular recanalization and stent placement across the filter in patients with filter-associated chronic iliocaval occlusion. Seven patients (mean age 56 ± 15 yrs; seven males) with symptomatic chronic iliocaval occlusion and occluded IVC filter were included. Immediate technical success rate, long term clinical effectiveness of endovascular recanalization and patency rate of the stents were assessed. In all patients, the endovascular treatment consisted of percutaneous venous access, recanalization of the occluded iliac veins and the IVC, transluminal angioplasty and stenting of the infrarenal inferior vena cava and iliac veins with self-expanding stents. The IVC filter was not removed, but rather the stents were extended across the filter. In four of seven patients (57 %), adjunctive pharmaco-mechanical thrombolysis was performed. All patients received anticoagulation post procedure. The mean clinical follow-up was 51.1 ± 27 months. Technical success rate was 100 %. Clinical success rate with symptomatic improvement was 85.7 %; one patient developed post-thrombotic syndrome on long term follow-up despite initial symptomatic improvement. Poststenting, the primary patency rate was 85.7 % (six of seven patients) and the secondary patency rate was 100 % (seven of seven patients). Endovascular recanalization with balloon angioplasty and placement of a self-expanding stent across a chronically occluded IVC filer can be performed safely and effectively for patients with symptomatic iliocaval thrombosis. An adjunctive pharmacologic-mechanical thrombolysis may be considered for selected patients.

A rare cause of ilio-femoral deep vein thrombosis in young adults: asymptomatic chronic inferior vena cava occlusion

Acute lower extremity deep venous thrombosis in young adults is usually related to thrombophilia, immobility, trauma, surgery or malignancy. Therapeutic options have recently included pharmacomechanical thrombus removal although there is no evidence of the indication or of the long-term benefit. Rarely unknown, asymptomatic chronic neonatal inferior vena cava occlusion could also lead to acute ilio-femoral thrombosis. The aim of the authors was to present the therapeutic possibilities in lower extremity deep venous thrombosis connected with chronic inferior vena cava occlusion. In a retrospective single center study data of 21 adults were analyzed. In 4 of the 21 patients chronic inferior vena cava obstruction was identified as an underlying cause of the acute thrombosis. Pharmacomechanical lysis was not offered to them and anticoagulation therapy was introduced. After an average 27.5 ± 11 month follow-up all the patients were alive and no adverse event occurred. In patients with acute lower extremity deep venous thrombosis and chronic inferior vena cava occlusion the indication of the endovenous pharmacomechanical lysis therapy is questionable. The authors suggest to consider computed tomography angiography or magnetic resonance angiography in addition to duplex sonography in patients with no obvious risk factors for lower extremity deep venous thrombosis to avoid unnecessary invasive treatment. Orv. Hetil., 2016, 157(34), 1361-1365.

The next frontier of office-based inferior vena cava filter placement.

There is an increasing number of procedures that traditionally were performed in the inpatient setting that arenow becoming office-based procedures. These include peripheral endovascular procedures such as angiograms, angioplasties, dialysis access interventions, and treatment for venous insufficiency. We chose to evaluate the feasibility, safety of inferior vena cava (IVC) filter placement in the office-based setting. All procedures were performed using local anesthesia, and ultrasound guidance for puncture. All venograms were performed with manual injection of iodinated contrast. An IVC filter was placed in the cases (except one failure of placement) using fluoroscopy in the infrarenal position. Patients were observed in a recovery area and then discharged. Follow-up data were obtained through an interview, physical examination, and 24-hour postoperative phone call. Over the course of 27months, 29 Greenfield filters (Boston Scientific, Marlborough, Mass) and three Celect temporary filters (Cook, Bloomington, Ind) were placed in the infrarenal IVC for 18 women and 14 men, with an average age of 75.3± 15.6years (range, 38-97years). Twenty-four acute, 6 recent (<6months ago) and three subacute lower extremity deep vein thromboses (DVTs) wereidentified. The indications for the procedure were patients with: DVT who were to undergo surgery (n= 6),acute large free-floating iliofemoral DVT (deemed high-risk for long-term anticoagulation) (n=7), new DVTduring anticoagulation therapy (n= 6), DVT with gastrointestinal bleeding (n= 4), DVT withhematuria (n= 2), recent DVT (which extended during fulldose anticoagulation treatment) while undergoing a longflight (n= 1) (temporary filter placement), DVTwith arm hematoma (n= 1), DVT with unsteady gaitand history offalls (n= 2), DVT with nose bleeding(n= 1), DVT withdementia and inability to receive anticoagulation treatment (n= 1), DVT and receiving chemotherapy and withthrombocytopenia (n= 1), and DVT and refusal to takeanticoagulation medication(n= 1). One patient had afailure to place a filterbecause of chronic IVC occlusion found on venogram.One patient with history of gastrointestinal bleeding,acute DVT, and atrial fibrillation suffered IVC filterthrombosis 1month after the procedure. We attemptedremoval of the temporary filters in the hospital in two patients but failed to retrieve the filter in thesetwo cases.We noted no insertion site DVT, extension ofDVT, orpulmonary embolism. Our preliminary experience suggests that placement of IVC filters for treatment of venous thrombotic eventsin an office-based facility is safe and efficacious with basic endovascular equipment. Long-term outcome cannot be determined at this point.

Chronic IVC Occlusion Predisposing to Acute Lower Extremity DVT in Children

Congenital atresia of the inferior vena cava (IVC) is a known risk factor for spontaneous lower extremity thrombosis in adults. However, little is known about the incidence of IVC occlusion and its relationship to spontaneous lower extremity thrombosis in children. We reviewed the medical records of consecutive patients with IVC occlusion and lower extremity DVT who presented to our institution between 2008 and 2015. Data were reviewed for risk factors for thrombosis, treatment, and outcomes including recurrent thrombosis, bleeding complications, and post-thrombotic syndrome. This represents the largest reported analysis of previously healthy pediatric patients with occult chronic IVC occlusion presenting with unprovoked acute lower extremity thrombosis. Ten patients aged 13 to 18 years (median age 16.5yrs, 90% male) presenting with acute lower extremity thrombosis were found to have chronic occlusion of the IVC. One patient presented with pulmonary embolism. Seven patients underwent site-directed thrombolysis, and 3 patients received anticoagulation alone. All patients had persistent IVC occlusion regardless of treatment. Two patients had recurrent thrombosis while on anticoagulation. There were no provoking factors identified that preceded the presentation of acute lower extremity thrombosis, and none had predisposing risk factors that could explain the IVC occlusion. Four patients had a negative thrombophilia work up. Five had mild thrombotic risk factors such as heterozygosity for Factor V Leiden or elevated factor VIII levels. Only one patient had a significant thrombophilic risk factor, familial mild protein C deficiency. Five patients had post thrombotic syndrome based on standardized scoring tools. All patients remain on indefinite anticoagulation. This case series suggests that chronic IVC occlusion increases the risk of unprovoked lower extremity thrombosis and pulmonary embolism in healthy children with resultant long-term complications. It also highlights the importance of imaging the IVC in young patients with unprovoked or minimally provoked iliofemoral DVT. Indefinite anticoagulation in patients presenting with unprovoked thrombosis secondary to IVC occlusion should be considered. DisclosuresNo relevant conflicts of interest to declare.

Office-Based IVC Filter Placement: The Next Frontier

An increasing number of procedures that traditionally were performed in the inpatient setting are now becoming office-based procedures. These include peripheral endovascular procedures such as angiograms, angioplasties, dialysis-access interventions, and venous insufficiency treatments. These have been performed in the office with minimal complications. We chose to evaluate the feasibility, safety of inferior vena cava (IVC) filter placement in the office-based setting. All procedures were performed under local anesthesia and using ultrasound guidance for puncture. All venograms were performed with hand injection of dye. An IVC filter was placed in the cases (except one failure of placement) under fluoroscopy at the level of L2-L3 in the infrarenal position. Patients were observed in a recovery area and discharged to home. Follow-up data were obtained through an interview, physical examination, and 24-hour postoperative phone call. At 1 week, duplex of the IVC filter and the puncture site was performed. At the 3-month follow-up, a venous and IVC duplex scan was performed. Over the course of 27 months, 29 Greenfield filters and 3 Celect temporary filters were placed in infrarenal IVC for 18 women and 14 men, with average age of 76.1 years (range, 38-97; standard deviation, ±15.1 years). Failure to place a filter occurred in one patient due to chronic IVC occlusion. The indications for the procedure were acute free-floating DVT in 10, contraindication to anticoagulation in 13, failure of anticoagulation in 5, high-risk patients in 2, patient-related contraindication such as dementia in 2, and refusal to be anticoagulated in 1. One 89-year-old patient had IVC filter thrombosis 2 months after placement of the IVC filter. The remainder of patients did not experience any complications, including but not limited to infection, bleeding, filter thrombosis, insertion-site thrombosis, perforation of the vena cava, recurrent pulmonary embolism, admission to the hospital, and death, within 24 hours (n = 32), 1 week (n = 32), and 3 months (n = 25) of follow-up time. Our preliminary experience suggests that placement of IVC filters for treatment of venous thrombotic events in an office-based facility is safe and efficacious with basic endovascular equipment. The long-term outcome cannot be determined at this point.

Excimer Laser–Assisted Removal of Embedded Inferior Vena Cava Filters

Although chronically implanted inferior vena cava filters may result in filter-related morbidity, there is currently no routine option for removing such filters when they become firmly embedded along the vena cava endothelium. During a 3-year period, 100 consecutive patients were prospectively enrolled in a single-center study. There were 42 men and 58 women (mean age, 46 years; limits, 18-76 years). Retrieval indications included filter-related acute inferior vena cava thrombosis, chronic inferior vena cava occlusion, and pain from retroperitoneal or bowel penetration. Filter retrieval was also performed to prevent risks from prolonged implantation and to potentially eliminate the need for lifelong anticoagulation. After standard methods failed, photothermal tissue ablation was attempted with a laser sheath powered by a 308-nm xenon chloride excimer laser. Applied forces were recorded with a digital tension meter before and during laser activation. Laser-assisted retrieval was successful in 98.0% (95% confidence interval [CI], 93.0%-99.8%) with mean implantation of 855 days (limits, 37-6663 days; >18 years). The following filter types were encountered in this study: Günther-Tulip (n=34), Celect (n=12), Option (n=17), Optease (n=20, 1 failure), TrapEase (n=6, 1 failure), Simon-Nitinol (n=1), 12F Stainless Steel Greenfield (n=4), and Titanium Greenfield (n=6). The average force during failed standard retrievals was 7.2 versus 4.6 pounds during laser-assisted retrievals (P<0.0001). The major complication rate was 3.0% (95% CI, 0.6%-8.5%), the minor complication rate was 7.0% (95% CI, 0.3%-13.9%), and there were 4 adverse events (2 coagulopathic hemorrhages, 1 renal infarction, and 1 cholecystitis; 4.0%; 95% CI, 1.1%-9.9%) at mean follow-up of 500 days (limits, 84-1079 days). Scar tissue ablation was histologically confirmed in 96.0% (95% CI, 89.9%-98.9%). Successful retrieval allowed cessation of anticoagulation in 30 of 30 (100%) patients and alleviated morbidity in 23 of 24 patients (96%). Excimer laser-assisted removal is effective in removing embedded inferior vena cava filters refractory to standard retrieval and high force. This method can be safely used to prevent and alleviate filter-related morbidity. http://www.clinicaltrials.gov. Unique identifier: NCT01158482.

Complex Retrieval of Embedded IVC Filters: Alternative Techniques and Histologic Tissue Analysis

We evaluated the safety and effectiveness of alternative endovascular methods to retrieve embedded optional and permanent filters in order to manage or reduce risk of long-term complications from implantation. Histologic tissue analysis was performed to elucidate the pathologic effects of chronic filter implantation. We studied the safety and effectiveness of alternative endovascular methods for removing embedded inferior vena cava (IVC) filters in 10 consecutive patients over 12months. Indications for retrieval were symptomatic chronic IVC occlusion, caval and aortic perforation, and/or acute PE (pulmonary embolism) from filter-related thrombus. Retrieval was also performed to reduce risk of complications from long-term filter implantation and to eliminate the need for lifelong anticoagulation. All retrieved specimens were sent for histologic analysis. Retrieval was successful in all 10 patients. Filter types and implantation times were as follows: one Venatech (1,495days), one Simon-Nitinol (1,485days), one Optease (300days), one G2 (416days), five Günther-Tulip (GTF; mean 606days, range 154-1,010days), and one Celect (124days). There were no procedural complications or adverse events at a mean follow-up of 304days after removal (range 196-529days). Histology revealed scant native intima surrounded by a predominance of neointimal hyperplasia and dense fibrosis in all specimens. Histologic evidence of photothermal tissue ablation was confirmed in three laser-treated specimens. Complex retrieval methods can now be used in select patients to safely remove embedded optional and permanent IVC filters previously considered irretrievable. Neointimal hyperplasia and dense fibrosis are the major components that must be separated to achieve successful retrieval of chronic filter implants.

Photothermal Ablation with the Excimer Laser Sheath Technique for Embedded Inferior Vena Cava Filter Removal: Initial Results from a Prospective Study

Purpose To evaluate the safety and effectiveness of the excimer laser sheath technique for removing embedded inferior vena cava (IVC) filters. Materials and Methods Over 12 months, 25 consecutive patients undergoing attempted IVC filter retrieval with a laser-assisted sheath technique were prospectively enrolled into an institutional review board–approved study registry. There were 10 men and 15 women (mean age 50 years, range 20–76 years); 18 (72%) of 25 patients were referred from an outside hospital. Indications for retrieval included symptomatic filter-related acute caval thrombosis (with or without acute pulmonary embolism), chronic IVC occlusion, and bowel penetration. Retrieval was also performed to remove risks from prolonged implantation and potentially to eliminate need for lifelong anticoagulation. After failure of standard methods, controlled photothermal ablation of filter-adherent tissue with a Spectranetics laser sheath and CVX-300 laser system was performed. All patients were evaluated with cavography, and specimens were sent for histologic analysis. Results Laser-assisted retrieval was successful in 24 (96%) of 25 patients as follows: 11 Günther Tulip (mean 375 days, range 127–882 days), 4 Celect (mean 387 days, range 332–440 days), 2 Option (mean 215 days, range 100–330 days), 4 OPTEASE (mean 387 days, range 71–749 days; 1 failed 188 days), 2 TRAPEASE (mean 871 days, range 187–1,555 days), and 2 Greenfield (mean 12.8 years, range 7.2–18.3 years). There was one (4%) major complication (acute thrombus, treated with thrombolysis), three (12%) minor complications (small extravasation, self-limited), and one adverse event (coagulopathic retroperitoneal hemorrhage) at follow-up (mean 126 days, range 13–302 days). Photothermal ablation of filter-adherent tissue was histologically confirmed in 23 (92%) of 25 patients. Conclusions The laser-assisted sheath technique appears to be a safe and effective tool for retrieving embedded IVC filters, including permanent types, with implantation ranging from months to > 18 years.

Endovascular stenting to treat chronic long-segment inferior vena cava occlusion

Chronic inferior vena cava (IVC) occlusion is often associated with debilitating symptoms. Supportive therapy is the treatment offered to most patients, often with poor symptom control. Patients have had to learn to cope with the sequelae of the syndrome and to accept lifelong disability and pain. This may no longer be the case, because endovascular procedures have emerged as a promising alternative for treatment of chronic IVC occlusion. We present 2 case reports of long-standing long-segment IVC occlusion successfully treated with endovascular procedures that incorporated progressive balloon dilation and stenting. The remarkably rapid relief of pain and swelling and overall improvement in quality of life warrants attempts to correct the condition in other patients with IVC occlusion.