Chronic Inferior Vena Cava 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.

P02] Inferior Vena Cava Reconstruction: A Single Centre Experience

<h3>Objective</h3> Inferior vena cava (IVC) stenting is carried out for symptomatic chronic IVC stenosis or occlusion, and for the treatment of malignant IVC obstruction. The patency of IVC stents placed for both acute on chronic and chronic venous occlusion was determined. <h3>Methods</h3> Retrospective analysis of prospectively collected data was completed on all patients who underwent technically successful IVC stenting for treatment of symptomatic venous outflow obstruction or stenosis between February 2015 and November 2021. All patients had standard pre-operative work up, including venography ± intravascular ultrasound for chronic cases, and followed standard anticoagulation and surveillance programmes post-procedure, unless there was malignant disease. <h3>Results</h3> Sixteen patients underwent IVC stenting. Seven cases (43%) presented acutely with deep vein thrombosis and chronic underlying IVC stenosis or occlusion. Five cases (31%) were for symptomatic malignant external IVC compression. In four cases (25%), kissing iliac stents were placed into the IVC to treat infrarenal IVC disease. The remainder required single stents in the IVC, or were combined with double barrelled iliac stents. Re-intervention occurred in four cases (25%) for in stent thrombosis. Primary patency was 75%, and primary assisted patency was 88%. Stenting the IVC in all cases for malignant obstruction gave symptomatic relief. <h3>Conclusion</h3> Stenting of the occluded/atretic IVC may require additional access from the right internal jugular vein. Stenting above and across the renal veins did not cause any additional complications in this series. Stenting of the IVC is safe, and can give significant improvement in symptoms in patients with limited alternative options for treatment.

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.

Reversal of cardiopulmonary exercise intolerance in patients with post-thrombotic obstruction of the inferior vena cava

BackgroundIt is unclear whether cardiopulmonary exercise intolerance in patients with chronic obstruction of the inferior vena cava (IVC) is reversible following endovascular IVC reconstruction. MethodsIn 17 patients (mean age 45 ± 15 years, 71% men) with post-thrombotic syndrome due to IVC obstruction and preserved left ventricular ejection fraction (mean 58 ± 3%), we performed cardiopulmonary exercise testing before and 3 months after IVC reconstruction (mean 4.1 ± 1.5 implanted stents). The median time from latest episode of deep vein thrombosis to intervention was 150 (interquartile range 102–820) days. ResultsAt baseline, 12 (71%) patients reported New York Heart Association (NYHA) class II or III symptoms, 76% did not achieve >85% of predicted oxygen uptake at peak exercise (mean 61.8 ± 13.7%). After IVC reconstruction, the following changes were observed at anaerobic threshold: work rate increased by 14.6 W, 95%CI (−0.7; 30.0), oxygen uptake increased by 1.8 ml/kg, 95%CI (0.3; 3.3). Oxygen pulse increased by 1.95 ml per beat, 95%CI (1.12; 2.78), corresponding to a mean relative increase of 22.5%, 95%CI (12.4; 32.7) (p < 0.001). The following changes were observed at peak exercise: work rate increased by 48.1 W, 95%CI (27.8; 68.4), oxygen uptake increased by 6.4 ml/kg, 95%CI (3.8; 9.1). Oxygen pulse increased by 2.68 ml per beat, 95%CI (1.60; 3.76), corresponding to a mean relative increase of 29.4%, 95%CI (17.7; 41.2) (p < 0.001). At follow-up, 5 (29%) patients remained in NYHA class II. ConclusionsIn patients with chronic IVC obstruction, cardiopulmonary exercise intolerance as a result of impaired cardiac filling is at least partially reversible following endovascular IVC reconstruction. Study registrationURL: https://clinicaltrials.gov. Unique identifier: NCT02433054.

Contemporary management of chronic indwelling inferior vena cava filters

ObjectiveDespite increasing retrieval rates of the inferior vena cava (IVC) filter, less than one-third are removed within the recommended timeline. Prolonged filter dwell times may increase the technical difficulty of retrieval and filter-related complications. We sought to evaluate the contemporary outcomes of patients with chronic indwelling IVC filters at a tertiary care center. MethodsA retrospective analysis was performed from August 2015 through August 2019 of all patients who were referred for removal of a prolonged IVC filter with a dwell time >1 year. Descriptive analysis was used to evaluate patients' characteristics and procedural outcomes, which were reviewed through electronic medical records. Data were expressed as median with interquartile range (IQR) or number and percentage, as appropriate. ResultsA total of 47 patients were identified with a median filter dwell time of 10.0 years (IQR, 6-13 years); 34 patients underwent IVC filter removal, and 13 patients refused retrieval. The median age of patients was 54.9 years (IQR, 42.5-64.0 years); the majority were female (57%) and white (53%). The most common indication for filter placement was high risk despite anticoagulation (49%), followed by venous thromboembolism prophylaxis (21%). The majority of patients were symptomatic (72%). If symptomatic, the most common reason for retrieval was IVC penetration (94%), and the chief complaint was pain (56%). Retrieval success was 97%, with a median length of stay of 0 days. The majority of retrievals were performed through an endovascular approach (97%). There was one postprocedural complication (3%). ConclusionsDespite prolonged dwell times, IVC filter retrieval can be performed safely and effectively in carefully selected patients at a tertiary referral center.

Abstract No. 658 Exercise intolerance caused by chronic iliocaval venous occlusion: non-invasive quantitative assessment

Patients with chronic inferior vena cava (IVC) and bilateral iliac vein postthrombotic occlusion often report subjective decreased exercise tolerance that improves after stent reconstruction. We report preliminary results of the use of quantitative exercise testing to assess change in exercise tolerance occurring after venous reconstruction. The Institutional Review Board approved this retrospective study. Exercise testing before and after intervention was conducted in the Human Performance Laboratory (HPL): resting blood pressure, heart rate, body mass index (BMI), body composition, standard pulmonary function tests, and incremental maximal exercise testing (VO2 max test). Maximal exercise was defined as a plateau in the oxygen uptake, a respiratory exchange ratio (RER) greater than 1.1, or voluntarily termination of exercise. The VO2 max (mL/kg/min), maximum work (W) and total exercise time were analyzed. Percutaneous venous reconstruction was performed using standard techniques and stents. Results were reported as simple averages and percentages. Three male patients with chronic postthrombotic IVC and bilateral iliac venous occlusions were studied. Mean age 63 ± 8 years, mean duration of occlusion 36 ± 12 months. The interval between reconstruction and testing ranged from 2.5 to 11 months. All patients had stents in the infra-renal IVC to bilateral common femoral veins. No exercise instructions were provided to patients after stent reconstruction. Following venous reconstruction, the V02 max increased an average of 38.7%, the total work increased 74.4%, and the total exercise time increased 18.7%. Each individual lost weight, with an average decrease of 7.5%. Subjectively, all patients reported an increased exercise tolerance and decreased shortness of breath with exertion. Subjective impairment in exercise tolerance and improvement after venous reconstruction was quantitated in three patients with chronic postthrombotic occlusion of the IVC and bilateral iliac veins. HPL testing may be a useful additional objective tool in the study of patients with chronic ilio-caval occlusions.

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.

Atrophic inferior vena cava is a marker of chronicity of intra-filter and inferior vena cava thrombosis: based on CT findings

BackgroundA permanently indwelling filter in the inferior vena cava (IVC) may induce caval thrombosis, which could develop and evolve from an acute to a chronic phase. The differential diagnosis of acute and chronic thromboses determines the treatment strategy. The role of computed tomography (CT) in diagnosing acute and chronic intra-filter and IVC thromboses has not been well established. This retrospective study summarizes the CT signs that indicate acute and chronic phases of intra-filter and IVC thromboses.MethodsThis study included eight patients who developed a lower-extremity deep venous thrombosis (DVT) and were treated with intracaval filter placement as an alternative to anticoagulation and thrombolysis. During the follow-up, all patients developed an intra-filter thrombosis in the IVC confirmed by CT and/or CT venography (CTV). Demographic and CT data of all patients during the follow-up period were collected for analysis.ResultsAll patients had normal-appearing IVCs prior to filter placement, as shown on trans-femoral venography. Eight filters (five TrapEase, three OptEase) were placed in the eight IVCs, respectively. Subsequently, IVC-CT or CTV revealed acute intra-filter or IVC thrombosis in all eight patients, manifesting as an intracaval filling defect and thickened IVC wall. Filter protrusion and secondary caval atrophy seen on CT indicated a chronically occluded IVC.ConclusionsIVC thrombosis may result from filter placement. The chronicity of caval thrombotic occlusion is likely to be associated with filter protrusion and secondary IVC atrophy revealed on CT scans.

Endovascular recanalization for nonmalignant obstruction of the inferior vena cava.

The aim of this study was to evaluate outcomes of endovascular recanalization of the inferior vena cava (IVC) and iliac veins with long-standing chronic venous obstruction caused by nonmalignant disease. Medical records for 66 patients who underwent endovascular recanalization of the IVC with or without iliac veins from January 2001 to December 2014 at our medical center were retrospectively reviewed. Primary outcomes included morbidity and mortality; secondary outcomes included primary, primary assisted, and secondary patency and resolution of symptoms. Forty-five (68%) patients were male; the mean age was 43years (range, 17-83years). All but one patient had chronic symptoms (mean duration, 8± 9years). Clinical, Etiology, Anatomy, and Pathophysiology classes included 3, 4a, 4b, 5, and 6 in 41, 2, 1, 2, and 20 patients, respectively. Mean Venous Clinical Severity Score was 12.4± 6.5. Fifty-nine patients (89%) had history of deep venous thrombosis, and 13 also had pulmonary embolism. Twenty-five patients (38%) had an IVC filter; 20 (30%) had thrombophilia. The obstruction involved the infrarenal IVC in 44 patients and both the infrarenal and suprarenal IVC in 22 patients. All recanalizations were performed under conscious sedation and local anesthesia and involved sequential angioplasty and stent placement into the IVC, with or without iliac vein stenting. Venous access included bilateral femoral veins and right internal jugular vein. Stents used were Wallstents (Boston Scientific, Marlborough, Mass; n=70), Protegé stents (ev3, Plymouth, Minn; n= 49), Gianturco (Cook Medical, Bloomington, Ind; n= 44), and Luminexx (Bard, Tempe, Ariz; n= 1). Pressure gradients were 6.7± 4.0mm Hg before and 0.9± 1.1mm Hg after stenting (P< .001). Procedural success was 90% and 100% at first and second attempt at recanalization, respectively. There was no mortality or clinically significant pulmonary embolism. Four patients had five complications: two developed an arteriovenous fistula, one patient developed groin hematoma that required open evacuation, and one had peri-IVC hematoma and femoral vein thrombosis that required repeated angioplasty and stenting; 93% of patients received long-term anticoagulation. Follow-up was 42± 36months. Four patients were lost to follow-up. Primary patency, primary assisted patency, and secondary patency at 36months were 78%, 87%, and 91%, respectively. Symptoms resolved in 83% of patients. On multivariable regression analysis, hypercoagulable state was the only predictor of reocclusion of the recanalized veins. Endovascular recanalization for nonmalignant symptomatic IVC and associated iliofemoral venous obstruction with balloon angioplasty and self-expanding stents is technically challenging; however, it is safe and durable. In our retrospective study, estimated patency rates at 36months were >85%, and clinical outcomes were excellent. Venous stenting should be attempted for chronic nonmalignant IVC and associated iliac or iliofemoral venous obstructions before open surgical reconstruction is contemplated.

Patency and Clinical Outcome After Stent Placement for Chronic Obstruction of the Inferior Vena Cava

The objective was to assess the technical success, patency, and clinical outcome after stent placement for chronic obstruction of the inferior vena cava (IVC). A retrospective analysis was carried out of patients with chronic IVC obstruction verified with computed tomography and/or magnetic resonance venography, accepted for stent placement at the Norwegian National Unit for Reconstructive Deep Venous Surgery from March 2010 to September 2015. Clinical status was categorized according to the CEAP classification and symptom severity was assessed using venous clinical severity score (VCSS). Stent patency was evaluated by colour duplex ultrasound. Large -diameter Wallstents were placed in the IVC and concurrent iliac and femoral obstructions via right internal jugular and femoral vein access. Sixteen patients presented with symptoms of chronic venous disease. Four patients had symptoms assumed to be related to a reduced cardiac preload. Twelve patients had IVC occlusion and eight had stenosis. Median follow-up was 25 months (range 3-70 months). Stent placement in the IVC was successful in 19 of 20 patients. Primary patency after 24 months was 67% and secondary patency 83%. Fifteen of 19 patients had open stents at final follow-up. Re-interventions were performed in four patients and included catheter directed thrombolysis in all and adjunctive stenting in three. Thirteen of 19 patients (68%) reported a sustained and significant clinical improvement. Mean VCSS improved from 8.5 (range 3-25) at baseline to 7 (range 2-23) at final follow-up (p=.007). There were no peri-procedural or long-term complications. The endovascular approach with stent placement for chronic IVC obstruction is a safe treatment option that should be offered to patients who otherwise have little opportunity for sustained clinical improvement.

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.

Endovascular management of chronic total occlusions of the inferior vena cava and iliac veins.

Percutaneous recanalization and stenting is currently the standard of care for symptomatic chronic total occlusions (CTOs) of the iliofemoral veins. CTO lesions involving the inferior vena cava (IVC) present a more complex patient subset. In this series we describe our single-center experience with endovascular recanalization of symptomatic occlusions of the IVC. Patients were evaluated with duplex ultrasound imaging, venous function tests, and venography before intervention. Occluded segments were recanalized, balloon dilated, and stented. The basic stent technique modified over time to accommodate the iliocaval junction, presence of IVC filters, and lesions extending to the renal veins and atrium. Between November 2000 and August 2015, 71 patients (41 men [58%]) underwent IVC endovascular recanalization procedures for symptomatic chronic IVC occlusions. Patients were an average age of 51 years (range, 23-77 years). Underlying contributing factors for venous occlusion included IVC filter occlusion in 38 (54%), caval ligation/clipping in 4(6%), and hypercoagulable disorder in 27 (38%). The technical success rate was 85% (n= 60). The proximal extent of the stents were infrarenal in 40 (67%), suprarenal in 11 (18%), or intrathoracic in 9 (15%). There was minimal perioperative morbidity (2 hematomas, 1 renal failure) and no postoperative mortality. Average follow-up was 48.0± 43.3 months (range, 6-172 months). Primary, primary assisted, and secondary patency rates at 60 months were 52%, 85%, and 93%, respectively. Significant improvement in pain and swelling was seen in 91% and 83%, respectively; and complete cumulative relief of pain and swelling was 66% and 41% respectively. Ulcers were present in 18 patients and healed completely without recurrence in 14 (78%) after recanalization. The Venous Clinical Severity Score was 8.4± 5.1 (range, 4-27) before the intervention and 3.9± 3.2 (range, 0-14) after the intervention (P< .001). Endovascular recanalization of chronic total IVC occlusions can be performed with minimal morbidity and mortality. When successful, symptoms can be substantially improved, with excellent patency.

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.

Acute Ilio-Femoral Thrombosis in a Patient with Chronic Infra-renal Inferior Vena Cava Occlusion Treated with Mechanical Thrombectomy Using a Rotational Catheter

Case Report: A 28-year-old man complained acute low-back pain three-day post-appendectomy. Computed tomography revealed thrombosis of both iliac veins and ascending lumbar vein in a patient with chronic occlusion of infra-renal inferior vein cava. Consequent lumbar and intraspinal epidural venous engorgements caused nerve root and thecal sac compression that simulated a spinal stenosis. Complete symptoms resolution was achieved after thrombectomy using a rotational catheter.

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.

Intraoperative Echocardiographic Diagnosis of Inferior Vena Cava Stenosis After Cardiopulmonary Bypass

THE INFERIOR VENA CAVA (IVC) is responsible for about two thirds of the total venous return to the right atrium (RA). Obstruction of the IVC can be due to chronic disease or an acute insult. The etiology of chronic IVC obstruction includes congenital abnormalities, indirect compression of the IVC (retroperitoneal tumors, hepatic tumors, giant left atrium), or intravascular tumor extension (metastatic renal tumors). Chronic obstruction of the IVC is associated with findings of hepatic congestion, ascites, lower extremity edema, and venous thrombosis. The slow progression of disease results in collateral venous return to the superior vena cava (SVC) via the azygos, intrathoracic, and vertebral veins. In contrast, acute stenosis of the IVC can result in hepatic and renal dysfunction, severe hemodynamic instability, and cardiovascular collapse if left untreated. Acute IVC obstruction is rare and has been reported as a complication of operative procedures, including bicaval heart transplantation, orthotopic liver transplantation, mitral valve replacement, and extrinsic compression from implantation of a Nuss bar for repair of pectum excavatum. The authors describe a case of acute IVC stenosis at the RA junction that was diagnosed by intraoperative transesophageal echocardiography after cardiopulmonary bypass (CPB). The intraoperative echocardiographic findings included a localized area of narrowing at the IVC-RA cannulation site, turbulent flow into the RA, underfilled cardiac chambers with hyperdynamic biventricular activity, and dilated hepatic veins. The echocardiographic findings were correlated with invasive hemodynamic measurements, and a therapeutic intervention with return to CPB was performed. The authors recommend the routine examination of the IVC at the IVC-RA junction with color-flow Doppler and spectral Doppler interrogation of flow after cardiac surgery cases, especially in the case of a bicaval venous cannulation technique.

Bland thrombus association with tumour thrombus in renal cell carcinoma: analysis of surgical significance and role of inferior vena caval interruption

What's known on the subject? and What does the study add? The surgical implications of renal cell carcinoma with coexisting bland and tumour thrombi of the inferior vena cava is not well described. In this study we review our experience managing these tumours. On multivariate analysis, we found that the presence of bland thrombus was associated with an increased need for surgical interruption of the inferior vena cava. • To study the role of interruption of the inferior vena cava (IVC) in patients with renal cell carcinoma (RCC) and associated bland and tumour thrombi. • We reviewed 129 consecutive patients with the preoperative diagnosis of RCC with tumour thrombus who underwent radical nephrectomy and tumour thrombectomy in one academic institution between May 1997 and February 2011. • Percentages of patients with levels I, II, III and IV tumour thrombus were 29%, 13%, 48% and 9%, respectively. • The perioperative mortality rate was 2.3%. There were 29 (22%) perioperative complications recorded. • In all, 19 patients underwent surgical interruption of the IVC by ligation or segmental resection, including one level II, 14 level III and four level IV thrombi. • A total of 15 patients (12%) had bland thrombus associated with the tumour thrombus; four of these underwent intraoperative IVC filter placement and eight underwent surgical IVC interruption. • Advanced level of tumour thrombus was the only significant factor predicting association of bland thrombus (odds ratio [OR]= 2.09, 95% confidence interval [CI]: 1.082-4.037, P= 0.028). • On multivariate analysis, level of thrombus (OR = 3.1, 95% CI: 1.30-7.74, P= 0.011) and association of bland thrombus (OR = 9.07, 95% CI: 2.42-34.01, P= 0.001) were significant factors for IVC interruption. • Surgical interruption of the IVC is a feasible option in selected patients with chronic IVC obstruction. Association of bland thrombus with tumour thrombus should alert the surgical team to the potential for a challenging surgery. • Precise preoperative imaging to assess the degree of venous obstruction and to help with differentiation between bland and tumour thrombus is key to achieving a surgical outcome with minimal morbidity.