Inferior Vena Cavagram Research Articles

Ruptured traumatic ovarian artery pseudoaneurysm in a pregnant patient.

A woman at 36 weeks' gestation was involved in a motor vehicle crash. She required emergency delivery of a healthy infant by cesarean section. She received anticoagulation, despite a splenic injury, for a possible inferior vena cava clot. She re-presented with new retroperitoneal hemorrhage around the juxtarenal aorta. A computed tomography scan suggested a vague contrast blush anterior to the aorta. Arteriography disclosed a right ovarian artery pseudoaneurysm, which was treated with microcoil embolization. The patient has subsequently recovered fully. In major trauma in pregnant patients, ovarian artery pathology needs to be considered in the differential diagnosis of post-traumatic hemorrhage.

Safety of Carbon Dioxide Digital Subtraction Angiography

Reports of fatality following carbon dioxide digital subtraction angiography (CO2-DSA) have raised concerns regarding its safety. This study reviews the safety of CO2-DSA. Single-institution retrospective review. Tertiary care teaching hospital in Los Angeles, California. A total of 951 patients who underwent 1007 CO2-DSA procedures during a 21-year period. Preprocedure and postprocedure creatinine values and periprocedural morbidity and mortality. A total of 632 arterial CO2-DSA were performed; 527 were aortograms with or without extremity runoff; 100, extremity alone; and 5, pulmonary. Venous CO2-DSA included 187 inferior vena cavagrams, 182 hepatic or visceral, 5 extremity venograms, and 1 superior vena cavagram. Associated endovascular procedures were performed in 499 cases; 162 were arterial interventions including 62 endovascular aneurysm repairs, 53 visceral or renal percutaneous angioplasty with/without stent, 41 extremity percutaneous angioplasty with or without a stent, and 4 cases of thrombolysis or embolization; 176 caval filters, 98 transjugular intrahepatic portosystemic shunts, 54 transjugular liver biopsies, and 9 other venous interventions. The mean preprocedure creatinine level was 2.1 mg/dL; postprocedure, 2.1 mg/dL (P = .56). There were a total of 61 (6.1%) procedural complications including 4 (0.4%) mortalities. Two were procedure-related complications: 1, suppurative pancreatitis following aortogram; and 2, hepatic bleed following failed transjugular intrahepatic portosystemic shunts. Two were attributable to patient disease; 1, metastatic adenocarcinoma; and 2, refractory, end-stage cardiomyopathy. Carbon dioxide digital subtraction angiography is a versatile technique that can be safely used for diagnostic and therapeutic endovascular procedures. Morbidity and mortality are acceptable with preservation of renal function. Thus, CO2-DSA is a safe alternative to iodinated contrast.

Budd-Chiari syndrome with fresh inferior vena cava thrombosis: agitation thrombolysis and balloon dilation

To evaluate retrospectively our initial clinical experience of agitation thrombolysis and balloon dilation in the treatment of Budd-Chiari syndrome (BCS) in patients with fresh inferior vena cava (IVC) thrombosis. Between August 2004 and March 2009, a total of 12 BCS patients with fresh IVC thrombosis were treated with agitation thrombolysis and balloon dilation. Color Doppler ultrasound results, as well as mortality, morbidity, and the clinical outcomes were evaluated immediately after the treatment and at one week and 1, 3, 6, 12 months after the procedure and then annually thereafter. Agitation thrombolysis and balloon dilation were technically successful in all patients, without immediate procedural complications. The inferior vena cavagrams after the procedure demonstrated complete resolution of the IVC thrombi without pulmonary embolism and full patency of the obstructed IVC. Thirty-day mortality was nil. Clinical success was observed in all patients respectively one month after the procedure. As of February 2010, the mean (± SD) follow-up period for the color Doppler ultrasound procedure was 21.7 ± 8.9 months (range, 12 - 32 months). All patients showed complete patency of the treated IVC without thrombosis, restenosis, or reobstruction, and all patients are alive with resolution of the symptoms at the time of this report. Our preliminary results suggest that agitation thrombolysis and balloon dilation may be a feasible approach for patients with BCS and fresh IVC thrombosis. However, larger studies are warranted to confirm these results.

Single Institution Experience with Inferior Vena Cava Filters.

Inferior vena cava (IVC) filters are used in patients (pts.) with Deep Venous Thrombosis (DVT) to prevent pulmonary embolism (PE) when anticoagulation cannot be administered. The purpose of this study was to analyze the use and outcomes of IVC filters in a community hospital. We reviewed the medical records of all pts. who had IVC filters implanted at William W. Backus Hospital between May 2003 and May 2005. Follow up information was obtained up to August 2005 by mailings from the attending physicians. 125 IVC filters were implanted in 121 pts., ages 18 to 93, with 61 males and 60 females. The indications for implantation were contraindication as follows: to anticoagulation in 72 pts. (58%), up coming surgical procedures in 33 pts. (26%), and severity of clot burden in 20 pts. (16%). 123 (98%) filters were deployed into an infrarenal position and 2 into a suprarenal position due to extensive clot in the IVC. Of the 105 filters that were not retrieved 60 were Gunther Tulip (GT) retrievable IVC filters, 42 were Cordis Trapease (CT) permanent IVC filters, 2 were stainless steel Greenfield IVC filters, and 1 was a Cordis Optease (CO) IVC filter. Of the 20 retrieved filters 19 were GT retrievable IVC filters and 1 was a CO IVC filter. Of the 125 filters, 74 were intended to be permanent filters (59%) and 51 (41%) were inserted with intention of retrieval. 31/51 (60%) were eventually not retrieved because of various reasons: need for additional surgery (12), poor pulmonary reserve (5), high-risk of bleeding (5), severity of clot burden (4), short life expectancy (4), and extremely high risk of recurrent DVT (1). Short-term and long-term anticoagulation was used in conjunction with the IVC filters in 21 and 81 pts. respectively. 38 (31%) of the 121 pts. experienced recurrent venous thromboembolism (VTE), 37 developed symptomatic DVT and 1 had a symptomatic PE. 3/20 (15%) of the pts. who had their filters retrieved developed recurrent DVT (18, 22, and 76 days after filter retrieval) compared with 34/105 (32%) pts. who had permanent filters. The only objectively documented symptomatic PE occurred in a pt. with a permanent filter. This pt. had a recurrent PE 7 months post GT IVC filter insertion diagnosed by chest CT scan with PE protocol. Complications were as follows: 1 pt. had transient hypertension immediately after IVC insertion and 1 pt. developed a transient low-grade fever after retrieval. 1 pt. developed retroperitoneal hematoma upon retrieval 75 days after implantation as documented by an IVC Gram and this pt. recovered without need for any intervention and there were no adverse clinical consequences. The implantation periods ranged from 2 to 104 days in the 20 retrieved filters with mean/median of 20/9 days. 4 of the 20 retrieved filters (20%) contained trapped emboli and none of these pts. subsequently developed PE. The GT retrievable IVC filter is now the filter of choice at our institution and can be implanted permanently or with retrieval in mind. Conclusion: Retrievable filters were removed up to 104 days post insertion in this series of pts. and the incidence of complications was negligible. Retrievable IVC filters may be substituted for permanent IVC filters to preserve the option of retrieval, and retrieval of filters beyond 3 months post implantation is feasible and should be studied further.

Bedside carbon dioxide cavagrams for inferior vena cava filters: Preliminary results

Objective: The objective of this study was to evaluate the feasibility of using carbon dioxide (CO2) as a contrast agent in performing bedside inferior vena cavagrams before the insertion of vena cava filters. There was a consecutive series of patients undergoing bedside preinsertion cavagrams with inferior vena cava filter insertion. The setting was an 825-bed tertiary care hospital. The subjects were trauma patients undergoing inferior vena cava filter insertion. Methods: The intervention used was vena cavagrams with CO2 as the contrast agent. The main outcomes we measured were image quality, adverse reactions, cardiorespiratory changes, and renal failure. Results: Ten patients underwent CO2 cavography. All cavagrams were successful, demonstrating opacification of the inferior vena cava with identification of the renal veins and iliac bifurcation. There were no adverse reactions of renal failure. Conclusions: Carbon dioxide–contrasted vena cavagrams can be safely performed at the bedside, and they give good opacification of the inferior vena cava. (J Vasc Surg 2000;32:144-7.)

Cardiac Lymphoma Associated with Superior Vena Caval Syndrome and Cardiac Tamponade: Case History

A sixty-three-year-old patient with malignant histiocytic lymphoma of the heart presented with both superior vena cava syndrome and cardiac tamponade. A two-dimensional echocardiogram showed a large tumor mass in the right atrium and pericardial effusion with right ventricular compression. Superior and inferior vena cavagrams disclosed a lobulated tumor located in the right atrium that extended into and obstructed the superior vena cava. After the pericardial effusion was drained and the diagnosis was established, the patient was irradiated and given chemotherapy with resolution of the tamponade and superior vena cava obstruction.

Venous prosthetic valves. The first step toward an investigation in the canine model.

Bioprosthetic valves were surgically placed in the inferior vena cava of four canines as a first step in the investigation of prosthetic valves for the treatment of nonobstructive chronic venous stasis. Valve patency and thrombus formation involving either the valve or the IVC was evaluated by serial follow-up inferior vena cavagrams in each canine. No thrombus occurred in any of the canines as observed at six months in two canines and eight months in two canines. The ultimate goal of this and other ongoing investigations is to develop a valvular prosthesis which may be placed into the venous system for the management of nonobstructive chronic venous stasis.

Treatment of Intra-atrial Cardiac Tumors

Intracavitary tumors of the atria are rare, generally diagnosed as myxoma, and considered benign. Of 20 such tumors presenting for surgery between Jan 1, 1967, and Jan 1, 1982, sixteen were myxomas: 13 in the left and three in the right atrium. Four additional patients operated on for suspected right atrial myxoma had other lesions: two thrombus (simulating myxoma), one leiomyoma originating in the right iliac vein, and one clear cell adenocarcinoma from the left kidney. One initially benign myxoma underwent malignant transformation. Eighteen hospital survivors were followed up from one month to 134 months (mean, 61 months). All are New York Heart Association class I. We recommend inferior vena cavagram for right-sided lesions. For patients older than 40 years, coronary angiography and appropriate bypass grafting should be performed. Surgery must include resection of all abnormal tissue. Follow-up with echocardiography should continue for five years.

Monoclonal antibodies in renal transplantation: Preliminary results

A 51-yearo1d man was referred to the Massachusetts General Hospital for evaluation of persistent proteinuria and azotemia. Five years ago he underwent an emergency right femoral artery embolectomy for symptomatic impairment ofthe circulation in his legs. Abnormal renal function first was discovered at that time. After an uneventful postoperative course, the patient was admitted to the Hospital of the University of Pennsylvania for further investigation. Mild hypertension and bilateral cataracts were noted. Laboratory findings disclosed a urine protein excretion of 2.2 g/day, a BUN of 40 nig/dI, and a serum creatinine concentration of 2.8 mg/dl. The serum cholesterol and triglyceride concentrations were 235 mg/dl. The serum calcium, phosphorus, and uric acid levels during allopurinol therapy for an episode of podagra were normal. An intravenous pyelogram revealed scarred kidneys, and retrograde pyelography suggested the possibility of papillary necrosis. Rena! arteriography, normal except for moderate attenualion of the smallest cortical arterial branches bilaterally, suggested moderate nephrosclerosis. Aortoiliac atherosclerotic disease was present. The patient had no history of diabetes niellitus, sickle cell disease, collagen vascular disease, or analgesic abuse. In addition, there was no family history of renal disease. The exact nature of his progressive renal failure remained unclear, and attempts to manage it by diet and pharmacologic control of the blood pressure were not wholly successful. The next 3 years witnessed progressive elevations of the serum creatinine and BUN to 6.4 mg/dI and 71 mg/dl, respectively. The patient complied poorly with various programs of antihypertensive medication. Two years ago, results of urinalysis revealed 4+ proteinuria and occasional hyaline and granular casts with 0 to rare red and white blood cells. The urinary protein excretion was 8.9 g/day, and the creatinine clearance was 24 L/day. Further studies included a negative LE prep, a negative ANA, and a negative test for Bence-Jones protein in the urine. An inferior vena cavagram and bilateral renal venograms showed no evidence of renal vein thrombosis. Renal ultrasonography demonstrated small kidneys, which were 8 cm in length. This finding, coupled with a prolonged bleeding time, precluded renal biopsy. The patient's medications included clonidine , chlorothiazide, clofibrate, allopurinol, and potassium chloride. One year ago, a left radial artery-cephalic vein fistula was constructed in anticipation of hemodialysis. Thrice-weekly hemodialysis was instituted 10 months ago because of progressive symptoms of uremia including incipient encephalopathy. Five months after hemodialysis was begun, the patient received a cadaver renal allograft in the right iliac fossa. None of the detectable HLA specificities of the donor matched those of the patient. Immunosuppressive therapy consisted of azathioprine and prednisone. On the 12th postoperative day, the patient developed left-sided sciatica and a temperature of 99° F. The serum creatinine climbed from a nadir of I .9 mg/dl to its zenith of 2.4 mg/dl over the next 3 days. A needle biopsy of the allograft performed on the 16th postoperative day demonstrated a dense interstitial infiltrate composed of lymphocytes and plasma cells that was consistent with an acute cellular allograft rejection. A 10-day course of treatment with a monoclonal antibody directed against all peripheral blood T cells (OKT-3), given intravenously at 2 mg/day, was started that day; the patient continued taking azathioprine and prednisone without changes in dosage. The patient developed a temperature of 101.6° F and shaking chills about one hour after receiving the initial dose of OKT-3 antibody; no other signs of toxicity were apparent and subsequent antibody injections were well tolerated. The BUN and serum creatinine levels peaked at 55 mg/dl and 4.8 mg/dl, respectively, on the third day of OKT-3 immunotherapy and fell to 32 mg/dl and 2.1 mg/dl, respectively, on the 10th and final day oftherapy. Another renal biopsy performed 2 days later showed a reduced cellular infiltrate. Therapy with azathioprine and prednisone was continued (see Fig. 1). Three months following transplantation. the patient continued to receive azathioprine and prednisone, the dose of both being gradually reduced; neither symptoms nor signs of further allograft dysfunction were apparent. The serum creatinine concentration declined slowly to 1.6 ing/dI.

Calcific thrombi of the inferior vena cava in infants and children

Calcified caval thrombus should be considered in any infant or child where calcifications are noted in the high right retroperitoneal area on plain x-rays of the abdomen. Although typically bullet-shaped in configuration, the calcium distribution in the neonate may be atypical or incompletely developed, suggesting neuroblastoma. Definitive diagnosis can be made by inferior vena cavagram. As no deaths or complications have been attributed to the lesion in the cases thus far reported, no specific treatment is recommended.

Wilmsʼ Tumor

Three cases of Wilms' tumor with inferior vena cava involvement are presented. All three cases were shown to have nonvisualization of the inferior vena cava on the initial intravenous pyelogram obtained by internal saphenous vein injection. The first case ended fatally, due primarily to delay in diagnosing extension of the tumor into the right atrium. There was no cardiac involvement in the other two cases, both of which were managed successfully. A right heart angiogram demonstrated intraatrial tumor in the first case and helped to identify the presence and extent of caval involvment in the other two. It is recommended that right heart angiography be performed in those cases of Wilms' tumor where the inferior vena cavagram shows non-visualization of the cava or suggests the presences of intraluminal tumor. The immediate availability of two separate surgical teams in the management of such cases is suggested.

On the Incidence of Renal Vein Thrombosis in the Nephrotic Syndrome

Forty-eight patients with nephrotic syndrome were evaluated prospectively; the studies included inferior venacavagrams and ventilation perfusion lung scans. Eleven patients were found to have renal vein thrombosis (RVT). Eight of 21 patients with membranous glomerulonephritis (MGN) or membranoproliferative glomerulonephritis (MPGN) has RVT (38%). Clinical, laboratory, and pathological findings were not different among those patients with MGN and MPGN whether RVT was present or not. Patients with diabetic nephropathy or lupus nephritis did not have RVT. There was a high incidence of other thromboembolic phenomena as well as asymptomatic perfusion defects demonstrated by the lung scan, especially in patients with MGN or MPGN. These data suggest the disease process underlying the nephrotic syndrome may play a paramount role in the genesis of RVT or thromboembolic phenomena.

Frequency of Inferior Vena Caval Abnormalcy due to a Juxtaposed Pathology

Radionuclide inferior vena cavagrams were done in 135 patients who had hepatomegaly, splenomegaly or a mass in the vicinity of the inferior vena cava (I.V.C.). 2-5mCi 66mTc phytate, 99mTc S colloid, 99mTc O4-, 99mTc-LIDA, 99mTc pyridoxyledene glutamate or 113mIn colloid were injected directly and rapidly into either a malleolar or a femoral vein while the patient lay supine under the 13.5'' detector head of a scinticamera. Rapid sequential scintiphotos were manually taken at approximately 1 sec. interval for 20-30 sec. Thus iliac vein, I.V.C., cardiopulmonary zone in infants, aorta and the arterial phase were visualized. 48% of these subjects had an abnormal I.V.C. and the depictions were interestingly varied, indicating that different patients responded in a different manner even to grossly similar pathologies. It became evident that this soft walled vessel could be compressed by both fluids and neoplastic tissue (Fig. 1, 2); the long I.V.C. channel could also be segmentally pushed away by a mass in its vicinity. (Fig. 2, 3, 4). An abnormal arterial flush usually differentiated between benign (Fig. 2) and malignant (Fig. 3) lesions, even when the mass was extra-hepatic (Fig. 4) and retiroperitoneal (Fig. 5). Such a systematic study of I.V.C. had not been possible earlier since the classical x-ray contrast inferior vena cavagram necessitates venous dissection, passage of a catheter, and the injection of large volume of fluid under an unphysiologically high pressure. The simplified radionuclide technique, however, permitted the study of neonates and critically ill subjects with massive ascites, while retaining a satisfactory reproducability.

Anterior displacement of the inferior vena cava by hepatic masses.

Two cases are reported in which hepatomas produced anterior displacement of the inferior vena cava, and because of this displacement were originally considered to represent retroperitoneal masses. The hepatoma in one case involved the caudate lobe and in the other the right lobe of the liver, with neither case having evidence of retroperitoneal disease. No previous inferior vena cavagram has been published which showed anterior displacement of the vena cava by a hepatic mass. Hepatic masses must be considered in the differential diagnosis when the upper portion of the inferior vena cava is displaced anteriorly. The anatomic factors which allow intrahe patic masses to displace the vena cava anteriorly are discussed.

Wilms tumor in right atrium.

A 2-year-old child had an abdominal mass, a systolic murmur, and electrocardiographic evidence of right atrial overload. An intravenous pyelogram and an inferior vena cavagram demonstrated a Wilms tumor of the right kidney with vena caval obstruction. At operation a caval thrombus could not be dislodged from the abdomen and required a right atriotomy with cardiopulmonary bypass to remove the lesion. This lesion should be suspected in children with Wilms tumor, vena caval obstruction, and cardiac murmurs.

Chylous ascites and the nephrotic syndrome Report of a case, associated with renal vein thrombosis

A patient with insidious onset of the nephrotic syndrome is described. The intravenous pyelogram and inferior venacavagram were normal, but at postmortem examination bilateral renal vein thrombosis was found. The presence of chylous ascites in this patient stimulated a review of patients with the nephrotic syndrome. It was apparent from this study that chylous ascitic fluid is present in the majority of patients with the nephrotic syndrome, irrespective of the underlying cause of the renal disorder. Chylomicrons were demonstrated on lipoprotein electrophoresis of the ascitic fluid in the case reported, suggesting leakage from abdominal lymphatics of lipid absorbed from the gastrointestinal tract. Lymphangiography and postmortem examination, however, revealed no evidence of lymphatic obstruction. The pathogenesis of chylous ascites in patients with the nephrotic syndrome remains unknown.

Inferior vena cavagrams.

Over half of the tumors of the retroperitoneal space, discounting primary organ neoplasms, such as those of the kidneys and pancreas, are due to in volvement of the lymph nodes (2) . The tumors that involve the para-aortic nodes are the lymphomas and metastatic carcinomas, the latter predominantly from a primary uterine or testicular source. Disease of these nodes is of prognostic and therapeutic significance. The retroperitoneal nodes lie along the main vascular trunks. Because of their distance from the rinary and intestinal tracts, these nodes must attain a considerable size before deforming the pacified ureter or stomach and intestine. Aortograms seldom reveal changes from expanding retroperitoneal masses, while the opacified inferior vena cava commonly shows defects produced by adjacent tumors (Fig . 7). The pressure within the aorta makes this vascular structure impervious to change from an extrinsic mass. The inferior vena cava, being thin-walled and of low in traluminal pressure, is easily distorted by firm, enlarged, tumorous masses. The results of inferior vena cavagrams were compared with gastrointestinal series and intravenous pyelograms and found to be more accurate not only in detecting lesions but al so in determining their extent (5). Technic Both femoral veins are catheterized percutaneously by the Seldinger method (6). The catheters are placed in the common iliac veins immediately caudad to their junction, and 30 c.c, of 35 per cent contrast medium is injected simultaneously through each catheter. The bilateral injection gives better filling than a unilateral injection. Six exposures are made, one every three-quarters of a second, with a film changer, during which time the patient is directed to suspend breathing in expiration and not to perform a Valsalva maneuver. The examination is carried out in the supine and the right posterior oblique or lateral positions. Upon completion of this examination, pyelograms are obtained; these are of superior quality because of the large amount of opaque medium used. This technic is safe and simple. We have utilized it in 150 examinations for retroperitoneal node enlargement, and no significant complications have occurred. Helander and Lindbom (5) have performed this procedure on 315 patients and noted its safety. Normal Anatomy The inferior vana cava is formed by the junction of the two common iliac veins opposite the fifth lumbar vertebra. As it ascends, it lies slightly to the right and parallel to the lumbar spine. It receives as tributaries: (a) the lumbar veins which anastomose with the azygos veins ; (b) the right spermatic or ovarian vein; (c) the renal veins; (d) the suprarenal veins; (e) the inferior phrenic veins; (f) the epatic veins. It is usually straight, although in older patients it may curve slightly to the right.