Interruption Of Inferior Vena Cava Research Articles

Noninvasive diagnosis of interrupted inferior vena cava: Gated pulsed doppler application

Noninvasive diagnosis of interrupted inferior vena cava: Gated pulsed doppler application

Inferior Vena Cava Thrombectomy for Pulmonary Embolism

Significant pulmonary embolism during adequate anticoagulation is an indication of inferior vena cava interruption. If a nonadherent thrombus is detected in the inferior vena cava, an attempt should be made to remove the thrombus at the time of inferior vena cava interruption to prevent the migration and fragmentation of the thrombus to the pulmonary circulation.

Left isomerism and complete atrioventricular block: A report of six cases

Six children, aged 12 days to 13 years, with left isomerism and complete atrioventricular (A-V) block are presented. In all six patients the diagnosis of left isomerism was suggested by an interrupted inferior vena cava found during cardiac catheterization and angiocardiography;four patients had complex heart disease consisting of endocardial cushion defect, five had a common atrium, three had pulmonary stenosis, three had patent ductus arteriosus and two had dextrocardia. Further anatomic abnormalities included situs inversus of the viscera (four patients) as well as partial malrotation of the bowel. Of the six patients, four had congenital complete A-V block, whereas the remaining two had A-V conduction disturbances documented during early infancy that progressed to complete A-V block later in life. All six patients required pacemaker implantation and five of the six patients died. This report discusses the clinical presentation of complete A-V block and left isomerism and reviews the literature.

Antithrombin III as a Factor in Recurrent Thromboembolism

A 43-year-old man with recurrent pulmonary emboli associated with antithrombin III deficiency is presented. After laparotomy for penetrating abdominal trauma, thrombophlebitis and emboli were treated with heparin. Subsequent failure of therapy resulted in application of an inferior vena cava clip. Recurrent emboli from the site of the clip were managed by vena cava division and reconstruction. The primary problem was antithrombin III deficiency with levels less than 40% of normal. The first recorded case of ligation of the inferior vena cava (IVC) for pulmonary embolus was by Trendelenburg in 1911.12 Homans2 suggested prevention of pulmonary embolus with ligation of the IVC in 1944. Since then, treatment of deep vein thrombosis with or without pulmonary embolus has focused on anticoagulant therapy. Recent studies have demonstrated a lower morbidity and mortality with anticoagulation than with any surgical procedure.3 The primary indications for IVC interruption are contraindica tion to anticoagulation or failure of anticoagulation to prevent pulmonary embolus. Partial interruption of the IVC with extraluminal plication or clip, or intraluminal device, is the usual surgical approach. We present a case of recurrent pulmonary embolus managed by IVC ligation with difficulties in anticoagulation due to an antithrombin III defi ciency and subsequent clot propogation above an IVC clip. This case illus trates the management of thrombus above a vena cava interuption as well as underlining Virchow's lessons of hypercoagulability and stasis as predisposing factors of deep vein thrombosis.

Requirements for a method of transvenous inferior vena cava interruption.

Six requirements were defined that would characterize a safe and effective technique of transvenous inferior vena cava (IVC) interruption: (1) the instrument should be placed transjugularly under local anesthesia; (2) the instrument should have "built-in" capability for venography; (3) the technique should produce complete occlusion of the IVC; (4) the occluder must adapt to any variable in IVC diameter; (5) the intracaval device must have no sharp edges, pins, or points; and (6) the technique must permit simultaneous heparin therapy. These specifications were met by a catheter-delivered detachable balloon that could be inflated to any needed diameter. This technique was used in 96 patients, with a follow-up period to ten years. Time and experience confirm the validity of the six requirements for a safe and effective technique.

Thirty-year Experience with Surgical Interruption of the Inferior Vena Cava for Prevention of Pulmonary Embolism

Case records of 237 patients treated by inferior vena cava (IVC) ligation (154), suture plication (27) or clip application (56) were reviewed. Indications for surgery included failure of anticoagulation or femoral vein ligation to control embolism and threat of potentially massive, septic or paradoxical emboli. Overall hospital mortality was 15% and recent operative mortality was 2%. The incidence of early postoperative leg swelling was 36% and late venous sequellae occurred in 50% of the follow-up group of 140 cases followed an average of 44.3 months. Morbidity secondary to IVC interruption was decreased by use of the prosthetic lip, but clip application was still associated with early leg swelling in 21% and late mild swelling in 24%. The incidence of proven or suspected recurrent emboli was 7.6% with no significant variation by type of IVC procedure, and recurrent emboli were fatal in 2.5%. Refinement of indications, operative methods and perioperative care for IVC interruption procedures over the years has substantially improved the surgical approach to prevention of life-threatening pulmonary embolism.

Prophylactic interruption of the inferior vena cava: immediate and long-term hemodynamic effects.

Two hundred patients were evaluated retrospectively to determine the clinical effects of prophylactic inferior vena cava (IVC) interruption in association with aortic reconstruction. No pulmonary embolism occurred in the group with IVC interruption, but embolisms did occur in seven of 68 patients who had aortic reconstruction performed without IVC interruption. In two patients, the pulmonary embolism was fatal. Postoperative incidence of deep vein thrombosis was fatal. Postoperative incidence of deep vein thrombosis was 9% in both groups. Clinical and hemodynamic effects of prophylactic IVC interruption were studied in 20 additional patients. Venous hemodynamics (maximum venous outflow, inferior vena cava pressure, and ambulatory venous pressure) showed no change following interruption in 19/20. Sixteen patients from the original group of patients with prophylactic interruption were studied hemodyamically. No pulmonary embolism was clinically evident. One new case of deep vein thrombosis was seen. Again, venous hemodynamics showed no change as a result of IVC interruption. Prophylactic IVC interruption is a safe means of decreasing the incidence of pulmonary embolism without increasing venous-related morbidity.

Experience With the Hunter-Sessions Inferior Vena Cava Balloon Occluder

During a two-year period, 12 patients with indication for inferior vena cava interruption underwent vena cava occlusion with the transvenous Hunter-Sessions balloon. The device permitted simultaneous anticoagulation (when not contraindicated), was tolerated by sick patients, did not cause mortality or significant morbidity, and prevented pulmonary emboli.

The Cavaportal Shunt in Interruptions of the Suprarenal Inferior Vena Cava

Abrupt interruption of the suprarenal inferior vena cava can have dramatic consequences and can be difficult to repair successfully. In the case reported, an excellent result was obtained by a cavaportal anastomosis, with minimal consequences on renal and hepatic functions.

Prophylactic interruption of the inferior vena cava: A retrospective evaluation

One hundred sixty patients were retrospectively evaluated to determine the effect of prophylactic inferior vena caval interruption in association with aortic surgery. Sixty-three patients underwent aortic procedures without inferior vena caval interruption and ninety-seven patients underwent placement of an Adams-DeWeese clip as prophylaxis against pulmonary embolism. Pulmonary embolism occurred in 10 per cent of the group without the clip and in no patients in the group with the clip. The incidence of deep vein thrombosis was identical in both groups (10 per cent). The 6 per cent rate of early (within 6 months) postoperative leg edema in the group with the inferior vena caval clip was a significant problem in only one patient after twenty-four months. Prophylactic interruption of the inferior vena cava has been shown to be a safe method of decreasing the incidence of pulmonary embolism without increasing the incidence of venous-related complications.

The role of operative inferior vena caval interruption in the management of venous thromboembolism.

AbstractInferior vena caval interruption by direct operative techniques remains the mainstay of therapy for those patients with pulmonary embolism who cannot be treated effectively by anticoagulation, or who sustain recurrent embolic episodes despite adequate anticoagulation therapy. Complete ligation of the cava is associated with a somewhat higher operative mortality than plication, but appears indicated for those situations in which even a small subsequent embolus would be life‐threatening. Plication, which has more frequent indications, is generally performed by placement of an external clip, with an acceptable operative mortality and effective control of recurrent emboli. Longterm caval patency following plication approximates 70%, and should minimize late sequelae, which appear most closely related to the extent of preexisting venous thrombotic disease. Technical aspects of the performance of caval interruption procedures are critical in insuring success and minimizing late recurrences and complications. The direct operative approaches permit precise anatomic location of the caval interruption and simultaneous ligation of associated major venous collaterals, which is an effective, low‐risk approach to the life‐threatening pulmonary embolism problem.

Long-term follow-up of vena caval clips and umbrellas

Fifty-one consecutive cases of inferior vena caval interruption for documented pulmonary embolism are reported. Forty-four patients underwent transabdominal vena caval clipping using the multichanneled Adams-DeWeese clip. This was placed subjacent to the renal veins with interruption to the gonadal veins. In addition, seven critically ill patients were treated with the vena caval umbrella. Postoperative heparinization was initiated within 48 hours, followed by long-term oral anticoagulation. Meticulous attention was paid to the mechanics of edema prophylaxis. Two patients (4 per cent) died during the thirty day postoperative period. Only one patient developed edema directly attributable to clipping, whereas postinterruption stasis sequelae were common after umbrella insertion. Cavography at six months to eight years in thirty-two patients demonstrated 85 per cent patency in the clip group and 16 per cent patency in the umbrella group. It has been shown that the multichanneled 3 mm clip, when appropriately employed, provides effective prophylaxis against pulmonary embolism with minimal postinterruption statis sequelae.

Therapeutic Balloon Occlusion Of the Inferior Vena Cava

Thirty-five patients with venous thromboembolism and indication for inferior vena cava (IVC) interruption were treated by experimental balloon occlusion. Experience with this group resulted in the development of a method and equipment to allow transjugular obstruction of the IVC in the awake patient receiving anticoagulants. The study showed that the new method is atraumatic even when applied to sick patients, that it permits simultaneous treatment with anticoagulants and venous occlusion, and that long-term results (to more than four years) are excellent.

The Sequelæ of Inferior Vena Caval Interruption

Recurrent pulmonary emboli occurred in 26 of 85 patients (31%) after inferior vena caval interruption to prevent pulmonary emboli. Sequelae following this procedure included early problems associated with bleeding, venous thrombosis, the sequestration syndrome, and death. Late sequelae were recurrent episodes of venous thrombosis, the post-phlebitic syndrome and recurrent emboli. Inferior vena caval interruption is associated with significant continuing disability, and it fails to solve the problem it was designed to prevent.

Visualization and measurement of the main bronchi by tomography as an objective indicator of thoracic situs in congenital heart disease.

When investigating complex congenital heart disease, determination of atrial situs is essential. Pathological studies have demonstrated that the best predictor of atrial situs is thoracic situs. To assess thoracic situs, bronchial tomography was performed in 92 patients with congenital heart disease. Sixty-four of these, without abnormalities of situs or cardiac position, formed 'normal' controls. The lengths of the left and right main bronchi were measured. When these were related to age, and the results analyzed statistically, linear discriminant equations resulted giving a chance of only 0.09% of misclassifying a bronchus of unknown morphology. The lowest ratio between bronchial lengths (BLR) in any individual was 1.71:1. These results were then used to assess thoracic situs in 17 patients with abnormal situs or CARDIAC POSITION. In 7 (2 with situs inversus), abdominal and thoracic situs agreed. Of 6 patients with bilateral left lung, 3 had an interrupted inferior vena cava. Of 4 patients with presumptive asplenia, 2 had bilateral right lung, but two had thoracic lateralization, one solitus and one inversus. The highest BLR in thoracic isomerism was 1.4:1. This emphasizes the complex interrelation of splenic status, thoracic, and abdominal situs, but demonstrates the value of bronchial measurement particularly in apparent situs indeterminatus.

Inferior vena caval ligation. With special reference to spontaneous resolution of pulmonary emboli and to postligation venous collateral circulation.

During the years 1968–1971, 95 cases of pulmonary embolism were verified at the Department of Surgery, University of Turku; 64% of the patients died. Interruption of the inferior vena cava (IVC) was performed on 24 patients. In 7 cases, IVC ligation was carried out in connection with pulmonary embolectomy. In 10 out of 24 cases the embolism was massive. All these patients were candidates for pulmonary embolectomy, but emergency embolectomy was necessary for 6 patients only and embolectomy for recurrent massive embolism in 1 case.Three patients died postoperatively after embolectomy and one (1/17) after IVC ligation alone. One patient developed phlegmasia coerulea dolens 10 days after IVC ligation. The case was successfully treated by balloon catheter thrombectomy.None of the patients had signs or symptoms of recurrent embolism during the relatively short follow-up period. Sixteen patients underwent follow-up examination on average 11/2 years after IVC interruption. Seven had no stasis of the lower limbs, 7 slight, one moderate and one incapacitating oedema. Lung scanning showed very marked improvement in lung perfusion in 13 out of 15 cases. Successful cavography was performed on 13 patients. The collateral venous drainage passed mainly through the paravertebral plexus and ovarian veins. Especially the ovarian veins were often greatly dilated. The role of spontaneous fibrinolysis and development of venous collateral circulation after IVC ligation was discussed.In our opinion, the complications in this series were minor ones and the favourable experience supports the performance of IVC interruption for prevention of recurrent pulmonary embolism.

Systemic venous anomalies and partial heterotaxia with normal heart.

A case of infrahepatic interruption of inferior vena cava with hemiazygos continuation into a persistent left superior vena cava and partial visceral heterotaxia in association with an otherwise normal heart is presented. The peculiarity of this rare lesion without cardiac malformation and the possible explanation for it are discussed. The clinical significance of systemic venous anomalies is discussed.

Reversible interruption of inferior vena cava by means of a balloon catheter: Preliminary report

Reversible interruption of inferior vena cava by means of a balloon catheter: Preliminary report

Successful cardiac catheterization in an infant with anomalous drainage of the inferior vena cava.

Summary Cardiac catheterization from the femoral vein in a patient with inferior vena caval interruption and hemiazygos continuation is described. The success of this procedure is in part attributed to the use of a floppy guide wire.

Clinically Deceptive Massive Pulmonary Embolism

The difficulty of determining the severity of thromboembolic pulmonary vascular obstruction by the usual clinical methods is illustrated by the reporting of four patients that had suffered massive pulmonary embolism yet presented benign clinical manifestations. Since the most effective therapeutic management may depend upon a reliable assessment of the degree of impairment of pulmonary blood flow, the radioisotope photoscan and the pulmonary arteriogram proved of critical value in guiding therapy. In patients of this type, one of the surgical procedures of inferior vena cava interruption in addition to anticoagulant therapy will serve to prevent further clinical deterioration and serve as an alternative to pulmonary embolectomy either as an elective procedure or subsequently as an emergency procedure.