Inferior Vena Cava Thrombosis Research Articles

HALF DOSE THROMBOLYSIS IN INTERMEDIATE – HIGH RISK PULMONARY EMBOLISM WITH TRICUSPID VALVE MOBILE MASS: A BAIL OUT STRATEGY

Abstract A 82–year–old previously healthy male was referred to the emergency department complaining sudden onset dyspnea and witnessed syncope complicated by head trauma. Recurrent dizziness occurred previously. No history or drug consumption noted. On admission: heart rate 90 beats/min, blood pressure 110/60 mmHg, respiratory rate 25 breaths/min, oxygen saturation 87% in room air, normal body temperature. No lower extremities tenderness or swelling reported. Consistent with peripheral blood oxygen saturation levels, arterial blood gas analysis showed hypoxemia and respiratory alkalosis. Laboratory exams were significant for thrombocytopenia (89.000 cells/L), elevated cardiac troponin T levels (222 ng/L) and natriuretic peptide (NT pro–BNP 3944 pg/mL). Head CT excluded acute cerebral hemorrhage. At the electrocardiogram, signs of RV strain were present (biphasic T–waves in V1–V3 leads, S1–Q3–T3). Transthoracic echocardiography (TTE) showed dilated RV with hypokinetic free wall, “D–shaped” LV, “60/60” sign and a mobile filiform mass crossing the tricuspid valve plan in the right atrium (fig. 1). The patient did not present structural valvular abnormalities or endocarditis–related risk factors. CT pulmonary angiography detected a “saddle” PE and extensive thrombosis in inferior vena cava. After unfractioned heparin (UFH) bolus, the patient was transferred to our intensive care unit and balancing risks and benefits the chosen treatment option consisted in half dose systemic thrombolysis (50 mg rtPA in 60’’; 10 mg as loading dose in 2’). Because of potential harmful effects in thrombocytopenia and recent head trauma, UFH was temporarily withheld and started again after 1 hour. The day after, a beside TTE showed complete tricuspid thrombus resolution, a significant decrease in RV/LV ratio and systolic pulmonary artery pressure (fig. 2). Apart from small hematomas, no bleedings were reported. The patient was shifted to the ward on the next day and following course was uneventful. On day 4 a direct oral anticoagulant (Dabigatran 110 mg) was started. Abdominal and inferior limb–deep–venous ultrasound were both negative for pathological reports. A total body CT was scheduled to exclude silent malignancies at discharge. Take home message: in intermediate–high risk PE, half dose systemic fibrinolysis strategy is controversial since its potential benefit is counterbalanced by concerns about major bleedings, but increasing data suggest its efficacy with low risk profile.

Clinical characteristics of lower extremity deep vein thrombosis in young vs. middle-aged adults: a single-center retrospective study.

The incidence of deep vein thrombosis (DVT) in the lower extremities is increasing in the younger population. However, there are fewer reported comparisons in the literature for lower extremity DVT. Patients aged <40 years admitted with lower-extremity DVT between January 2018 and December 2023 were retrospectively analyzed and followed up for 1 year. A total of 61 patients were included in the study and divided into two groups: 33 patients over 30 years of age (middle-aged group) and 28 patients under 30 years of age (young group). A significant gender difference was observed, with a higher proportion of males in the young group compared to the middle-aged group (P < 0.001). Five patients in the young group were treated with anticoagulation alone, whereas all patients in the middle-aged group underwent endovascular therapy. A higher prevalence of inferior vena cava thrombosis in the young group compared to the middle-aged group (60.71% vs. 33.3%, P = 0.032). The proportion of iliac vein stenosis was significantly higher in the middle-aged groups than in the young group (P = 0.002). There was no statistically significant difference in venous function scores (Villalta and rVCSS) between the two groups during both the preoperative period and the postoperative follow-up (P > 0.05). The incidence of lower-extremity DVT post-thrombotic syndrome and thrombus recurrence was higher in the young group than in the middle-aged group at 1 year postoperatively (PTS: 78.57% vs. 33.3%, P < 0.001, and thrombus recurrence: 28.57% vs. 9.09%, P < 0.05). Univariate and multivariate analyses revealed that inferior vena cava thrombosis was an independent risk factor for severe DVT post-thrombotic syndrome and recurrent DVT (P < 0.05), whereas gender was an independent risk factor for recurrent DVT (P < 0.05). This study suggests differences in the clinical characteristics and prognosis of lower-extremity DVT.

Experimental multiparametric magnetic resonance imaging characterization of iliocaval venous thrombosis pathological changes

ObjectiveIliocaval thrombotic obstruction is a challenging condition, especially because thrombus age and corresponding pathological remodeling at presentation are unknown, which directly impacts management. Our aim was to assess the ability of magnetic resonance imaging (MRI) in determining age thresholds of experimentally created inferior vena cava (IVC) thrombosis in pigs. MethodsWe used a previously described swine model of IVC thrombosis. The animals underwent MRI at baseline, immediately after thrombosis creation, and after a follow-up period extending from 2 to 28 days. Thirteen pigs were divided into three groups according to disease chronicity: acute group (AG; n = 5), subacute group (SAG; n = 4), and chronic group (CG; n = 4), with a mean thrombosis age of 6.4 ± 2.5 days, 15.7 ± 2.8 days, and 28 ± 5.7 days, respectively. A T1-weighted volumetric interpolated breath-hold examination sequence was used to anatomically delineate IVC thrombus as a region of interest. Three other MRI sequences were used to assess the thrombus signal. ResultsThe Kruskal-Wallis test showed a statistically significant difference in T1 relaxation times after contrast injection (P = .026) between the three groups of chronicity. The AG (360.2 ± 102.5 ms) was significantly different from the CG (336.7 ± 55.2 ms; P = .003), and the SAG (354.1 ± 89.7 ms) was significantly different from the AG (P = .027). There was a statistically significant difference in native T2 relaxation times (P = .038) between the three groups. The AG (160 ± 86.7 ms) was significantly different from the SAG (142.3 ± 55.4 ms; P = .027), and the SAG was significantly different from the CG (178.4 ± 11.7 ms; P = .004). ConclusionsThis study highlighted MRI characteristics in a swine model that might have the potential to significantly differentiate subacute and chronic stages from an acute stage of deep vein thrombosis in humans. Further clinical studies in humans are warranted. Clinical RelevanceIn addition to providing a better understanding of venous thrombosis remodeling over time, magnetic resonance imaging has the potential to be a tool that could allow us to characterize the composition of venous thrombus over an interval, allowing for a refined analysis of the local evolution of venous thrombosis. We propose a noninvasive and innovative method to characterize different thresholds of chronicity with magnetic resonance imaging features of central deep vein thrombosis of the inferior vena cava experimentally obtained using a totally endovascular in vivo swine model, mimicking human pathophysiology. Being able to determine these features noninvasively is critical for vascular specialists when it comes to choosing between fibrinolytic therapy, percutaneous thrombectomy, or surgical management.

Point-of-care ultrasonography role in detecting inferior vena cava thrombosis in a patient with low back pain: a case report

A 73-year-old woman arrived at the ER claiming to be experiencing low back pain. To investigate the source of her pain, she was admitted to the Internal Medicine department. After a heterogeneous abdominal mass in the right upper quadrant was discovered by abdominal point-of-care ultrasonography (POCUS), it was confirmed by an abdominal CT scan, which also identified a metastatic lytic bone lesion in the L4. This finding is consistent with a malignant tumor of the right adrenal gland. POCUS was repeated right after the occurrence of dyspnea, and a 40x6 mm floating thrombus in the inferior vena cava was detected. A conservative approach with anticoagulants was chosen, with improvement of the clinical conditions. The diagnosis of adrenal carcinoma was ultimately made possible by the mass biopsy. POCUS is a safe, low-cost method that provides prompt results at the patient's bedside. We support the implementation of POCUS in all clinical departments, as it provides significant contributions to the assessment of prognosis and diagnosis.

Budd-Chiari syndrome following abdominal trauma

We report a case of Budd-Chiari syndrome (BCS) in a 44-year-old man with inferior vena cava (IVC) thrombosis and nephrotic syndrome. This case was complicated by right atrial clot and pulmonary emboli. Endothelial injury of the IVC was the likely mechanism, following a kick from a donkey. Abdominal ultrasonography revealed a large thrombosis located in a segment of IVC near its orifice in the right atrium. Transthoracic echocardiography (TTE) revealed IVC thrombosis that extended to the right atrium; however, pulmonary emboli (PE) were not documented in TTE. Intraoperative exploration revealed multiple clots in the main and left pulmonary artery branches. The patient recovered well after open-heart surgery with resection of the right atrium, IVC, and pulmonary artery emboli. BCS should be routinely considered for patients with nephrotic syndrome.

Syringe-assisted test-aspiration with mechanical aspiration thrombectomy results in good safety and short-term outcomes in the treatment of patients with deep venous thrombosis.

To evaluate the short-term outcomes and safety of syringe-assisted test-aspiration with mechanical aspiration thrombectomy in the treatment of deep venous thrombosis. This was a single-center, retrospective study of hospitalized patients with iliofemoral and/or inferior vena caval deep venous thrombosis, excluding those with pulmonary embolism. We collected the following patient data from the electronic medical records: age, sex, provoked/unprovoked deep venous thrombosis, symptom duration, thrombosed segments, and the presence of a tumor, thrombophilia, diabetes, and/or iliac vein compression syndrome. Venography and computed tomographic venography were performed in all patients before the procedure. All patients underwent syringe-assisted test-aspiration with mechanical aspiration thrombectomy under local anesthesia and sedation, and all received low-molecular-weight heparin peri-operatively. All patients underwent implantation of an inferior vena caval filter. Rivaroxaban was administered post-procedure, instead of heparin, for 3-6 months, with lower extremity compression. Overall, 29 patients with deep venous thrombosis underwent syringe-assisted test-aspiration with mechanical aspiration thrombectomy from January 2022 to October 2022 in our institution. Technical success (>70% thrombus resolution) was achieved in all patients, and using a single procedure in 25/29 patients (86%). Concomitant stenting was performed in 18/29 (62%) of the patients, and 21/29 (69%) underwent angioplasty. The median (interquartile range) procedure time was 110min (100-122), the median intra-operative bleeding volume was 150mL (120-180), and the median decrease in the hemoglobin concentration from pre- to post-operative was 7g/L (4-14). The median follow-up duration was 7 months (5-9). All patients obtained symptomatic relief, and 27/29 achieved near-remission or full remission (combined total). No patients experienced peri-operative bleeding complications, or symptom recurrence or post-thrombectomy syndrome during follow-up. The short-term outcomes following syringe-assisted test-aspiration with mechanical aspiration thrombectomy in the treatment of deep venous thrombosis were excellent, and the procedure was safe.

Efficacy of 4-(2-(4-nitrophenyl)-2-oxoethyl)-1-(thietane-3-yl)-1h-1,2,4-triazol-4 bromide in the rat model of inferior vena cava thrombosis

Introduction. According to WHO, acute disorders of cerebral circulation are anticipated to become a predominant contributor to the global disease burden by 2030. The comprehensive management of vascular depression entails not only the use of antidepressants but also fundamental interventions. The development of a novel molecule based on thietane-containing heterocycles, merging the attributes of an antidepressant and an antiplatelet agent, holds promise for enhancing therapeutic efficacy in patients with acute cerebrovascular accidents through multimodal action. Objective is to conduct a preclinical assessment of 4-(2-(4-nitrophenyl)-2-oxoethyl)-1-(thietane-3-yl)-1H-1,2,4-triazole-4-th bromide concerning model thrombosis in rats. Materials and Methods. The investigation involved the evaluation of thrombosis processes and the haemostasis system in rats subjected to complete occlusion of the inferior vena cava within 24 hours post-thrombosis induction. Techniques employed included thromboelastography, Born aggregometry, standard clotting assays to appraise the coagulation facet of haemostasis, and morphological examinations. Results. The results demonstrate that 4-(2-(4-nitrophenyl)-2-oxoethyl)-1-(thietane-3-yl)-1H-1,2,4-triazole-4-th bromide mitigates thrombosis mass, restores platelet hyper aggregation, and counters hypercoagulation observed in acute inferior vena cava thrombosis in rats. Comparative analysis with reference drugs substantiates the superior effectiveness of the chosen compound in thrombosis prevention. Conclusion. The preclinical investigation of 4-(2-(4-nitrophenyl)-2-oxoethyl)-1-(thietane-3-yl)-1H-1,2,4-triazole-4-th bromide unveils a fusion of established antidepressant and antithrombotic activities, laying groundwork for further drug development endeavours.

Characterization and risk factors of inferior vena cava thrombosis in situ detected by computed tomography venography following filter placement: A single-center retrospective cohort study

ObjectiveThis study aimed to characterize radiographic characteristics on computed tomography venography and risk factors of inferior vena cava thrombosis (IVCT) in situ after retrievable vena cava filter (VCF) placement. MethodsBetween September 2018 and June 2023, a single-center retrospective cohort study was conducted in patients with or without IVCT in situ following VCF placement. Patient baseline demographics, presentation of lower extremity deep vein thrombosis (LEDVT), thrombus characteristics, concurrent pulmonary embolism, comorbidities and risk factors for LEDVT, and IVCT and VCF-related information were collected and analysed. Univariable analysis followed by multivariable analysis was performed to evaluate the odds ratio (OR) with a 95% confidence interval (CI). ResultsOne hundred and seventeen eligible patients were included, regionally isolated filling-defect surrounding the support pillars of VCF and contacting inferior vena cava (IVC) wall on computed tomography venography images were identified, clots were more frequently found on the minor axis or anterior wall of IVC. Univariable analyses suggested that the incidence of IVCT in situ (31.6%, 37/117) was closely associated with age (P = .001), thrombus limb (left (P = .001) and bilateral side (P = .001)), hypertension (P = .008), filter shapes (P < .001), short IVC diameter (P = .009) or magnification percentage (P = .004), and long IVC diameter (P = .006). Multivariable analyses suggested that bilateral side LEDVT (OR, 4.92; 95% CI, 1.56-15.51; P = .007) and increased short IVC magnification percentage (OR, 1.01; 95% CI, 1.00-1.03; P = .013) statistically significant increase the IVCT in situ risk, whereas increased age (OR, 0.96; 95% CI, 0.94-0.99; P = .013) and short IVC diameter (OR, 0.87; 95% CI, 0.77-0.98; P = .026) were associated with decreased odds against IVCT in situ. ConclusionsIVCT in situ represents regionally isolated filling-defect at points of filter contact with IVC wall. Bilateral side LEDVT and increased short IVC magnification percentage may be potential risk factors impacting the occurrence of IVCT in situ, while increased age and short IVC diameter may decrease the incidence of IVCT in situ and seem to be protective factor against IVCT in situ emergence.

Acute caval thrombosis leading to obstructive shock in the early post insertion period of an inferior vena cava filter: a case report and literature review

BackgroundObstructive shock is extremely rare in clinical practice and is caused by acute blood flow obstruction in the central vessels of either the systemic or pulmonary circulation. Utilizing inferior vena cava filters (IVCFs) to prevent pulmonary embolism (PE) is associated with some potential complications, such as inferior vena cava thrombosis (IVCT). Shock as a direct result of IVCT is rare. We present a case of obstructive shock secondary to extensive IVCT caused by inadequate anticoagulant therapy after the placement of an IVCF.Case presentationA 63-year-old male patient with a traffic accident injury presented orthopaedic trauma and lower limb deep vein thrombosis (DVT). He experienced sudden and severe abdominal pain with hypotension, tachycardia, tachypnea, oliguria and peripheral oedema 5 days after IVCF placement and 3 days after cessation of anticoagulant therapy. Considering that empirical anti-shock treatment lasted for a while and the curative effect was poor, we finally recognized the affected vessels and focused on the reason for obstructive shock through imaging findings—inferior vena cava thrombosis and occlusion. The shock state immediately resolved after thrombus aspiration. The same type of shock occurred again 6 days later during transfer from the ICU to general wards and the same treatment was administered. The patient recovered smoothly in the later stage, and the postoperative follow-up at 1, 3, and 12 months showed good results.ConclusionThis case alerts clinicians that it is crucial to ensure adequate anticoagulation therapy after IVCF placement, and when a patient presents with symptoms such as hypotension, tachycardia, and lower limb and scrotal oedema postoperatively, immediate consideration should be given to the possibility of obstructive shock, and prompt intervention should be based on the underlying cause.

Transcatheter closure of patent ductus arteriosus in preterm infants: results from a single-center cohort.

To assess the success rate of patent ductus arteriosus (PDA) transcatheter closure in preterm infants and to describe the nature of procedural adverse events and short-term clinical status. All the preterm infants with PDA transcatheter closure were evaluated retrospectively between July 2019 and March 2023 in a single level III neonatal intensive care unit in France. The procedure was performed in the catheterization laboratory using venous canulation. We retrospectively collected data about the patients' characteristics, procedural outcomes and complications. Twenty-five infants born between 23.4 and 32.0 weeks of gestational age (mean ± SD 26.3 ± 1.9 weeks) underwent transcatheter PDA closure. Their mean age and weight at the time of the procedure were 52 days (range 22-146 days) and 1,620 g (range 890-3,700 g), respectively. Successful closure was achieved in all but one patient. Procedure related complications were reported in 10 infants (40%), including 6 left pulmonary artery stenosis one of which required a balloon dilatation, two cardiac tamponades and two inferior vena cava thrombosis. Only two post-ligature syndromes occurred after the procedure. Two infants died one of which was related to the procedure. Transcatheter closure of a PDA is a valid alternative to surgical ligation due to its high success rate and low incidence of post-ligature syndrome. Nevertheless, we also report rare, although serious complications.

Unprecedented Coexistence of Autoinflammatory Myositis and Chronic Thrombosis with heterozygotic M694V mutation: An atypical presentation of Familial Mediterranean Fever.

Familial Mediterranean Fever (FMF) is a hereditary autoinflammatory disorder predominantly characterized by periodic fever, abdominal pain, and joint manifestations. It can exhibit various atypical presentations and affects individuals globally. However, cases of FMF concurrently presenting with chronic thrombosis and myositis have not been previously reported. A 41-year-old male presented with alternating severe bilateral leg pain, stiffness, and localized swellings without fever or abdominal symptoms. His history included recurrent inflammatory joint pain treated with prednisolone. Physical examination revealed leg pain, limited ankle joint movement, and tender swellings in thighs, forearms, and feet. Collateral abdominal veins were also observed. Unresponsive to prednisolone and colchicine, the patient underwent MRI, revealing muscle inflammation in both legs and thighs and chronic thrombosis in the infrarenal inferior vena cava. Genetic testing confirmed the heterozygotic M694V mutation, diagnosing an atypical FMF. Anakinra treatment led to substantial clinical and laboratory improvement. Although FMF diagnosis typically relies on characteristic clinical features and genetic analysis, atypical presentations challenge established criteria. This case uniquely showcases coexisting myositis and chronic thrombosis in FMF. Myalgia is common in FMF, with M694V mutation associated with severe muscular symptoms. The lack of fever and myositis findings differentiate our case from protracted febrile myalgia syndrome. FMF's chronic inflammatory state is known to influence thrombosis risk, and our findings align with this association. Chronic thromboembolism and myositis together signify an unusual clinical presentation of FMF. This case highlights the potential for FMF to present with complex manifestations beyond the conventional symptoms. Myositis and vascular involvement should prompt consideration of FMF diagnosis when combined with patient history, clinical features, and laboratory results. These rare associations underscore the need for further research to enhance understanding of FMF's diverse clinical spectrum.

Challenges in the diagnosis of the enigmatic primary adrenal leiomyosarcoma: two case reports and review of the literature

BackgroundPrimary adrenal leiomyosarcoma is a rare and aggressive mesenchymal tumor derived from the smooth muscle wall of a central adrenal vein or its tributaries; therefore, tumors tend to invade the inferior vena cava and cause thrombosis. The great majority of tumors grow rapidly, which makes the disease difficult to diagnose in its early clinical stages and needs differentiation from adrenocortical carcinomas for the selection of chemotherapy including mitotane which causes adrenal insufficiency.Case presentationWe presented two patients with adrenal leiomyosarcoma who were referred to our hospital with abdominal pain and harboring large adrenal tumors and inferior vena cava thrombosis. The endocrine findings, including serum catecholamine levels, were unremarkable. These two patients were considered clinically inoperable, and CT-guided core needle biopsy was performed to obtain the definitive histopathological diagnosis and determine the modes of therapy. The masses were subsequently diagnosed as primary adrenal leiomyosarcoma based on the histological features and positive immunoreactivity for SMA (smooth muscle actin), desmin, and vimentin.ConclusionsAdrenal leiomyosarcoma derived from the smooth muscle wall of a central adrenal vein or its tributaries is rare but should be considered a differential diagnosis in the case of nonfunctioning adrenal tumors extending directly to the inferior vena cava. CT-guided biopsy is considered useful for histopathological diagnosis and clinical management of patients with inoperable advanced adrenal tumors without any hormone excess.

Abstract 17847: Typical Right Atrial Flutter Ablation Using Subclavian Venous Access in Patients With Interrupted or Occluded Inferior Vena Cava

Introduction: Ablation for typical atrial flutter (AFL) traditionally involves vascular access from the femoral vein to facilitate advancing catheters through the Inferior Vena Cava (IVC) to the right atrium (RA). In patients with interrupted or occluded IVC, this procedure is challenging to perform. We report a case series of typical right AFL ablation using subclavian access in interrupted or occluded IVC. Cases: A 63-year-old female with typical AFL refractory to medical therapy was referred for radiofrequency ablation (RFA). She had a history of surgically corrected atrial septal defect at age 4 years with known IVC interruption draining into RA via an azygous venous extension. Another case involved a 41-year-old male with quadriplegia and typical AFL who underwent an attempted RFA from femoral access that was aborted due to massive thrombosis of IVC. Decision making: In both cases, two sheaths were placed into the left subclavian venous system using ultrasound guidance. A coronary sinus catheter and irrigated tip ablation catheter were advanced into the coronary sinus and RA respectively. Additionally, in the second case, an intracardiac echocardiography probe was inserted via separate venous access. Using the electroanatomic mapping system, entrainment and activation mapping confirmed a tricuspid isthmus-dependent AFL. RFA was performed using an open irrigated RFA catheter in a linear fashion resulting in the termination of the tachycardia to sinus rhythm. In the first case, ablation extended from the tricuspid annulus to the os of the hepatic vein at the 06:00 position. Post ablation, hemostasis was achieved using a suture-mediated closure device. At follow-up, both patients were asymptomatic without evidence of AFL on extended-duration cardiac monitoring. Conclusion: In patients with interrupted or occluded IVC, the subclavian veins can be accessed for mapping and ablation of typical AFL when traditional femoral venous access is challenging.

Investigation of the Effects of an Inferior Vena Cava Filter and Captured Clot Size on the Hemodynamic Parameters in Non-Newtonian Turbulent Pulsatile Blood Flow

In this computational fluid dynamics (CFD)-based study, the effects of inferior vena cava (IVC) filter implantation on the risk of IVC thrombosis have been investigated using different hemodynamic parameters, including time-averaged wall shear stress (TAWSS), the oscillating shear index (OSI), and the relative residence time (RRT). The boundary conditions in this study have been based on physiological pulses. Additionally, the k–ω model and the Carreau model have been chosen to represent the turbulent flow regime and non-Newtonian blood, respectively. For this purpose, three blood clots with the largest cross-sectional diameters of 30%, 50%, and 70% of the filter diameter have been used. Capturing a small clot in the filter has the minimum effect on the hemodynamic parameters, while by increasing the size of the captured clot, OSI and RRT parameters increase in areas downstream of the filter on the wall. The presence of a filter and clot increases the risk of thrombosis. In the case of capturing large clots, there is the possibility of damage to endothelial cells or platelet activation. Captured clots lead to the formation of plaque and thrombus on the IVC wall. However, the possibility of thrombus growth on its surface is not negligible, particularly if larger clots are trapped in the filter.

Tissue-type plasminogen activator (tPA) homozygous Tyr471His mutation associates with thromboembolic disease.

Tissue-type plasminogen activator (tPA) encoded by PLAT is a major mediator that promotes fibrinolysis and prevents thrombosis. Pathogenetic mutations in PLAT associated with venous thromboembolism have rarely been reported. Here, we report the first case of a homozygous point mutation c.1411T>C (p.Y471H) in PLAT leading to thromboembolic events and conduct related functional studies. The corresponding tPA mutant protein (tPA-Y471H) and wild-type tPA (tPA-WT) were synthesized in vitro, and mutant mice (PLATH/H mice) were constructed. The molecular docking and surface plasmon resonance results indicated that the mutation impeded the hydrogen-bonding interactions between the protease domain of tPA and the kringle 4 domain of plasminogen, and the binding affinity of tPA and plasminogen was significantly reduced with a difference of one order of magnitude. mRNA half-life assay showed that the half-life of tPA-Y471H was shortened. The inferior vena cava thrombosis model showed that the rate of venous thrombosis in PLATH/H mice was 80% compared with 53% in wild-type mice. Our data suggested a novel role for the protease domain of tPA in efficient plasminogen activation, and demonstrated that this tPA mutation could reduce the fibrinolysis function of the body and lead to an increased propensity for thrombosis.

Efficacy of TACE Combined with Lenvatinib Plus Sintilimab for Hepatocellular Carcinoma with Tumor Thrombus in the Inferior Vena Cava and/or Right Atrium.

To validate the safety and effectiveness of transarterial chemoembolization (TACE) combination with lenvatinib and sintilimab in treating hepatocellular carcinoma (HCC) patients with inferior vena cava (IVC) and/or right atrium (RA) tumor thrombosis (TT). This study retrospectively analyzed HCC patients with IVC and/or RA TT treated with TACE combined with lenvatinib plus sintilimab. Overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and disease control rate (DCR) were calculated to evaluate the anti-tumor efficacy. Treatment-related adverse events (TRAEs) were analyzed to assess the safety profiles. A total of 58 patients were screened for eligibility between March 2019 and May 2022. At the time of data collection, 48.2% of patients were still receiving treatment. The median follow-up was 23.5 months. The ORR was 48.3%, the DCR was 91.4%, the median OS was 17.3 months, and the median PFS was 13.0 months. The ORR for IVC/RA TT was 62.1%, DCR was 94.9%, and the median PFS was 14.3 months. 56.9% of patients experienced ≥ grade 3 TRAEs, such as hypertension (10.3%) and elevated liver enzymes (13.8%). No new safety signals were identified. Participants with low levels of serum PCT value had satisfactory prognoses. TACE combination with lenvatinib plus sintilimab is effective in treating HCC with IVC and/or RA TT. The toxicities were manageable, with no unexpected safety signals. The baseline levels of serum PCT might be the predictive biomarkers for the triple combination therapy.

Nephrectomy and IVC thrombectomy in renal cancer: a narrative review.

Renal cell carcinoma accounts for two to three percent of adult malignancies and can lead to inferior vena cava (IVC) thrombosis. This condition can decrease the rate of 5-year survival for patients to 60%. The treatment of choice in such cases is radical nephrectomy and inferior vena cava thrombectomy. This surgery is one of the most challenging due to many perioperative complications. There are many controversial methods reported in the literature. Achieving the free of tumor IVC wall and the possibility of thrombectomy in cases of level III and level IV IVC thrombosis are two essential matters previously advocated open approaches. Nevertheless, open approaches are being replaced by minimally invasive techniques despite the difficulty of the surgical management of IVC thrombectomy. This paper aims to review recent evidence about new surgical methods and a comparison of open, laparoscopic, and robotic approaches. In this review, we present the latest surgical strategies for IVC thrombectomy and compare open and minimally invasive approaches to achieve the optimal surgical technique. Due to the different anatomy of the left and right kidneys and variable extension of venous thrombosis, we investigate surgical methods for left and right kidney cancer and each level of IVC venous thrombosis separately.

Effect of inferior vena cava filter placement position on device complications

BackgroundIndwelling inferior vena cava (IVC) filters can cause complications, including penetration into surrounding structures, migration, and thrombosis of the vena cava. Computational fluid dynamics suggests juxtarenal placement of IVC filters decreases the risk of thrombosis; however, this has not been explored clinically. The present study examines the effect of filter placement position on long-term device complications with an emphasis on IVC thrombosis. We hypothesized that IVC filters placed further caudal to the renal veins were more likely to develop long-term thrombosis. MethodsA retrospective review of the medical records of patients receiving IVC filters at a single tertiary center between 2008 and 2016 was performed. Patients missing follow-up or procedural imaging data were excluded. The placement procedure venograms were reviewed, and the distance from the filter apex to the more inferior renal vein was measured using reported IVC filter lengths for calibration. The patients were divided into three groups according to the tip position relative to the more inferior renal vein: at or superior (group A), 1 to 20 mm inferior (group B), and >20 mm inferior (group C). The patient and procedural characteristics and outcomes were compared between the three groups. The primary end points were IVC thrombosis and device-related mortality. ResultsOf 1497 eligible patients, 267 (17.8%) were excluded. The most common placement position was group B (64.0%). The mean age was lowest in group C, followed by groups A and B (age, 59.5 years, 64.6 years, and 62.2 years, respectively; P = .003). No statistically significant differences were found in the distribution of sex or the measured comorbidities. Group C was the most likely to receive jugular access (group C, 71.7%; group A, 48.3%; group B, 62.4%; P < .001) and received more first-generation filters (group C, 58.5%; group A, 46.6%; group B, 52.5%; P = .045). The short-term (<30-day) and long-term (≥30-day) outcomes, including access site hematoma, deep vein thrombosis, and pulmonary embolism, were uncommon, with no differences between the groups. Cases of symptomatic filter penetration, migration, and fracture were rare (one, one, and three cases, respectively). Although a pattern of increasing thrombosis with more inferior placement was found, the difference between groups was not statistically significant (group A, 1.5%; group B, 1.8%; group C, 2.5%; P = .638). No cases of device-related mortality occurred. All-cause mortality after a mean follow-up of 2.6 ± 2.3 years was 41.3% and did not vary significantly between the groups (P = .051). Multivariate logistic regression revealed that placement position did not predict for short- or long-term deep vein thrombosis, pulmonary embolism, IVC thrombosis, or all-cause mortality after adjustment for the baseline patient characteristics. ConclusionsIVC filters have low rates of short- and long-term complications, including IVC thrombosis. The placement position did not affect the occurrence of device complications in this study.

A Case of Complete Resolution of Cauda Equina Syndrome Caused by Extensive Iliocaval Thrombosis: The Role of Thrombolysis and Venous Stents.

The cauda equina syndrome (CES) is a rare condition affecting less than 1 in 100,000 patients annually. Diagnosing CES is challenging because of its rare incidence, potentially subtle presentation, and various underlying etiologies. Vascular causes, such as inferior vena cava (IVC) thrombosis, are uncommon but should be considered, since timely recognition and treatment of deep vein thrombosis (DVT) as a cause of CES can avoid irreversible neurological damage. A 30-year-old male presented with partial CES caused by nerve root compression due to venous congestion from an extensive iliocaval DVT. He completely recovered after thrombolysis and stenting of the IVC. His iliocaval tract remained patent until the last date of follow-up at 1 year without signs of post-thrombotic syndrome. Broad molecular, infectious, and hematological laboratory tests did not reveal any underlying disease for the thrombotic event, particularly no hereditary or acquired thrombophilia. Timely recognition of venous thrombosis as a cause of CES is essential. This is the first case report of CES caused by an extensive iliocaval DVT successfully treated with thrombolysis and venous stenting with good resolution of DVT and CES. This case-report describes a patient with cauda equina syndrome resulting from an extensive iliocaval deep vein thrombosis due to an underlying stenosis of the inferior vena cava. Thrombolysis and venous stenting succesfully restored venous patency and thereby relieved symptoms and signs of cauda equina syndrome, in addition to (long-term) therapeutic dose anticoagulation. It is important to timely recognize deep vein thrombosis as a cause of cauda equina syndrome and to consider endovenous treatment in a specialized center.

Inferior Vena Cava Filters and Complications: A Systematic Review.

Inferior vena cava(IVC) filters have been used since the 1960s to treat patients with acute risk of pulmonary embolism (PE) to prevent migration of thrombus by trapping it within the filter. Traditional usage has been in patients with contraindication to anticoagulation that carry a significant mortality risk. In this systematic review, we sought to evaluate complications associated with placement of inferior vena cava filters based on published data from the past 20 years. A search was performed on October 6th, 2022, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews, using three databases (ProQuest, PubMed and ScienceDirect) for articles published between the dates of February 1, 2002 and October 1, 2022. Results were filtered to include full-text, clinical studies, and randomized trials written in English pertaining to keywords "IVC filter AND complications", "Inferior Vena Cava Filter AND complications", "IVC filter AND thrombosis" and "Inferior Vena Cava Filter AND thrombosis". Articles identified by the three databases were pooled and further screened for relevance based on inclusion and exclusion criteria. Initial search results yielded 33,265 hits from all three databases combined. Screening criteria were applied, with 7721 results remaining. After further manual screening, including removal of duplicate hits, a total of 117 articles were selected for review.While there are no consensus guidelines for best practice, there is compelling evidence that IVC filters can provide significant protection against PE with minimal complications if the treatment window is appropriate. Increase in the variety of filter models has led to broader availability, but skepticism remains about their efficacy and safety, with ongoing controversy surrounding appropriate indications. Further research is needed to establish clear guidelines on appropriate indications for IVC placement and to determine time course of complications versus benefits for indwelling filters.