A case of chronic recurrent pulmonary embolism treated by pulmonary embolectomy and Günther vena caval filter implantation

A case report of chronic recurrent pulmonary embolism treated by embolectomy and Günther vena caval filter. A 62-year-old man had suffered from dyspnea on effort for 4 years, and his feeling of dyspnea had gradually increased during the past 3 months. On the day of admission he was in a preshock state, and his pulmonary artery pressure was very high at 90/30 mmHg. Pulmonary blood perfusion scintigraphy showed multiple defects of isotope uptake. Immediately after the scintigraphy, pulmonary embolectomy was performed while using extracorporeal circulation. The operation was successful and his physical activity was markedly improved. After the operation, anti-coagulant and anti-platelet therapies were continued, but recurrence of pulmonary emboli was detected by scintigraphy, and some thrombi were found by venography in deep veins of the lower parts of both legs. To prevent recurrent pulmonary embolism, a Günther vena caval filter was inserted into the inferior vena cava. We considered this case as an acute worsening of chronic recurrent pulmonary embolism and we had the impression that pulmonary embolectomy is a very effective therapeutic method for serious pulmonary embolism, and that insertion of the Günther vena caval filter is a very easy and safe procedure.     

Very long-term outcome of 68 vena cava filters percutaneously implanted

Between January 1987 and December 1991, 68 consecutive patients aged 71.5 +/- 12.0 years underwent percutaneous implantation of a vena caval filter, mainly the LGM (N = 64). Fifty seven patients had pulmonary embolism, 61 had deep vein thrombosis of the lower limbs. The average follow-up interval was 4.9 +/- 3.3 years (7.0 +/- 2.7 years for the patients still alive). The follow-up included a telephonic enquiry to determine the date and cause of death, recurrent deep vein thrombosis and/or pulmonary embolism; surviving patients underwent clinical examination, plain abdominal X-ray with a lateral decubitus view and duplex ultrasonography of the lower limb veins to assess the patency of the filter. Fifty three per cent of the patients died. Four predictive factors for mortality were identified: a contra-indication to anticoagulant therapy, chronic post-embolic cor pulmonale, an indication of prophylactic implantation in the elderly and the presence of underlying malignant disease. There were 5.8% recurrences of pulmonary embolism, 26.1% of lower limb deep vein thrombosis and 25% of filter thrombosis. The only predictive factor of thrombosis was a proximal venous thrombus and was associated in 50% of filter thrombosis. Seventy per cent of the plain abdominal X-rays were abnormal with 9 displacements. 9 migrations and 10 closures of the filters. There was a significant correlation between closure on plain abdominal X-ray and caval thrombosis and between recurrent deep vein thrombosis and caval thrombosis. The frequency of long-term complications after implantation of a caval filter in this study suggests that interruption of the vena cava should be reserved for the only validated indications in the presence of a formal contra-indication to or failure of anticoagulant therapy. Other indications require evaluation with prospective randomised trials.     

Retrievable Günther Tulip filter complicated by sepsis and retroperitoneal hemorrhage: successful management by filter retrieval

We encountered complications of septic shock and retroperitoneal hemorrhage which occurred after implantation of a retrievable Günther Tulip filter. A 79-year-old woman was diagnosed as right femoral vein thrombosis, and a retrievable Günther Tulip filter was deployed prior to a total knee replacement surgery. However, the patient developed septicemia due to Citrobacter freundii, followed by thrombocytopenia and retroperitoneal hemorrhage. A large hematoma was formed along the lateral side of the filter struts. We considered that the filter should be removed to control retroperitoneal hemorrhage and prevent secondary infection of the hematoma. Removal of the retrievable filter was effective in managing these complications.     

Interruption of the inferior vena cava for prevention of pulmonary embolism: transvenous filter devices

The availability of a safe, effective, and easily introducible percutaneous vena cava filter is crucial in the management of certain patients with pulmonary embolism. If thrombolytic or anticoagulant therapy for pulmonary embolism is contraindicated or fails, interruption of the inferior vena cava (IVC) blood flow is the logical alternative. Indications for filter insertion include a contraindication to anticoagulation, or recurrent pulmonary embolism despite adequate anticoagulation therapy. Common routes of filter insertion are from the right internal jugular vein, or the right or left femoral veins. The Mobin-Uddin umbrella filter (no longer available in the USA) and the Kimray-Greenfield filters have been the most widely used. Complications of vena cava filters include malpositioning, migration, venous thrombosis proximal or distal to the filter, hemorrhage at the percutaneous site of insertion, or sepsis. Despite these problems, IVC filters have been extremely useful in the management of pulmonary embolism among certain subsets of patients. Percutaneously inserted filters have now superseded surgical vena caval interruption in most US centers. Newer filters are currently under development in the US and Europe, and feature improved filtering function, anti-tilt abilities, retrievability, memory wire properties, and improved ease of insertion.     

Retrievability of the Günther Tulip vena cava filter after dwell times longer than 180 days in patients with multiple trauma.

PURPOSE: To evaluate the retrieval feasibility of the Günther Tulip inferior vena cava filter (IVCF) after dwell times >180 days in patients with multiple trauma. METHODS: A retrospective study was conducted of 117 multiple-trauma patients (70 men; mean age 36 years, range 17 to 64) who underwent prophylactic placement of Günther Tulip retrievable IVCFs between December 1, 2003 and October 1, 2006. Prior to IVCF retrieval, all patients had vena cavography to identify possible IVCF thrombus entrapment. Filter retrieval was performed in the catheterization laboratory under sterile conditions from a right internal jugular vein approach. After IVCF retrieval, repeat vena cavography was performed to evaluate the IVC for contrast extravasation, intraluminal defects, or IVC narrowing. RESULTS: Twelve (10.3%) filters were not retrieved as the patients died of their injuries (no deaths related to IVCF placement or retrieval). Forty-one (35.0%) filters had dwell times >180 days (mean 261.5 days, range 182-403). Of these, 31 (76%) were uneventfully retrieved; 10 were left in place permanently. Pre-retrieval vena cavography identified filter tilting in 13 filters: 9 had a mild tilt < or =10 degrees, and 4 had severe tilting > or =25 degrees. All of the 10 filters that could not be retrieved were tilted (4 severe and 6 mild). In comparison to the 64 (54.7%) filters in place for <180 days (mean 51 days, range 42-180), 4 (6.2%) could not be retrieved (p = 0.367). No filter had trapped thrombus identified by vena cavography at the time of retrieval. None of the retrieved filters had structural fracture or collapse, and none had migrated. Post-retrieval vena cavograms demonstrated no contrast extravasation, intraluminal defects, or impingement on adjacent organs. CONCLUSION: If retrieval of a Gunther Tulip filter with an dwell time >180 days is considered, the patient should be ambulatory and a candidate for anticoagulation if indicated; notably, the filter should have a <25 degrees tilt. Under these circumstances, retrieval of the Günther Tulip filter after 180 days of dwell time appears justified and safe.     

腔静脉过滤器预防肺动脉栓塞的临床研究

目的：评估腔静脉过滤器预防肺动脉栓塞的临床疗效。方法：对10例下肢深静脉血栓患(4例已并发肺栓塞)植入腔静脉过滤器。观察其预防肺栓塞的效果。结果：10例患共植入过滤器10个，其类型为：西蒙记忆合金过滤器3个、Greenfield过滤器3个和郁金香(Tulip)过滤器4个。过滤器植入后经尿激酶溶栓7例下肢血栓溶解消失，余3例残留部分血栓，4例肺梗死灶全部消失，随访2至36个月，未再发肺梗死，没有出现过滤器移位、下腔静脉阻塞现象。结论：下腔静脉过滤器植入术是一种安全、有效、可预防肺动脉栓塞发生的临床措施。     

Inferior Vena Cava Filter Migration to the Right Ventricle Causing Nonsustained Ventricular Tachycardia

Inferior vena cava filters are commonly used to prevent pulmonary embolism in patients who manifest deep vein thrombosis and recurrent pulmonary embolism despite anticoagulation, or in patients with contraindications to anticoagulation. We report the case of a 69-year-old man with a structurally normal heart who experienced migration of an inferior vena cava filter to the right ventricle, which caused the abrupt onset of recurrent episodes of nonsustained ventricular tachycardia unresponsive to intravenous antiarrhythmic medication. Cardiac imaging revealed the location of the filter within the right ventricle, and the device was removed, with subsequent resolution of the arrhythmia. We anticipate that the incidence of inferior vena cava filter migration might increase in the future because of recent changes in device construction. The sudden appearance of nonsustained ventricular tachycardia in a patient with an inferior vena cava filter might indicate the occurrence of this potentially life-threatening sequela and should lead to emergent cardiac imaging.Key words: Foreign-body migration, inferior vena cava filter, pulmonary embolism/prevention & control, tachycardia, ventricular/etiology/diagnosis, vena cava, inferior, vena cava filters/adverse effects/utilization, venous thrombosis, ventricular tachycardiaInferior vena cava (IVC) filters were first developed in 1972 and have come into increasingly common use as a prophylactic measure in patients with contraindications to anticoagulation. The overall incidence of adverse sequelae for IVC filters has been extremely low. Intracardiac migration, in particular, has been rare: slightly more than 100 cases have been reported in almost 40 years. Recently, device migration has increased, apparently because of the use of lighter and more flexible alloys to facilitate insertion of the filter. Presented here is a case of IVC filter migration across the tricuspid valve into the right ventricle (RV), heralded by the abrupt onset of frequent episodes of nonsustained ventricular tachycardia (VT) unresponsive to intravenous amiodarone. The tricuspid valve is notoriously arrhythmogenic, and the sudden development of complex ventricular ectopic beats should alert the clinician to the possibility of intracardiac device migration. As the use of these new filters increases in the near future, we suspect that this serious sequela will become more common.     

Temporary vena cava filters do not always protect from fatal pulmonary embolism

We describe the case of a young woman who developed fatal pulmonary embolism during thrombolytic therapy of a deep pelvic and leg vein thrombosis, despite the insertion of a temporary vena cava filter. So the opinion that the insertion of inferior vena cava filters always prevents lethal pulmonary embolism caused by thrombi of the deep vein system must be revised.     

Present-day role of vena cava filters

BACKGROUND: The purpose of the present is to assess the effectiveness of pulmonary embolism prevention using temporary or permanent vena cava filters in deep venous thromboses of the lower extremities with a discussion of indications and complications. METHODS: In the period between 1989 and 1998 we observed 46 patients (33 m, 13 f) suffering from deep venous thrombosis of the lower extremities. RESULTS: The cases treated with cava filter showed an improvement in clinical conditions in 15-19 cases with 4/19 cases of complications: filter ascent, lipothymia, one case of pneumothorax and one case of filter ascent with thrombosis of the contralateral venous axis. All complications were solved without further sequelae. After catheterisation of the femoral vein, the thrombosis of the contralateral venous axis in patients with caval filter was a frequently observed event (in 75% of cases). In the cases without filter, an evident improvement was observed in 22/27 cases, a slight improvement in 2/27 cases, with 3/27 cases of complications: two cases of cardiocirculatory arrest and one case of severe dyspnea with suspected pulmonary embolism which survived the event. CONCLUSIONS: From our experience, the use of caval filters is unquestionably useful for the prevention of pulmonary embolism, but is not wholly free from complications.     

Clinical experience with retrievable vena cava filters for prevention of pulmonary thromboembolism

OBJECTIVES: To evaluate the feasibility, effectiveness and complications of the retrievable vena cava filter [Güther tulip vena cava filter(GTF)] for the prevention of pulmonary thromboembolism in patients with deep vein thrombosis. METHODS: Seventeen patients, 3 males and 14 females, aged 21 to 82 years (mean age 59 +/- 19 years), underwent implantation of GTFs between December 2000 and February 2002 at Mie University Hospital. All patients were treated under diagnoses of deep vein thrombosis with or without pulmonary thromboembolism based on venous ultrasonography, venography or computed tomography. Eleven patients were treated with thrombolysis. RESULTS: Significant thromboembolus was trapped within the filter in 3 of 12 patients. No acute pulmonary thromboembolism occurred during implantation or at retrieval of the GTF. Retrieval of the GTF was attempted in 9 patients, and 8 GTFs were retrieved successfully. Mean interval of the filter implantation was 13.4 +/- 6.3 days and the mean retrieval time was 4.8 +/- 3.2 min. No complications occurred except for one case of minor hemorrhage at the puncture site. CONCLUSIONS: The placement and retrieval of the retrievable vena cava filter was feasible and safe. This filter was also effective for the prevention of pulmonary thromboembolism. This retrievable vena cava filter may be a good first-choice filter for both permanent and temporary use.     

Long-term results of inferior vena cava filters: experiences in a Japanese population

OBJECTIVE: In this prospective, non-controlled observational study, we evaluated the middle- to long-term results of placement of inferior vena cava (IVC) filter devices in Japanese patients. METHODS AND RESULTS: In 42 Japanese patients with deep vein thrombosis (DVT) or pulmonary thromboembolism (PTE) who underwent percutaneous insertion of IVC filters, follow-up examinations at fixed intervals of 2 years were performed, and the data was evaluated including complications. There were no fatal complications during IVC filter implantation. About 5% of patients with an inserted IVC filter developed symptomatic PTE, another 5% developed asymptomatic PTE. The trapped thrombus was demonstrated in about 22% of the inserted IVC filters. Lower rates of PTE development, occlusion of IVC, and captured thrombus were found in the cases where concurrent use of anticoagulation therapy with filters was used. Trapped thrombi were found in half of IVC filters inserted prophylactically for proximal femoral venous thrombosis. CONCLUSION: These experiences with IVC filters suggest that they are safe and effective for the prevention of PTE in the Japanese population.     

Combined percutaneous aspiration thrombectomy and rheolytic thrombectomy in massive subacute vena cava thrombosis with IVC filter occlusion.

PURPOSE: To report the combined use of percutaneous aspiration thrombectomy and rheolytic thrombectomy in the setting of extensive inferior vena cava (IVC) thrombosis and filter occlusion. CASE REPORT: A 28-year-old paraplegic man with a vena cava filter in situ for previous deep vein thrombosis (DVT) was referred to our center for evaluation of dyspnea and right leg edema and swelling. Computed tomography excluded a pulmonary embolism and revealed severe, massive DVT of both iliac veins and the IVC, including the vena cava filter. Percutaneous aspiration thrombectomy was attempted because intravenous heparin therapy was ineffective, and moderate anemia contraindicated regional thrombolysis. Several passes of a guiding catheter proximally and distally to the filter, with suction provided by a 50-mL syringe, achieved minimal IVC recanalization. Subsequently, a 6-F AngioJet catheter was passed via the guiding catheter through the filter, the IVC, and both iliac veins, obtaining a satisfactory result. The patient was discharged after 7 days and did very well at 6-month follow-up, with no recurrent DVT. CONCLUSION: This case demonstrates the usefulness of combined percutaneous aspiration and rheolytic thrombectomy in treating extensive IVC thrombosis and occluded IVC filters, especially when thrombolytic therapy cannot be used.     

下腔静脉滤器置入术预防肺动脉栓塞61例临床分析

目的探讨经皮穿刺下腔静脉滤器置入术在治疗下肢深静脉血栓中预防肺动脉栓塞的作用。方法2003年3月至2005年2月,经股静脉或颈静脉穿刺放置永久性下腔静脉滤器61例,男性34例,女性27例,年龄34～90岁,平均66.7岁。深静脉血栓位于右下肢24例,左下肢34例,双下肢3例。常规行下腔静脉造影,了解并确定下腔静脉和释放途径无血栓形成,将滤器放置到肾静脉开口下的腔静脉。结果本组病例均释放成功,其中3例双下肢深静脉血栓的患者经颈静脉释放,其余均经股静脉释放;2例在超声定位下释放,其余均在静脉造影下完成。术后随访1～18个月,均无肺栓塞发生。结论经皮穿刺下腔静脉滤器置入术操作简便,可以有效预防下肢深静脉患者肺动脉栓塞的发生。     

Radiofrequency minimally invasive endovascular treatment of lower limbs varicose veins: clinical experience and literature review

AIM: Varicose veins of the legs are a common condition affecting 10-15% of men and 20-25% of women in the western world. This high prevalence is responsible of high medical and social costs. Most primary varices are associated with greater saphenous vein (GSV) incompetence. A new method, radiofrequency (RF) endovenous obliteration (VNUS-Closure' procedure), recently has been described as a less invasive and cost-saving alternative to stripping for the treatment of refluxing GSV. METHODS: Twenty-four patients with varicose veins underwent endovenous obliteration of the above knee GSV by VNUS Closure' procedure. The vein diameters were from 5 to 10 mm. The RF catheter was inserted via percutaneous puncture or through a small skin incision. All operations were performed in local, tumescent anesthesia, under ultrasound guidance. All patients were discharged 2 h after operation. Clinical and ultrasound follow-up was performed at 1 week, and at 1, 6, 12, 24 months. RESULTS: The complete or partial occlusion of the treated segment of the GSV has been achieved in 23 cases. In only one patient persisting patency of the GSV was immediately detected after the procedure. That was successfully treated by ultrasound guided foam sclerotherapy. All patients could resume all normal activities within 3-5 days. Every patient had reduction of varicosities, leg pain, fatigue and oedema. Adverse sequelae were minimal: 2 patients had transient thigh paresthesias. We didn't report deep venous thrombosis or pulmonary embolism (mean follow-up 26.7 months, range 15-33 months). CONCLUSION: A literature review and the authors'experience reveal that, in absence of significant complications, such as deep vein thrombosis and pulmonary embolism, there are significant advantages in the RF endovascular obliteration of the GSV. In effect, the Closure' procedure, in selected patients, offers reduced postoperative pain, shorter sick leaves, faster return to normal activities compared with vein stripping, and it appears to be cost-saving for society. The mid-term (36 months) recurrence rates after RF obliteration seem to be similar to the results of the conventional surgical management.     

Treatment of recurrent stroke and pulmonary thromboembolism with percutaneous closure of a patent foramen ovale and placement of inferior vena cava filter.

The association between recurrent episodes of pulmonary embolism, stroke, and congenital anomalies of the clotting system features a condition of increased risk of recurrences despite anticoagulant therapy. We report the successful management of this association with percutaneous closure of the foramen ovale and placement of an inferior caval vein filter.     

The role of intracaval filters in patients with COPD and DVT

A retrospective study of the Coney Island Hospital experience with Greenfield filters over a five-year period was undertaken. During this period, a total of 78 intracaval filters were placed in 76 patients. The patients' charts were reviewed for (1) indication for Greenfield filter placement, (2) complications of the procedure, (3) associated medical problems, and (4) follow-up information. The data revealed one statistically significant subpopulation within the group that had particularly poor survival statistics after intracaval filter insertion. These were patients who had a pulmonary embolism and also had chronic obstructive pulmonary disease (COPD). Considering the low morbidity associated with this procedure, it is the author's feeling that prophylactic intracaval filters in patients with deep vein thrombosis and COPD may be warranted.     

腔内治疗下腔静脉漂浮血栓8例

目的 总结下腔静脉(inferiorvenacava,IVC)漂浮血栓的临床特点.方法 选取2014年1月至2019年8月北京友谊医院收治的8例接受腔内治疗的IVC漂浮血栓患者,并总结其诊断和治疗方法及漂浮血栓的临床特点.结果 3例经IVC造影发现,5例经增强CT发现,其中5例有肺栓塞,1例伴有左肾静脉血栓,5例有下肢...     

Transfemoral venous access through inferior vena cava filters for interventions requiring large sheaths.

The presence of a filter in the inferior vena cava (IVC) to prevent pulmonary embolism from lower extremity deep vein thrombosis has traditionally been a contraindication for venous catheterization from the femoral vein. Certain interventional procedures require femoral access and occasionally, patients with IVC filters require these procedures. The authors report two such patients, one with a Greenfield filter requiring balloon mitral valvuloplasty and one with a Trapease filter requiring atrial septostomy. These cases demonstrate the technical feasibility of interventions across vena cava filters. Based on this experience and a review of the literature we describe in detail the techniques that allowed the procedures to be performed safely and successfully.     

滤器植入结合溶栓/抗凝预防肺动脉栓塞的长期随访结果

目的分析应用静脉滤器结合栓和抗凝治疗在深静脉血栓患者治疗及预防肺动脉栓塞的长期随访结果.方法24例急性或亚急性深静脉血栓患者,其中男13例,女11例;年龄14～86岁,平均52.4岁.24例患者经皮经股静脉植入静脉滤器.2例在术中辅以深静脉导管尿激酶溶栓治疗,20例在术后进行尿激酶静脉溶栓治疗.同时皮下注射低分子肝素10 d.口服华法林6个月.结果全部病例介入操作成功.对全部病例临床平均随访15个月(10～48个月).术后一周内18例患者的下肢水肿及疼痛迅速消失,其余6例患侧肢体肿胀、无力症状均有不同程度减轻.本组没有发生滤器移位及腔静脉血栓阻塞和肺栓塞病例,也没有发生出血性并发症.结论静脉滤器植入结合溶栓和抗凝是治疗急性或亚急性下肢深静脉血栓形成的一种安全、有效的方法,并能有效地预防肺栓塞的发生.