A case of deep venous thrombosis with a double inferior vena cava effectively treated by suprarenal filter implantation

Embryogenesis of the inferior vena cava (IVC) is a complex process involving the formation and regression of several anastomoses, thus, various anomalies may occur. We report a case of deep venous thrombosis (DVT) accompanied by a double inferior vena cava (DIVC). A 76-year-old-man was admitted because of right leg edema and pain. Venography revealed two IVC and massive venous thrombus. To avoid massive pulmonary embolism (PE), it was necessary to block both the right and the left IVC. However, the right IVC was too small to implant the filter, so we placed a temporary IVC filter (Antheor filter) in the suprarenal portion of the IVC, after the confluence of the two IVC, and started thrombolytic and anticoagulant therapy. Venography, performed 6 days after filter implantation, showed a considerable amount of remaining thrombus. We replaced the Antheor filter with a Gunther retrievable filter because the former has a catheter and is not suited for long-term use, whereas the latter can be used permanently. Two weeks after filter exchange, thrombus had decreased but remained. We therefore did not remove the Gunther filter. The patient's symptoms gradually improved in response to anticoagulant therapy, and he was discharged with no complications. The present case illustrates the importance of a correct understanding of anatomy and demonstrates the effectiveness of using a suprarenal IVC filter in DVT.     

Migration of an inferior vena cava filter to the right ventricle and literature review

Migration of an inferior vena cava (IVC) filter to the heart after placement is an extremely rare complication. The case of a 42-year-old man who presented with ventricular arrhythmia and tricuspid valve regurgitation, and underwent open heart surgery to extract an IVC filter from the right ventricle 12 days after infrarenal IVC filter placement, is reported.     

Transpopliteal removal of an OptEase inferior vena cava filter after treatment of symptomatic filter thrombosis.

PURPOSE: To describe a case of transpopliteal retrieval of an inferior vena cava (IVC) filter. CASE REPORT: A paraplegic patient had an IVC filter placed for deep venous thrombosis (DVT) after anticoagulant therapy was stopped. Two weeks later, he developed massive scrotal and bilateral lower extremity swelling due to iliocaval thrombosis, which was treated by power pulse-spray thrombectomy and catheter-directed thrombolytic infusion via bilateral popliteal approaches. Following successful thrombus removal, the filter was uniquely retrieved via the right popliteal access; the patient was discharged on warfarin anticoagulation. CONCLUSION: Transpopliteal IVC filter retrieval is feasible and may be a useful alternative technique in selected instances.     

An Unusual Cause of Acute Cardiogenic Shock in the Operating Room

A 51‐year‐old man with a renal carcinoma with inferior vena cava (IVC) invasion was referred to our hospital for the performance of a radical nephrectomy with IVC thrombus excision. To prevent embolism, an IVC filter was implanted the day before surgery below the suprahepatic veins. On nephrectomy completion, the clinical status of the patient started to deteriorate and an unsuccessful attempt was made to excise the IVC thrombus. The patient developed profound refractory hypotension without significant bleeding and worsening splanchnic stasis was noted. A transesophageal echocardiogram was immediately performed in the operating room, revealing a hemispheric mass protruding from the IVC ostium to the right atrium, completely blocking all venous return. Volume depletion was evident by low left and right atrial volumes and increased septum mobility. No other abnormalities were found that could explain the shock, namely ventricular dysfunction or valvular disease. Cardiac surgery consultation was immediately obtained, ultimately deciding to perform a median sternotomy with direct exploration of right atrium. Under cardiopulmonary bypass, a 6‐cm long thrombotic mass was identified, involving the IVC filter, blocking all lower body venous return; the removal of the mass reversed the shock. The patient had an uneventful recovery. Adverse outcomes associated with IVC filters are common. Our case highlights the importance of a team approach to rapid changes in hemodynamic status in the operating room, including the surgeon, the anesthesiologist, and the cardiologist. It also emphasizes the pivotal role of transesophageal echocardiogram in the clinical evaluation of severely unstable patients.     

The inferior vena cava: an exceptional source of atrial fibrillation

Mapping in a patient undergoing radiofrequency ablation for drug-refractory paroxysmal atrial fibrillation in the setting of repetitive, monomorphic atrial ectopic beats with negative p waves in the inferior leads revealed an arrhythmogenic focus located in the posteromedial inferior vena cava (IVC) 1 cm below the right atrium to IVC junction. The focus was mapped using a Lasso catheter with successful irrigated-tip catheter ablation at the site of earliest activity. This case demonstrates that, in rare cases, arrhythmogenic muscular sleeves can be found in the IVC and that the IVC can be electrically disconnected from the right atrium using radiofrequency energy.     

Pulmonary embolization as primary manifestation of hepatocellular carcinoma with intracardiac penetration： A case report

Intracardiac manifestation of hepatocellular carcinoma (HCC) is a rare condition and an uncommon finding even at autopsy. Pulmonary tumor embolism as a presenting feature of HCC has been published only twice previously. In our case report, a 63-year-old man presented with high fever and six episodes of recurrent pneumonias during the last half year. Echocardiography was performed, a solid mass was found in the right atrium. Transesophageal echocardiography proved a tumor mass in the inferior vena cava (IVC) extending into the right atrium, abdominal ultrasound revealed tumor mass in the IVC and a solid tumor in the liver. Combined liver and heart surgery was attempted in order to remove the tumor mass from both the liver and the right atrium. Acute cor pulmonale occurred during tumor removal from the right atrium and the patient expired. In addition to local factors the possibility of embolization should arise in the background of recurrent pneumonia. Occult carcinoma must be included in possible causes of recurrent pulmonary embolism. Searching for primary malignancy should include HCC as frequent cause of hypercoagulability. In case of HCC, echocardiography is suggested because of the possibility of expansion in IVC or right atrium and tumor-embolization.     

Leiomyosarcoma of the inferior vena cava--a very rare case report.

The authors present a case report of a patient with abdominal pain that began 6 months before hospital admission. Ambulatory abdominal echography and computed tomography (CT) revealed partial thrombosis of the inferior vena cava (IVC) with right atrial extension. During hospitalization, magnetic resonance imaging (MRI) revealed aspects suggesting a tumoral lesion of the right atrium, rather than a thrombus, with tumoral extension to the IVC. The echocardiogram showed images suggesting a right atrial tumor. Transesophageal echocardiography confirmed the diagnosis. During surgery, an IVC tumor was found invading the right atrium, which histopathology confirmed as a leiomyosarcoma. The authors present this case because this type of tumor is rare (21 cases worldwide at this anatomic site), it is difficult to diagnose, and its management has not been adequately described. The authors review the literature relevant to this case.     

Temporary caval filter allowing diagnosis and fibrinolytic therapy in patients suspect of massive pulmonary embolism

The authors propose a therapeutic strategy enabling diagnosis, treatment and prevention in the same clinical procedure based on a series of 8 patients presenting with signs of massive pulmonary embolism (acute cardiorespiratory distress, shock, loss of consciousness, and/or cardiac arrest). A removable vena cava filter is rapidly introduced percutaneously via a brachial, femoral or jugular vein, and opened in the inferior vena cava. Using the same catheter and without a second venous puncture, pulmonary angiography and cavography are performed by digitised angiography using a small quantity of contrast medium (40 ml, 12 ml/sec). The diagnosis of massive pulmonary embolism (index of pulmonary obstruction 70 to 90%) was confirmed in 6 out of the 8 cases. In 2 patients, the contrast medium passed from the right atrium into the left atrium and one of the patients developed hemiplegia. Thrombolytic drugs (rt-PA followed by Streptokinase) were injected via the same filter catheter. The dosage of rt-PA was 20 to 50 mg as a bolus followed by 50 mg in 2 hours. Streptokinase was then infused at a dose of 100,000 U/hour for an average of 36 hours (24-48 hours), followed by intravenous heparin and oral vitamin K antagonists. Two patients required blood transfusion for haemorrhage during the relay with heparin. The temporary caval filter was removed in all cases but 3 patients required a definitive filter because of the persistence of life-threatening venous thrombosis. Seven of the 8 patients survived their pulmonary embolism. This approach is rapid, saves time, and spares the patients from more invasive procedures.     

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.     

Azygos continuation of interrupted inferior vena cava in association with sick sinus syndrome

Various diagnostic and therapeutic procedures of the right side of the heart and the systemic venous system have increased the need for ready access to the inferior vena cava (IVC) through the transfemoral route. Anatomical variations or obstruction of the IVC can make these procedures difficult. The case of 47 year old woman with an interrupted infrahepatic IVC with azygos continuation accompanied by sick sinus syndrome and a structurally normal heart is reported. Negotiating a temporary pacing lead from the IVC to the right atrium was difficult. Ultimately, the lead took the course from the IVC to azygos vein to superior vena cava to right atrium to right ventricular apex. Permanent VVI pacing through the right subclavian route was uneventful, as the superior vena cava and its tributaries had a normal course. An awareness of the existence of these anomalies before pacing can lead to the use of an alternative route for pacing, which may avoid undue delay of an otherwise urgently needed procedure.     

Recurrent hepatocellular carcinoma with tumor thrombus in right atrium - report of a successful liver resection with tumor thrombectomy using total hepatic vascular exclusion without concomitant cardiopulmonary bypass

For resection of advanced hepatocellular carcinoma (HCC) in which tumor thrombus (TT) extends into inferior vena cava (IVC) or right atrium (RA) surgery is challenging and requires skillful techniques. Here, we report a case of recurrent HCC with TT extending to the RA, who underwent successful resection with tumor thrombectomy without concomitant cardiopulmonary bypass. A 71-year-old man, who had been followed- up for hepatitis C by a local hospital, was diagnosed as having HCC in segment 6 for which he had undergone segmentectomy of segment 6 in May 2009. During follow-up, he developed severe leg edema and ascites with investigations revealing recurrent HCC in segment 7 with TT extending to the right atrium via IVC. After transarterial embolization the patient underwent extended resection of the segment 7 with tumor thrombectomy of the IVC and the right atrium and partial resection of the IVC wall using total hepatic vascular exclusion, without concomitant cardiopulmonary bypass. Total ischemic time was 23 minutes, operation time was 6 hours and blood loss was 2,474mL. The postoperative course was uneventful. Histopathology was recurrent hepatocellular carcinoma with hepatic venous invasion. We report the case of resected recurrent HCC with TT extending to right atrium without concomitant cardiopulmonary bypass.     

Successful MitraClip® implantation after angioplasty of a chronic inferior vena cava filter thrombosis

The MitraClip® has increasing use for severe, high surgical risk mitral regurgitation (MR). The MitraClip® is implanted percutaneously across the interatrial septum. Given the large diameter of the device delivery system, the femoral vein is the best option for central venous access. This is the first reported case of successful MitraClip® implantation through a chronically occluded IVC filter. © 2015 Wiley Periodicals, Inc.     

Placement of a large transseptal cannula through an inferior vena cava filter for TandemHeart percutaneous left ventricular assist

We report a case of successful TandemHeart implantation for cardiogenic shock due to critical aortic stenosis using a 21 Fr transseptal cannula which was safely advanced through an existing inferior vena cava (IVC) filter under fluoroscopic guidance. This supported the patient through balloon valvuloplasty and subsequent definitive surgical valve replacement. This report demonstrates that the IVC filter can be safely crossed with a sheath as large as 21 Fr in size. In addition, patients with an existing IVC filter requiring a TandemHeart percutaneous ventricular assist device should not be denied this device for fear of dislodging the filter.     

Perforation of inferior vena cava during filter placement

The placement of an inferior vena cava (IVC) filter is a therapeutic method for selected patients with deep venous thrombosis and pulmonary embolism. However, insertion and placement of the filter may be associated with certain complications. For instance, retroperitoneal hematoma resulting from perforation of the wall by the filter is such a very rare but serious complication. We report the case of a 64-year-old woman with perforation of the IVC wall and consecutive hematoma caused by the filter who was treated surgically.     

Surgical management of a penetrated greenfield inferior vena cava filter

This is a case report of an IVC filter penetration identified during lymph-node dissection for endometrial carcinoma. Although the spread strut put the adjacent abdominal aorta in danger of penetration, surgical removal of the filter could not be performed because there was still an increased risk of pulmonary embolism. Instead of IVC interruption, we used a wrapping technique as a prophylaxis against major bleeding complication due to IVC filter dislocation and recurrent pulmonary embolism.     

Successful resection of renal cell carcinoma with tumor thrombi extending into the right atrium: a case report.

Renal cell carcinoma (RCC) is often associated with an extension of tumor thrombi into the inferior vena cava (IVC) and occasionally up to the right atrium. RCC with IVC involvement has a relatively favorable prognosis when it is completely resected. We present a successfully resected case of RCC with tumor thrombi extending into the right atrium. We performed radical right nephrectomy with lymph node dissection and removed the tumor thrombi en bloc under total hepatic vascular exclusion with the veno-venous bypass between the IVC and the right atrium using an active centrifugal force pump. The patient has been in good condition for 3 years since surgery with no evidence of recurrence.     

The use of inferior vena cava filter as a treatment modality for massive pulmonary embolism. A case series and review of pathophysiology

The use of inferior vena cava (IVC) filter for massive pulmonary emboli (PE) with cardiopulmonary instability has not been clinically studied. We present a case series of six such patients who received an IVC filter with anticoagulation rather than thrombolysis because of high risk of bleeding. Acute pulmonary embolectomy was considered, but was not possible for a variety of individual clinical situations.These six hospitalized patients prospectively followed during their admission. They were triaged to three medical intensive care units (ICUs) and one surgical ICU in three university teaching hospitals. One patient was transferred from another institution. All six patients had severe hypoxia and tenuous cardiopulmonary status. All required high inspiratory oxygen and hemodynamic support; two required mechanical ventilation and vasopressors. An IVC filter was placed emergently and anticoagulation was started immediately All six patients had resolution of pulmonary thromboemboli (PTE) on anticoagulation while the IVC filter prevented further PE. All six patients were discharged home in their pre-critical illness state. None ofthe patients suffered complications from this therapy and had excellent resolution ofcardiopulmonary collapse. The IVC filter placement prevented further major embolic events while the PTE resolved with anticoagulation. An IVC filter should be considered as an adjunct to anticoagulation therapy for those patients with massive PE and cardiopulmonary instability who are not candidates for thrombolysis, and acute pulmonary embolectomy is not readily available or is of very high risk.     

Sudden cardiac death caused by migration of a TrapEase inferior vena cava filter: case report and review of the literature

CASE: A 43-year-old female presented with sudden onset of palpitations, chest pain, and shortness of breath associated with hypoxemia. A helical computed tomography (CT) scan of the chest revealed a large saddle pulmonary embolism. Intravenous tPA relieved the shortness of breath and improved the hypoxemia. Inferior vena cava (IVC) filter (TrapEase, Cordis Corp., Miami, FL, USA) was placed. On day 6 of her hospitalization, she went into cardiopulmonary arrest while walking back from the rest room. The patient died despite a prolonged attempt at cardiopulmonary resuscitation. At that time, ventricular tachycardia and then ventricular fibrillation were recorded. Autopsy of the heart showed the IVC filter entrapped within the tricuspid valve. DISCUSSION: The incidence of IVC filter migration ranges from 0.3 to 6% with rare migration to the heart or lung (0.1-1.25%). Sudden cardiac death from migration of IVC filter is extremely rare. We report the first case of sudden cardiac death caused by migration of the TrapEase filter to the heart. There are two reports in the literature of death from migrating Greenfield and Antheor filters. CONCLUSION: An IVC filter migration to the heart, although rare, can cause serious arrhythmia and sudden cardiac death.     

Two discrete masses of leiomyomatosis in a patient, one extending to the right atrium

Leiomyomatosis extending to the right side of the heart through the inferior vena cava (IVC) is an extremely rare neoplasm. Although it is pathologically classified as a benign neoplastic formation, its growth and recurrence rate makes its extirpation mandatory. In this case report, we describe a 57-year-old woman who presented with leiomyotosis extending from the IVC to the right atrium (RA). This patient had presented with uterine leiomyoma three years previously. The patient died in the operating theatre from hemostatic problems after surgical complications arising from the unexpected presence of a second tumor.     

Abnormal drainage of inferior vena cava to left atrium together with a partial abnormal pulmonary venous drainage to right atrium in the presence of atrial septal defect

The direct abnormal drainage of the inferior vena cava (IVC), while rare, is well‐recognized anomaly of systemic venous drainage. It has been reported both in isolation and in association with other cardiac defects. This is a case of an abnormal drainage of IVC into left atrium (LA) together with partial abnormal pulmonary venous drainage to the right atrium (RA) and atrium septal defect (ASD).