Stent implantation for iliac compression syndrome with acute deep vein thrombosis: a case report

An 80-year-old woman presented with left lower limb pain and swelling with tenderness over the great saphenous vein. Venography revealed thrombus in the lower leg vein and occlusion of the femoral vein. A temporary vein filter was placed below the renal vein and catheter intervention was performed. The wire was carefully advanced from the left femoral vein to the vena cava. Hard resistance was felt at the proximal iliac vein. After balloon dilation, intravascular ultrasonography showed a very flat lumen at the occlusion site. Stent implantation was performed followed by anticoagulation therapy. Venography at 3 months follow-up showed a widely opened iliac vein. Angiography showed the occlusion site was the crossing point of the right iliac artery and left iliac vein. Stenting for iliac compression syndrome is effective to maintain patency of the vein.     

Massive deep vein thrombosis after cesarean section treated with a temporary inferior vena cava filter: a case report

A 25-year-old woman suffered a massive deep vein thrombus in her left common iliac vein extending to the inferior vena cava after an abdominal cesarean section. The massive and floating inferior vena cava thrombus was considered to pose a high risk of pulmonary thromboembolism. After placement of a temporary inferior vena cava filter via the left brachial vein, thrombolytic therapy and anticoagulation therapy were instituted. The filter successfully prevented pulmonary thromboembolism during thrombolytic therapy. This patient was confined to bed because the filter moved vertically with left shoulder joint abduction. Although a temporary inferior vena cava filter is very useful for the prevention of pulmonary thromboembolism in a patient with deep vein thrombus, the appropriate range of activity for such a patient needs careful consideration.     

Placement of the inferior vena cava filter proximal to the renal vein in a patient with left-sided inferior vena cava complicated by pulmonary embolism: a case report]

A 55-year-old man was admitted to our hospital complaining of dyspnea and chest pain. Transthoracic echocardiography showed dilation of the right ventricle. Chest computed tomography with contrast medium showed multiple emboli in the pulmonary arteries. Venography of the lower extremities showed multiple thrombi in the right popliteal vein and the presence of left-sided vena cava. This unusual case of left-sided vena cava was complicated by deep vein thrombosis due to hemostasis. A Greenfield filter was placed in the vena cava proximal to the right renal vein in a right internal jugular vein approach.     

Use of a temporary caval filter in a young man with pulmonary embolism to prevent migration of massive caval thrombus during an attempt of caval thrombolysis

A 33 year old male with no known risk factors for hypercoagulability developed a massive thrombi in the inferior vena cava (IVC). The patient had a history of both pulmonary embolism and embolism related syncope. The thrombus which extended proximally to the level of the renal vein and distally to the left superficial femoral vein did not respond to anticoagulant therapy or thrombolysis. Thirteen days after admission, we decided to use a temporary caval filter to provide protection from migration of the thrombus while attempting invasive thrombolytic therapy, which was performed using a tissue type plasminogen activator through a coaxial catheter of the temporary filter. This resulted in a marked decrease in the size of the thrombus, and multiple thrombi were found to be trapped in the temporary filter. Although the temporary caval filter was effective in capturing emboli, resulting in a decrease in the thrombus size, the thrombus was not completely dissolved within two weeks, which is the maximal implantation time. A permanent filter was eventually used to prevent pulmonary embolism, which could arise from the remaining thrombus. We have found placement of a temporary caval filter to be a safe and effective adjunct, in select cases, when attempting thrombolysis of massive thrombi in the IVC. Since we inserted the temporary filter 13 days after admission, use of a temporary filter during thrombolysis may have been more effective if conducted earlier in our patient's clinical course.     

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.     

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.     

A case of superior vena cava syndrome due to extensive venous thrombosis of an idiopathic nature]

A 37-year-old man was admitted with facial edema and right arm swelling. Venography, computed tomography and magnetic resonance imaging showed massive organizing thrombi in the superior vena cava and bilateral internal jugular as well as subclavian veins, and showed no mass lesions occluding the veins in the mediastinum. Angioscopy demonstrated a white thrombus at the entrance of the right subclavian vein. All results of blood coagulation tests were normal. The patient was diagnosed as having superior vena cava syndrome caused by idiopathic venous thrombosis. Anti-coagulant therapy with intravenous tissue plasminogen activator injection and continuous urokinase and heparin infusion into the thrombi through a catheter were not effective in lysing the thrombi. Collateral circulation gradually developed and his symptoms decreased. We decided to follow this patient on warfarin medication because of the difficulty in removing the thrombi surgically.     

Anomalous inferior vena cava with azygos continuation, dysgenesis of lung, and clinically suspected absence of left pericardium

We report a case of anomalous continuation of the inferior vena cava with azygos vein, defect of left pericardium, and dysgenesis of lobes of the lungs. A 43-year-old man came to our hospital, complaining of dyspnea and cough with blood in the sputum. The chest roentgenogram showed moderate cardiomegaly with deviation to the left side of the thorax. Therapy with diuretics and bronchodilators reduced his complaints. A bronchogram and fiberoptic bronchoscopy showed double bronchial branches to the right upper lobe, one from the trachea and the other from the right main bronchus, and a blind pouch of the left lobe. Thoracic computed tomography showed the heart just behind the sternum. Venography showed anomalous continuation of the inferior vena cava and dilated azygos vein. We could not find such a complicated anomaly of the thoracic vessels and bronchus in an adult in the literature, so we believe that it is important to reconfirm the position of major vessels or organs before a thoracic procedure.     

Simultaneous urokinase perfusion in renal artery and vein in a case of renal vein thrombosis]

We present he case of a young man with nephrotic syndrome, caused by membranous glomerulonephritis, who developed renal vein thrombosis with extension to the inferior vena cava is presented. Renal vein thrombosis was diagnosed by echo Doppler and confirmed by angio-CT scan. At the hospitalization the patient presented a severe left flank pain, edema of the lower limbs and painful left testicular tumefaction. The treatment consisted of: 1) systemic anticoagulation with sodic heparin, 2) placement of temporary vena cava filter through the right jugular vein, 3) direct thrombolysis into endocaval thrombus with early lysis of thrombus, and 4) renal thrombolysis with selective simultaneous renal artery and renal vein infusion of urokinase. Angiography performed after 24 hours of loco-regional thrombolysis showed complete lysis of renal thrombus; clinically there was a regression of left flank pain. We conclude that, face to renal vein thrombosis, thrombolytic treatment with simultaneous renal artery and renal vein perfusion is mandatory. Furthermore it is very important, in presence of caval extension of renal thrombus, to place a temporary vena cava filter before starting thrombolysis, considering the high risk of pulmonary embolism related to this pathology.     

Retrievable vena cava filters: clinical experience

PURPOSE OF REVIEW: To summarize currently available literature regarding indications for inferior vena cava filters, potential problems associated with the different filters available, and the efficacy and safety of retrievable inferior vena cava filters. RECENT FINDINGS: The placement of permanent filters may present a number of long-term complications such as filter occlusion and an increased risk of recurrent deep vein thrombosis. Furthermore, patients who require inferior vena cava interruption often have short-term contraindications to anticoagulant therapy, and thus only require filters for temporary indications. Four different retrievable filters have recently received approval for temporary insertion, and preliminary data suggest that the use of these filters is associated with a low rate of pulmonary embolism and complications related to filter insertion. Retrieval was uneventful in almost all patients. No randomized clinical trials have yet been performed, and available information is based on the results of either retrospective or prospective cohort studies. SUMMARY: Retrievable filters are a very attractive alternative to either permanent or temporary filters when inferior vena cava interruption becomes necessary, thanks to the advantages of very easy management and the possibility of their being left in place for a long time and removed when they become unnecessary.     

Complex electrophysiology intervention in a patient with an inferior vena cava filter

Catheter ablation is currently a routine clinical method for the treatment of heart rhythm disorders. The presence of a filter in the lumen of the inferior vena cava represents a mechanical obstruction that may complicate or contraindicate the procedure. Still, there is not enough information available on this topic and there is no research data on the catheter ablation of complex left atrial arrhythmias with a transseptal puncture in the presence of an inferior vena cava filter. Our case report represents a successful complex electrophysiology intervention in both the left and right atria with femoral venous access in a patient with an inferior vena cava filter.     

Methodology of renal vein renin study: comparison between simultaneous and sequential sampling (author's transl)

Purpose of this study has been to compare the results obtained using two different procedures in blood sampling from the renal veins for measuring renal venous renin. The first is the classical procedure which employs three catheters for simultaneous sampling from both renal veins and from the inferior vena cava, or from an artery. The other one is a simplified procedure which employs a single catheter that allows blood to be collected in the following rapid sequential manner: right renal vein, inferior vena cava, left renal vein, inferior vena cava. We have studied 13 patients (8 with essential hypertension, 5 with unilateral renal artery stenosis). Two catheters were introduced through a femoral vein and inserted into both renal veins; a third catheter was inserted into the femoral artery; then the blood sampling was performed strictly simultaneously. Soon after, the blood sampling was repeated according to the above mentioned sequential single catheter procedure. PRA was measured by Angiotensin I radioimmunoassay, then the Renal Vein Ratios (RVRR) were calculated. Even though as average of less than 20 seconds elapsed between the blood sampling in a renal vein and that in inferior vena cava, our results demonstrate that the release of renin can vary so quickly that erroneous informations may be obtained unless a strictly simultaneous sampling of blood is performed. In conclusion, our study demonstrates that the only reliable renal vein renin sampling procedure must employ the simultaneous renal venous and arterial (or inferior vena cava) blood collection.     

Total anomalous pulmonary venous draining to inferior vena cava

A 12-year-old girl complained of tachycardia and dyspnea after exertion but without cyanosis. Her echocardiogram showed an ASD and a widened inferior vena cava. A difference in PO2 between inferior and superior vena cava was evident. An anastomosis between left atrium and pulmonary vein, and a long oval pericardium to cover the opening of the descending vein and ASD into left atrium were performed during cardiopulmonary bypass. The patient recovered without complications.     

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.     

Protected iliofemoral venous thrombectomy in a pregnant woman with pulmonary embolism and ischemic venous thrombosis

Although thromboembolism is uncommon during pregnancy and the postpartum period, physicians should be alert to the possibility because the complications, such as pulmonary embolism, are often life threatening. Pregnant women who present with thromboembolic occlusion are particularly difficult to treat because thrombolysis is hazardous to the fetus and surgical intervention by any of several approaches is controversial. A 22-year-old woman, in her 11th week of gestation, experienced an episode of pulmonary embolism and severe ischemic venous thrombosis of the left lower extremity The cause was determined to be a severe protein S deficiency in combination with compression of the left iliac vein by the enlarged uterus. The patient underwent emergency insertion of a retrievable vena cava filter and surgical iliofemoral venous thrombectomy with concomitant creation of a temporary femoral arteriovenous fistula. The inferior vena cava filter was inserted before the venous thrombectomy to prevent pulmonary embolism from clots dislodged during thrombectomy When the filter was removed, medium-sized clots were found trapped in its coils, indicating the effectiveness of this approach. The operation resolved the severe ischemic venous thrombosis of the left leg, and the patency of the iliac vein was maintained throughout the pregnancy without embolic recurrence. At full term, the woman spontaneously delivered an 8-lb, 6-oz, healthy male infant.     

Histopathology of membranous obstruction of the inferior vena cava in the Budd-Chiari syndrome.

It is generally believed that membranous obstruction of the inferior vena cava in the Budd-Chiari syndrome is caused by congenital malformation. However, it does not explain the late onset of the disease. In the current study, hepatic portion of the inferior vena cava and hepatic veins were studied in 17 autopsy cases of the Budd-Chiari syndrome, 16 of which had no demonstrable cause (idiopathic). A sufficient amount of vena cava tissue was available for evaluation in 15 cases. Nine had membranous obstruction, with thickness varying from 3 to 8 mm. Thrombus formation was recognized in 7 of 9 cases. Occlusion of hepatic vein orifices of varying degree was present in 8 cases. In these occluding lesions, the basic structure of the venous wall was maintained. The intima was transformed into a fibrous laminar structure, and organized thrombi of varying ages were recognized; they were a mixture of fresh thrombi, organized thrombi, fibrous tissues, recanalizations, and calcifications. It is concluded that in these cases of the Budd-Chiari syndrome, occluding and stenosing lesions in the inferior vena cava and hepatic veins were thrombosis and its sequelae. There was no indication of congenital malformation.     

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.     

Successful metallic stent placement for recurrent stenosis after balloon angioplasty of membranous obstruction of inferior vena cava.

A 23 year-old Taiwanese male presented with complete membranous obstruction of the inferior vena cava at its suprahepatic portion. After 3 angioplasty procedures using Inoue-balloon catheters, a Wall stent was deployed for restenosis 4 years after the first procedure. Venography at 6 months showed no significant restenosis. At 20 months transfemoral venography confirmed patency of the vena cava.     

Growth of hepatocellular carcinoma into the right atrium. Report of five cases

Five patients had hepatocellular carcinoma growing into the right atrium. Clinically, all patients had edema in the legs, venous dilatation in the abdominal wall, ascites, and dyspnea. Paroxysmal aggravation of dyspnea and its alleviation by a left decubitus position were noted in three patients. Three patients developed shock after a change in posture. A gallop rhythm in the cardiac murmur was detected in two. Pathologically, all livers had hepatocellular carcinoma and macronodular cirrhosis. At autopsy, a tumor thrombus was found that completely occluded the right hepatic vein and extended into the inferior vena cava and right atrium, partially occluding the inferior vena cava. Antemortem diagnosis of right atrial tumor thrombi in patients with primary hepatocellular carcinoma is difficult, but the condition should be suspected when dyspnea, abnormal cardiac sounds, and shock develop.     

Urokinase recanalization of extensive thrombosis of the superior vena cava secondary to an implantable perfusion device

A superior vena cava syndrome developed suddenly in a 36 year old man who had been undergoing chemotherapy via an implanted venous access catheter for 18 months. Venography showed superior vena cava thrombosis extending bilaterally to the subclavian veins. Direct local thrombolysis with low-dose Urokinase resulted in partial recanalisation with an excellent clinical result despite the persistence of an endovenous sequestrum situated at the catheter tip, a sequela of previous thrombosis. This case underlines the importance of direct local thrombolysis in patients with a Port-a-Cath system complicated by a thrombosis.