What to do with a free-floating venous thrombus

Among patients with deep vein thrombosis (DVT), the frequency of pulmonary embolism seems conditioned by the location of DVT and thrombus adherence. Consequently, patients with free-floating iliac thrombus are at high risk of life-threatening pulmonary embolism. As regards their definition, non adherent thrombus and free-floating thrombus are not synonymous. Non adherent thrombi are usual in recent DVT and have the same prognosis and treatment as common DVT. The term of free-floating thrombi should be reserved for the iliac location when a small area of the thrombus is attached to the iliac vessel wall but the rest of it does not adhere to the wall. At present, venography is the gold standard for diagnosis but duplex scanning and scanner or magnetic resonance imaging should also be evaluated for this purpose. The treatment comprises the usual anticoagulant therapy with heparin and a specific treatment for the free-floating thrombus. 1) Vena cava filter is a rapid safe solution that avoids severe pulmonary embolism, but in the case of thrombus detachment, vena cava obliteration might occur with the subsequent risk of severe bilateral venous stasis and insufficiency. The indications for such treatment might be elderly patients in a poor general condition. 2) Venous thrombectomy. Venous thrombectomy only removes the free part of the thrombus, thus preserving the contralateral iliac vein from further complications. A clip is positioned on the inferior vena cava. 3) Protected fibrinolysis. The latest catheters allow transient vena cava filter device placement. Thrombolytic therapy with rTPa might achieve thrombolysis and subsequently restore the venous circulation.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Catheter interventional therapy in an elderly patient with deep vein thrombosis and a brain tumor

A 92-year-old woman with a brain tumor developed swelling of the left lower extremity. Venography showed considerable thrombi from the left common iliac vein to the femoral vein. Following implantation of a temporary inferior vena cava filter, catheter aspiration therapy and catheter-directed thrombolysis were performed. Venography after 3 days showed disappearance of the thrombi and an improvement in vein flow. A permanent inferior vena cava filter was implanted. Local intensive thrombectomy and thrombolysis by catheter together with a temporary inferior vena cava filter were effective treatments in this elderly patient with deep vein thrombosis.     

Deep venous thrombosis: results of thrombectomy versus medical therapy. Presented at the 5th European-American Symposium on Venous Diseases, Vienna, Austria, Nov. 7-11, 1990.

Between 1.1.1985 and 1.1.1988, 158 patients were referred because of acute deep venous thrombosis. They were 82 women (median age 48.5) and 76 men (median age 56.5). On admission, 4 patients had already a pulmonary embolism in 3 others embolism occurred during hospitalisation. The segment involved was the isolated iliac in 10, iliofemoral in 53, isolated femoral in 7, femorotibial in 47 and isolated tibial in 41 patients. Anticoagulation and compression therapy was undertaken in 102 and mortality was 21%. At follow-up 63% had at least 1 sign of venous insufficiency, in all 16% had no sequelae and were subjectively symptom-free. Thrombolytic therapy was carried out in 25, mortality was 8%. At follow-up, 72% had at least one sign of venous insufficiency. Venous thrombectomy was performed in 31, combined in 4 with balloon dilatation of an iliac spur. Mortality was low with 3%, 58% had at least one sign of venous insufficiency at follow-up and 39% were subjectively symptom-free. Our results show that an objective assessment is insofar difficult because subjective and clinical results do not correlate; 51% with clinically verified post-therapeutic venous insufficiency had normal venous drainage in strain-gauge plethysmography, whilst 41% without subjective discomforts demonstrated an insufficient drainage. Our results show that a full restitution is seldom achieved, thrombectomy does not prevent chronic venous insufficiency. Best results were observed in isolated iliac thrombosis. We conclude that thrombectomy should be restricted to the phlegmasia caerulea dolens form of DVT, while floating thrombus and ascending thrombus extending into the vena cava should be treated with a cava filter or ligation.     

Acute pulmonary embolism unmasking underlying chronic thromboembolic pulmonary hypertension and iliac vein compression syndrome

We describe the case of a 72‐year‐old gentleman who was referred to our institution for management of cardiogenic shock from a massive pulmonary embolism. Right heart catheterization revealed a low cardiac index and markedly elevated pulmonary pressures, suggested long‐standing venous thromboembolic (VTE) disease that evolved into chronic thromboembolic pulmonary hypertension (CTEPH). The patient was cannulated to veno‐arterial extra‐corporeal membrane oxygenation and eventually treated with pulmonary embolectomy and thromboendarterectomy. Subsequently discovered inferior vena cava clot and left iliac deep vein thrombosis were treated with suction and mechanical thrombectomy. Intravascular ultrasound of the left lower extremity venous system identified iliac vein compression syndrome (IVCS) as the culprit of the patient's VTE and CTEPH. A left iliac stent was placed and the patient was discharged on Warfarin for anticoagulation. The case illustrates the rapidly expanding armamentarium for VTE treatment and proposes IVCS as a new, potentially underrecognized risk factor for CTEPH.     

Recurring pulmonary embolism despite the presence of a vena cava filter: a case report from the CNHU Cotonou-Benin

A 50-year-old man presents several clinical signs of pulmonary embolism, but this diagnosis was excluded due to the lack of venous thrombosis of the lower limbs and because the presence of a vena cava filter. The same signs reoccurred a few months later, leading to the diagnosis of venous thrombosis of the lower limbs with severe successive pulmonary embolism. This clinical case illustrates the potentially incomplete efficacy of vena cava filters for the prevention of pulmonary embolism.     

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.     

Deep venous thrombosis and pulmonary thromboembolism associated with a huge uterine myoma--a case report

A 51-year-old woman with a large uterine myoma suffered from acute pulmonary thromboembolism. Venography revealed thrombosis in the right common iliac vein and almost complete obstruction of the left common iliac vein. The ascending lumbar vein showed collateral drainage. Treatment was initiated with continuous intravenous heparin sodium, and a Greenfield filter was inserted to prevent the extension of the pulmonary embolism during and after hysterectomy. After a total hysterectomy, venography revealed restoration of patency in the bilateral common iliac veins, and no flow was seen in the ascending lumbar vein. Thorough clinical examinations failed to identify any other prothrombotic conditions. These results suggest that a large uterine myoma compressed veins in the pelvis, and the resulting impaired blood flow caused deep venous thrombosis and pulmonary thromboembolism.     

A population-based study of the effectiveness of inferior vena cava filter use among patients with venous thromboembolism

BACKGROUND: There are few population-based data regarding the effectiveness of inferior vena cava filter use in the prevention of symptomatic pulmonary embolism. OBJECTIVE: To determine the 1-year cumulative incidence of rehospitalization for venous thrombosis or pulmonary embolism among patients with thromboembolism treated with a vena cava filter compared with the incidence in a control population with thromboembolism. PATIENTS AND METHODS: Population-based retrospective analysis of linked hospital discharge abstracts in California. From January 1, 1991, through December 30, 1995, 3632 patients were treated with a filter and 64,333 controls were admitted with a principal diagnosis of venous thromboembolism. RESULTS: Filter-treated patients had significantly greater comorbidity, with a higher frequency of previous pulmonary embolism, recent major bleeding, malignant neoplasm, and stroke. Patients who initially manifested pulmonary embolism were significantly more likely to be rehospitalized for pulmonary embolism than patients with an initial diagnosis of venous thrombosis alone, among filter-treated patients (relative risk, 6.72; 95% confidence interval, 3.61-12.49) and controls (relative risk, 5.30; 95% confidence interval, 4.61-6.10). Risk-adjusted proportional hazards modeling showed no significant difference between filter-treated patients and controls in the relative hazard of rehospitalization for pulmonary embolism. However, filter placement was associated with a significantly higher relative hazard of rehospitalization for venous thrombosis among patients who initially manifested pulmonary embolism (relative hazard, 2.62; 95% confidence interval, 2.09-3.29), but not among those who presented with venous thrombosis (relative hazard, 1.14; 95% confidence interval, 0.92-1.43). CONCLUSIONS: Insertion of a vena cava filter was not associated with a significant reduction in the 1-year incidence of rehospitalization for pulmonary embolism. Use of a filter was associated with a higher incidence of rehospitalization for venous thrombosis, but only among patients who initially manifested pulmonary embolism. A prospective clinical study is needed to determine the efficacy of filter use among patients with pulmonary embolism who do not meet strict guidelines for insertion of a vena cava filter.     

Arterial and venous thrombosis in rare congenital bleeding disorders: a critical review

A thorough review of the literature and of personal files has allowed the gathering of 81 patients with rare congenital bleeding disorders and thrombotic phenomena. Sixteen of these patients had congenital afibrinogenemia, eight involved factor V deficiency, 20 factor VII defects, 33 factor XI deficiencies and only one, a factor XIII defect. Altogether 42 patients showed arterial thrombosis (myocardial infarction [MI] in 28 cases; ischemic stroke in 4; arterial occlusion in 8; 2 patients with disseminated intravascular coagulation (DIC)). Ages varied between 13 and 74. Twenty-two patients were males and 16 females. In four cases, sex was not reported. There were three fatalities: two after a MI and one because of heart failure. With regard to venous thrombosis: 9 patients had pulmonary embolism, 15 patients had deep vein thrombosis, 9 patients had both pulmonary embolism and deep vein thrombosis; 1 patient had superficial vein thrombosis, whereas, 5 cases had an unusual site venous thrombosis (two portal systems, two cerebral sinuses, one inferior vena cava) for a total of 39 cases. Age varied between 3 and 86. In this case, 20 patients were males and 17 were females. In two cases, sex was not reported. There were three fatalities: two because of pulmonary embolism and one because of inferior vena cava thrombosis. The fact that thrombosis has never been described in patients with factor II or factor X seems to underscore the central antithrombotic role that these two factors have in the coagulation system.     

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.     

Initial clinical experience with an endoluminal spiral prosthesis for treating complicated venous thrombosis and preventing pulmonary embolism

Fourteen patients with complicated venous thrombosis or recurrent pulmonary embolism were treated by implantation of an endoluminal spiral prosthesis subsequent to balloon angioplasty, surgical thrombectomy or embolectomy, a combination of these, or, in 2 cases, no other treatment. The patients were divided into 2 groups, based on their primary diagnosis and the purpose of the prosthesis. Group I included 8 patients with extensive iliofemoral or caval thrombosis, caused by congenital caval stenosis (1 case) or extravascular compression or retraction (7 cases); 7 of these patients had had previous operations, and the remaining patient had undergone thrombolysis, which failed. The current treatment consisted of balloon angioplasty and surgical thrombectomy or embolectomy, and implantation of an endoluminal spiral stent to prevent elastic recoil of the vessel. In 4 cases, an arteriovenous fistula was constructed and was taken down 3 months later; in 1 additional patient, a bilateral arteriovenous fistula was created. Group II comprised 6 patients with recurrent pulmonary embolism (4 cases), massive pulmonary embolism (1 case), or paradoxical bilateral carotid artery embolism (1 case). Four of these patients underwent surgical thrombectomy or embolectomy, while 2 had no treatment other than filter implantation. All 6 underwent transluminal implantation of a helix caval filter (a modification of the endoluminal spiral stent). All but 1 implantation was accomplished by means of either a transfemoral or a transjugular cutdown; the remaining implantation was performed transatrially after a pulmonary embolectomy. The only device-related complication was a retroperitoneal hematoma in Group I, resulting from perforation of the inferior vena cava by the guidewire during device implantation. This complication necessitated an emergency laparotomy and takedown of the arteriovenous fistula, which resulted in rethrombosis of the left iliofemoral vein. The other 7 stented veins were patent at early phlebographic follow-up, as were all 5 of those studied later. One Group-I patient died 4 months after surgery, due to tumor progression and without signs of caval restenosis. Twelve months postoperatively, 1 Group-II patient died of urosepsis without a recurrence of pulmonary embolism. Four of the 6 Group-II patients were studied late postoperatively, and all of their stented vessels were patent. There was no operative mortality or postoperative embolism. On the basis of these results, we conclude that endoluminal stenting with an expandable spiral prosthesis is a promising method for remote venous reconstruction. Moreover, it appears that the modified stent, or helix caval filter, compares favorably with commercially available filters.     

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。     

Venous thrombectomy and caval interruptions

Authors study the role of surgical treatment in the venous thrombo-embolic disease. At the moment, venous thrombectomy can be performed only in post-operative unilateral iliac thrombosis as well as in juxtarenal vena cava thrombosis (so as to enable a sub-nephric cava interruption) and finally to ilio-cava thrombosis. Vena cava interruptions can be performed either through a peri-cava clip, or by an intra-cava filter (the most efficient appears to be the K.R. Greenfield filter). Various advantages are thus studied. Vena cava interruptions are then discussed, according to clinical and angiographic data.     

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.     

Popliteal venous aneurysm, a cause of pulmonary embolism

Generally, most aneurysms of the venous system are probably congenital and rarely have clinical significance. Popliteal aneurysms are an exception of this rule and are known to be a source of recurrent pulmonary emboli. We present a previously healthy 42 year old man with multiple pulmonary emboli, diagnosed with a high probability lung scan. Venous duplex imaging and magnet resonance imaging showed a mass with connection to the popliteal vein of the left knee, suggesting a venous aneurysm. Despite therapeutic anticoagulation he suffered further pulmonary emboli. After insertion of a temporary vena cava inferior filter aneurysm resection and patch reconstruction of the popliteal vein was performed. By duplex imaging we proved the patency of the popliteal vein after surgical repair. Popliteal venous aneurysms should be kept in mind as possible thromboembolic source in young patients with pulmonary embolism. Our review of the current literature about popliteal venous aneurysms revealed a high rate of pulmonary embolism.     

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.     

Critical review of mouse models of venous thrombosis

Deep vein thrombosis and pulmonary embolism are a significant health care concern, representing a major source of mortality and morbidity. In order to understand the pathophysiology of thrombogenesis and thrombus resolution, animal models are necessary. Mouse models of venous thrombosis contribute to our understanding of the initiation, propagation, and resolution of venous thrombus, as well as allow for the evaluation of new pharmaceutical approaches to prophylaxis and treatment of deep vein thrombosis. In this work we review the ferric chloride model, the inferior vena cava ligation model, the inferior vena cava stenosis models, and the electrolytic inferior vena cava model and compare their advantages and disadvantages.     

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...     

Paradoxical pulmonary embolism. A rare complication of arteriovenous fistulization of an aorto-iliac aneurysm

Aneurysms of the infra-renal abdominal aorta or iliac arteries result in ilio-caval compression in about 10% of cases which may cause venous thrombosis by stasis and pulmonary embolism. Fistulisation of these aneurysms into the inferior vena cava or an iliac vein is rare and paradoxical pulmonary embolism from arterial thrombus of the aneurysmal pouch is exceptionally rare. The authors report a new case in which the ilio-iliac arteriovenous fistula caused high output cardiac failure, ischaemia of the homolateral leg and pulmonary embolism. Doppler ultrasonography diagnosed the fistula and excluded a deep vein thrombosis. This case illustrated the essential value of clinical examination and of Doppler ultrasonography, especially of the abdomen, in the investigation of the causes of pulmonary embolism.