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Utilisation d’un Wallstent pour exclure un filtre cave inférieur thrombosé
Cas cliniques Utilisation d’un Wallstent pour exclure un filtre cave inferieur thrombos e Scott R. Golarz, Brad Grimsley, Dallas, TX, USA
rieure (VCI) a augmente drastiquement au cours des L’utilisation des filtres de veine cave infe res de cennies. La thrombose de la VCI est une complication potentiellement deux dernie e variant entre catastrophique de la mise en place d’un filtre cave avec une incidence rapporte 3,6 et 11,2%, en fonction du type de filtre. Nous rapportons le cas d’une patiente de 69 ans ayant ce dent de thrombose veineuse profonde de la jambe droite. Un filtre Gunther Tulip (Cook un ante alable d’une intervention rachidienne. Au Medical, Bloomington, IN) fut mis en place au pre cours de l’intervention, la patiente pre sentait une thrombose bilate rale ilio-fe morale e tendue de s plusieurs semaines d’essais infructueux de recanalisation au centre de vers le filtre cave. Apre te re fe re e pour sa prise en charge. Apre s une tensoins communautaire, la patiente nous a e ballonnet, deux stents Prote ge GPS 10 60 mm (EV3, tative infructueuse d’angioplastie a te de ploye s de manie re bilate rale dans les veines fe morale, iliaque externe Plymouth, MN) ont e s un e chec de retrait, le filtre Tulip a e te exclu de la VCI en utilisant un et iliaque interne. Apre tait note depuis le Wall Stent 16 60 mm (Boston Scientific, Natick, MA, USA). Un flux continu e me fe moral jusqu’a la veine cave supe rieure. La re solution des sympto ^mes cliniques fut syste diate. imme
The use of inferior vena cava (IVC) filters has increased dramatically over the last two decades.1 Thrombosis of the IVC is a potentially catastrophic complication of caval filter placement, and its reported incidence ranges 3.6-11.2%, depending on filter type.2 We present a 69-year-old female with a history of deep vein thrombosis of the right leg. Prior to a planned spinal operation, a Gunther Tulip filter was placed (Cook Medical, Bloomington, IN). Postoperatively, the patient developed bilateral iliofemoral thrombosis that extended into the IVC filter. Several weeks passed, and after unsuccessful attempts at recanalization in the community setting, the patient was referred for treatment. After an unsuccessful attempt at balloon angioplasty, two DOI of original article: 10.1016/j.avsg.2009.08.018. Baylor University Medical Center, Dallas, TX, USA. Correspondence : Scott R. Golarz, MD, FACS, Baylor Medical Center, 621 Hall Street, Dallas, TX 75226-1305, USA, E-mail: sgolarz@ hotmail.com Ann Vasc Surg 2010; 24: 690.e5-690.e7 DOI: 10.1016/j.acvfr.2011.01.028 Ó Annals of Vascular Surgery Inc. e par ELSEVIER MASSON SAS Edit
10 60mm Protege GPS stents (EV3, Plymouth, MN) were deployed in the common femoral, external, and internal iliac veins bilaterally. After an unsuccessful attempt at retrieval, the Tulip filter was excluded from the IVC using a16 60mm Wall Stent (Boston Scientific, Natick, Ma). Unobstructed flow was now noted from the femoral system all the way through the superior vena cava (SVC). The patient experienced immediate relief of her symptoms.
CASE REPORT We were referred a 69-year-old female with a history of type 2 diabetes, breast cancer, and a recurrent right lower extremity deep venous thrombosis requiring lifelong anticoagulation. She underwent a 360-degree polar fusion on the fourth and fifth lumbar vertebrae. In anticipation of this surgery, her coumadin was stopped and a Gunther Tulip filter was placed. She underwent the procedure and was discharged. She returned 2 days later complaining of leg weakness. She was found to have a cerebral spinal fluid leak and required two additional operative washouts. Her coumadin was held during this time. During her readmission, bilateral leg swelling was noted. Vascular surgery consultation was obtained. An 754.e5
754.e6 Cas cliniques
Annales de chirurgie vasculaire
Fig. 1. Venogram indicating complete bilateral iliac vein occlusion. ultrasound indicated new bilateral iliofemoral thrombosis. After consulting with neurosurgery, low molecular weight heparin was given and coumadin was restarted. The patient was taken to the catheterization lab. The procedural venogram indicated clot extending into, but not beyond, the IVC filter. Rheolytic thrombectomy was attempted using the AngioJet (Possis Medical, Minneapolis, MN). This was not successful. Thrombolytics were avoided secondary to the recent surgery. The patient was referred to Baylor Dallas for further management. The patient was evaluated in our clinic several weeks after the attempted thrombectomy. She had recovered from her spinal procedure and was ambulatory. She was complaining of worsening swelling in each lower extremity, short-distance venous claudication, and the onset of new ulcers on each leg. Her international normalized ratio was therapeutic. She was taken to the catheterization lab. Bilateral access was obtained via the common femoral veins. Venograms indicated complete bilateral iliac vein occlusion (Fig. 1). The occlusions were crossed using 0.035-inch angled guidewires (Boston Scientific). Angioplasty was attempted using 8 80mm Fox Plus balloons (Abbott Vascular, Abbott Park, IL). Significant iliofemoral stenosis remained. This required placement of two 10 60mm Protege GPS stents in both the right and left iliofemoral systems. Venograms now indicated open iliofemoral systems bilaterally but also clotting in and around the Gunther Tulip filter (Fig. 2). An attempt was made to remove the filter via a right internal jugular approach. This was unsuccessful secondary to both the angulation of the filter and the large burden of chronic thrombus surrounding it. It was felt that if not addressed, this obstruction of flow would cause rethrombosis of the newly stented iliofemoral system. The filter was easily crossed from the right internal jugular using the guidewire. Now, a 16 60mm Wall
Fig. 2. Venogram indicating open iliofemoral systems bilaterally and clotting in and around the Gunther Tulip filter. Stent was placed across the filter and deployed. Followup venography indicated unobstructed flow through the stent and into the SVC (Fig. 3).
DISCUSSION Guidelines for the placement of IVC filters are well established.3-5 In this case, the patient had an upcoming spinal procedure and a known, recurrent deep venous thrombosis requiring anticoagulation. The list of potential complications from filter placement includes pulmonary embolism, filter migration, perforation of the IVC, filter fracture, guidewire entrapment, and thrombosis of the IVC.6 It is not clear why some patients develop thrombosis after placement of an IVC filter and others do not. It is worth noting that the anticoagulation was withheld after the patient’s spinal procedure. Harris et al.7 reviewed 32 patients with caval interruption filters. They found that four cases of phlegmasia occurred when anticoagulation was withheld. No cases occurred when anticoagulation was given. While the causes of thrombosis of the IVC are unclear, the treatment of the problem is even more so. Treatment options range from anticoagulation only to clot lysis to mechanical thrombectomy with distal protection8 and open thrombectomy with or without removal of filter. The technique of filter exclusion using largecaliber stents has been described previously. In their outstanding series, Raju and Neglen9 described
Vol. 24, No. 5, 2010
Cas cliniques 754.e7
filter but also for easy passage of the stent beyond the filter. Any difficult passage would indicate passage through the filter and not around it.
CONCLUSION IVC filters are safe, effective, and generally easy to use. They also produce known complications, and their retrieval is not always possible.12 The method we used is not suggested as first-line therapy for thrombosis of an IVC filter, but given the circumstances of chronic clot within a nonremovable filter, we feel the result was excellent. REFERENCES
Fig. 3. Follow-up venogram indicating unobstructed flow through the stent and into the SVC.
recannulation of 139 limbs with total occlusion of the iliac vein. They encountered 14 thrombosed caval interruption filters of various types. They were able to cross all of the filters safely and exclude them in a manner similar to that described above. We feel this method was well suited to this patient for several reasons. First, this patient suffered severe symptoms, and observation alone was not desirable. Second, she had already been fully anticoagulated, with no improvement noted. Third, although sufficient time from her operation had passed to safely use thrombolytics, we felt the clot was too chronic for these to be effective. Next, rheolytic thrombectomy had already been attempted without success. Finally, open thrombectomy would not have been well tolerated in this chronically ill patient. We understand that there are inherent risks to this method. Foremost there is the risk of caval penetration by one of the filter struts as it is pushed against the vessel wall. There are case reports of caval penetration with perforation into adjacent organs.10,11 A high index of suspicion will be maintained and interval computed tomographic scans will be used to monitor the filter. We were also aware that deployment of the stent inside the filter was possible. To prevent this, we looked not only for wire apposition to the caval wall as it passed the
1. Stein PD, Kayali F, Olson RE. Twenty-one-year trends in the use of inferior vena cava filters. Arch Intern Med 2004;164: 1541-1545. 2. Streiff MB. Vena caval filters: a comprehensive review. Blood 2000;95:3669-3677. 3. Grassi CJ, Swan TL, Cardella JF, et al. Quality improvement guidelines for percutaneous permanent inferior vena cava filter placement for the prevention of pulmonary embolism. J Vasc Interv Radiol 2003;14:S271-S275. 4. Buller HR, Agnelli G, Hull RD, Hyers TM, Prins MH, Raskob GE. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(3 Suppl):401S-428S. 5. Hann CL, Streiff MB. The role of vena caval filters in the management of venous thromboembolism. Blood Rev 2005;19:179-202. 6. Kinney TB. Update on inferior vena cava filters. J Vasc Interv Radiol 2003;14:425-440. 7. Harris EJ, Kinney EV, Harris EJ, Olcott C, Zarins CK. Phlegmasia complicating prophylactic percutaneous inferior vena caval interruption: a word of caution. J Vasc Surg 1995;22:606-611. 8. Myers JL, Mukherjee D. Treatment of inferior vena cava filter thrombosis by mechanical thrombectomy and temporary vena cava filter protection vascular and endovascular surgery. 2000;34:175-181. 9. Raju S, Neglen P. Percutaneous recanalization of total occlusions of the iliac vein. J Vasc Surg 2009;50:360-368. 10. Veroux M, Tallarita T, Pennisi M, Veroux P. Late complication from a retrievable inferior vena cava filter with associated caval, aortic, and duodenal perforation: a case report. J Vasc Surg 2008;48:223-225. 11. Dabbagh A, Chakfe N, Kretz J-G, et al. Late complication of a Greenfield filter associating caudal migration and perforation of the abdominal aorta by a ruptured strut. J Vasc Surg 1995;22:182-187. 12. Rosenthal D, Wellons ED, Hancock SM, Burkett AB. Retrievability of the G€ unther Tulip vena cava filter after dwell times longer than 180 days in patients with multiple trauma. J Endovasc Ther 2007;14:406-410.
rieure (VCI) a augmente drastiquement au cours des L’utilisation des filtres de veine cave infe res de cennies. La thrombose de la VCI est une complication potentiellement deux dernie e variant entre catastrophique de la mise en place d’un filtre cave avec une incidence rapporte 3,6 et 11,2%, en fonction du type de filtre. Nous rapportons le cas d’une patiente de 69 ans ayant ce dent de thrombose veineuse profonde de la jambe droite. Un filtre Gunther Tulip (Cook un ante alable d’une intervention rachidienne. Au Medical, Bloomington, IN) fut mis en place au pre cours de l’intervention, la patiente pre sentait une thrombose bilate rale ilio-fe morale e tendue de s plusieurs semaines d’essais infructueux de recanalisation au centre de vers le filtre cave. Apre te re fe re e pour sa prise en charge. Apre s une tensoins communautaire, la patiente nous a e ballonnet, deux stents Prote ge GPS 10 60 mm (EV3, tative infructueuse d’angioplastie a te de ploye s de manie re bilate rale dans les veines fe morale, iliaque externe Plymouth, MN) ont e s un e chec de retrait, le filtre Tulip a e te exclu de la VCI en utilisant un et iliaque interne. Apre tait note depuis le Wall Stent 16 60 mm (Boston Scientific, Natick, MA, USA). Un flux continu e me fe moral jusqu’a la veine cave supe rieure. La re solution des sympto ^mes cliniques fut syste diate. imme
The use of inferior vena cava (IVC) filters has increased dramatically over the last two decades.1 Thrombosis of the IVC is a potentially catastrophic complication of caval filter placement, and its reported incidence ranges 3.6-11.2%, depending on filter type.2 We present a 69-year-old female with a history of deep vein thrombosis of the right leg. Prior to a planned spinal operation, a Gunther Tulip filter was placed (Cook Medical, Bloomington, IN). Postoperatively, the patient developed bilateral iliofemoral thrombosis that extended into the IVC filter. Several weeks passed, and after unsuccessful attempts at recanalization in the community setting, the patient was referred for treatment. After an unsuccessful attempt at balloon angioplasty, two DOI of original article: 10.1016/j.avsg.2009.08.018. Baylor University Medical Center, Dallas, TX, USA. Correspondence : Scott R. Golarz, MD, FACS, Baylor Medical Center, 621 Hall Street, Dallas, TX 75226-1305, USA, E-mail: sgolarz@ hotmail.com Ann Vasc Surg 2010; 24: 690.e5-690.e7 DOI: 10.1016/j.acvfr.2011.01.028 Ó Annals of Vascular Surgery Inc. e par ELSEVIER MASSON SAS Edit
10 60mm Protege GPS stents (EV3, Plymouth, MN) were deployed in the common femoral, external, and internal iliac veins bilaterally. After an unsuccessful attempt at retrieval, the Tulip filter was excluded from the IVC using a16 60mm Wall Stent (Boston Scientific, Natick, Ma). Unobstructed flow was now noted from the femoral system all the way through the superior vena cava (SVC). The patient experienced immediate relief of her symptoms.
CASE REPORT We were referred a 69-year-old female with a history of type 2 diabetes, breast cancer, and a recurrent right lower extremity deep venous thrombosis requiring lifelong anticoagulation. She underwent a 360-degree polar fusion on the fourth and fifth lumbar vertebrae. In anticipation of this surgery, her coumadin was stopped and a Gunther Tulip filter was placed. She underwent the procedure and was discharged. She returned 2 days later complaining of leg weakness. She was found to have a cerebral spinal fluid leak and required two additional operative washouts. Her coumadin was held during this time. During her readmission, bilateral leg swelling was noted. Vascular surgery consultation was obtained. An 754.e5
754.e6 Cas cliniques
Annales de chirurgie vasculaire
Fig. 1. Venogram indicating complete bilateral iliac vein occlusion. ultrasound indicated new bilateral iliofemoral thrombosis. After consulting with neurosurgery, low molecular weight heparin was given and coumadin was restarted. The patient was taken to the catheterization lab. The procedural venogram indicated clot extending into, but not beyond, the IVC filter. Rheolytic thrombectomy was attempted using the AngioJet (Possis Medical, Minneapolis, MN). This was not successful. Thrombolytics were avoided secondary to the recent surgery. The patient was referred to Baylor Dallas for further management. The patient was evaluated in our clinic several weeks after the attempted thrombectomy. She had recovered from her spinal procedure and was ambulatory. She was complaining of worsening swelling in each lower extremity, short-distance venous claudication, and the onset of new ulcers on each leg. Her international normalized ratio was therapeutic. She was taken to the catheterization lab. Bilateral access was obtained via the common femoral veins. Venograms indicated complete bilateral iliac vein occlusion (Fig. 1). The occlusions were crossed using 0.035-inch angled guidewires (Boston Scientific). Angioplasty was attempted using 8 80mm Fox Plus balloons (Abbott Vascular, Abbott Park, IL). Significant iliofemoral stenosis remained. This required placement of two 10 60mm Protege GPS stents in both the right and left iliofemoral systems. Venograms now indicated open iliofemoral systems bilaterally but also clotting in and around the Gunther Tulip filter (Fig. 2). An attempt was made to remove the filter via a right internal jugular approach. This was unsuccessful secondary to both the angulation of the filter and the large burden of chronic thrombus surrounding it. It was felt that if not addressed, this obstruction of flow would cause rethrombosis of the newly stented iliofemoral system. The filter was easily crossed from the right internal jugular using the guidewire. Now, a 16 60mm Wall
Fig. 2. Venogram indicating open iliofemoral systems bilaterally and clotting in and around the Gunther Tulip filter. Stent was placed across the filter and deployed. Followup venography indicated unobstructed flow through the stent and into the SVC (Fig. 3).
DISCUSSION Guidelines for the placement of IVC filters are well established.3-5 In this case, the patient had an upcoming spinal procedure and a known, recurrent deep venous thrombosis requiring anticoagulation. The list of potential complications from filter placement includes pulmonary embolism, filter migration, perforation of the IVC, filter fracture, guidewire entrapment, and thrombosis of the IVC.6 It is not clear why some patients develop thrombosis after placement of an IVC filter and others do not. It is worth noting that the anticoagulation was withheld after the patient’s spinal procedure. Harris et al.7 reviewed 32 patients with caval interruption filters. They found that four cases of phlegmasia occurred when anticoagulation was withheld. No cases occurred when anticoagulation was given. While the causes of thrombosis of the IVC are unclear, the treatment of the problem is even more so. Treatment options range from anticoagulation only to clot lysis to mechanical thrombectomy with distal protection8 and open thrombectomy with or without removal of filter. The technique of filter exclusion using largecaliber stents has been described previously. In their outstanding series, Raju and Neglen9 described
Vol. 24, No. 5, 2010
Cas cliniques 754.e7
filter but also for easy passage of the stent beyond the filter. Any difficult passage would indicate passage through the filter and not around it.
CONCLUSION IVC filters are safe, effective, and generally easy to use. They also produce known complications, and their retrieval is not always possible.12 The method we used is not suggested as first-line therapy for thrombosis of an IVC filter, but given the circumstances of chronic clot within a nonremovable filter, we feel the result was excellent. REFERENCES
Fig. 3. Follow-up venogram indicating unobstructed flow through the stent and into the SVC.
recannulation of 139 limbs with total occlusion of the iliac vein. They encountered 14 thrombosed caval interruption filters of various types. They were able to cross all of the filters safely and exclude them in a manner similar to that described above. We feel this method was well suited to this patient for several reasons. First, this patient suffered severe symptoms, and observation alone was not desirable. Second, she had already been fully anticoagulated, with no improvement noted. Third, although sufficient time from her operation had passed to safely use thrombolytics, we felt the clot was too chronic for these to be effective. Next, rheolytic thrombectomy had already been attempted without success. Finally, open thrombectomy would not have been well tolerated in this chronically ill patient. We understand that there are inherent risks to this method. Foremost there is the risk of caval penetration by one of the filter struts as it is pushed against the vessel wall. There are case reports of caval penetration with perforation into adjacent organs.10,11 A high index of suspicion will be maintained and interval computed tomographic scans will be used to monitor the filter. We were also aware that deployment of the stent inside the filter was possible. To prevent this, we looked not only for wire apposition to the caval wall as it passed the
1. Stein PD, Kayali F, Olson RE. Twenty-one-year trends in the use of inferior vena cava filters. Arch Intern Med 2004;164: 1541-1545. 2. Streiff MB. Vena caval filters: a comprehensive review. Blood 2000;95:3669-3677. 3. Grassi CJ, Swan TL, Cardella JF, et al. Quality improvement guidelines for percutaneous permanent inferior vena cava filter placement for the prevention of pulmonary embolism. J Vasc Interv Radiol 2003;14:S271-S275. 4. Buller HR, Agnelli G, Hull RD, Hyers TM, Prins MH, Raskob GE. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(3 Suppl):401S-428S. 5. Hann CL, Streiff MB. The role of vena caval filters in the management of venous thromboembolism. Blood Rev 2005;19:179-202. 6. Kinney TB. Update on inferior vena cava filters. J Vasc Interv Radiol 2003;14:425-440. 7. Harris EJ, Kinney EV, Harris EJ, Olcott C, Zarins CK. Phlegmasia complicating prophylactic percutaneous inferior vena caval interruption: a word of caution. J Vasc Surg 1995;22:606-611. 8. Myers JL, Mukherjee D. Treatment of inferior vena cava filter thrombosis by mechanical thrombectomy and temporary vena cava filter protection vascular and endovascular surgery. 2000;34:175-181. 9. Raju S, Neglen P. Percutaneous recanalization of total occlusions of the iliac vein. J Vasc Surg 2009;50:360-368. 10. Veroux M, Tallarita T, Pennisi M, Veroux P. Late complication from a retrievable inferior vena cava filter with associated caval, aortic, and duodenal perforation: a case report. J Vasc Surg 2008;48:223-225. 11. Dabbagh A, Chakfe N, Kretz J-G, et al. Late complication of a Greenfield filter associating caudal migration and perforation of the abdominal aorta by a ruptured strut. J Vasc Surg 1995;22:182-187. 12. Rosenthal D, Wellons ED, Hancock SM, Burkett AB. Retrievability of the G€ unther Tulip vena cava filter after dwell times longer than 180 days in patients with multiple trauma. J Endovasc Ther 2007;14:406-410.