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Bidirectional vena cava filter placement
Bidirectional vena cava filter placement A n d r e w K e r r , M D , and D o u g l a s C. B o x e r , M D , Bronx, N.Y. We report a case o f left brachiocephalic vein thrombosis, acute pulmonary embolus, and contraindication to anticoaguladon treated with superior and inferior vena caval filters. (J VASC SORG 1995;22:501-4.)
Central venous catheters are frequently placed in the jugular or subclavian veins for h e m o d y n a m i c m o n i t o r i n g , parenteral alimentation, and chemotherapy. Catheter-induced venous thrombosis m a y be a source o f p u l m o n a r y emboli. W e describe a patient with left brachiocephalic venous thrombosis, acute p u l m o n a r y embolus, and a contraindication to anticoagulation in w h o m V e n a t e c h - L G M filters (Vena Tech Division, B. Braun Medical Inc., Evanston, I11.) were placed in the superior and inferior vena cava.
CASE REPORT A 75-year-old man with medical history significant for hypertension was admitted with worsening dysphagia and weight loss over a 3-month period. Workup included esophagraphy and computed tomography scanning, which revealed a 4 cm lesion at the gastroesophageal junction. Biopsy confirmed diagnosis of gastroesophageal junction adenocarcinoma, and the patient underwent esophagogastrectomy and splenectomy with placement of a jejunostomy tube. The postoperative course was remarkable for urinary retention and poor peripheral access necessitating placement of a central venous catheter. Multiple attempts at placement of a left-sided central venous line were unsuccessful. The left upper extremity was subsequently noted to be edematous, erythematous, and painful. Symptoms did not resolve with conservative treatment, and left subclavian Doppler study revealed a clot in the left jugular and subclavian veins and a clot in the proximal axillary and cephalic veins. There was also the suggestion of a fistula between the proximal subclavian artery and vein. Thoracic aortography with selective left subclavian arteriography was obtained; no evidence of arterial injury From the Department of Radiology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx. Reprint requests: Andrew Kerr, MD, Department of Radiology, Bronx Municipal Hospital Center, Pelham Parkway and Eastchester Road, Bronx, NY 10461. Copyright © 1995 by The Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter. 0741-5214/95/$5.00 + 0 24/4/66444
Fig. 1. Superior vena cavagrana demonstrates occlusion of left brachiocephalic vein.
was demonstrated. Immediately after the procedure, the patient had acute dyspnea and tachycardia. Room air arterial blood gas was p H = 7.44, P c o 2 = 3 3 , P o 2 = 62, oxygen saturation (Sat O2) = 93% (baseline pH = 7.43, Pco 2 = 45, Po 2 = 95, Sat 0 2 = 97%). Electrocardiography revealed sinus tachycardia at 130 beats/min; chest roentgenography did not show pulmonary vascular congestion. The presumptive diagnosis was acute pulmonary embolus, and emergency intubation was required. Inferior and superior venacavography was performed with use of a right femoral vein approach. Occlusion of the left innominate vein was present (Fig. 1), and thrombi in the inferior vena cava could not be excluded because the inferior vena cava study was limited by overlying bowel gas. Acute emboli were noted in the right pulmonary artery (Fig. 2). Subsequently, a Venatech-LGM vena cava filter was placed in an inverted position in the superior vena cava, and a second Venatech-LGM vena cava filter was deployed in the infrarenal inferior vena cava through the same introducer sheath (Fig. 3).
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Fig. 2. Later film from superior vena cava injection shows embolus in ascending branch of right pulmonary artery (arrow).
The patient tolerated the filter placements well and was extubated 1 day after the procedure. He was doing well until 17 days later when he died of an unrelated gastrointestinal bleed. At postmortem examination, both vena cava filters were completely expanded. No emboli were trapped in the tilters. A subacute embolus measuring 7 mm in diameter was found in the right middle lobe, and a subacute embolus measuring 2 mm in diameter was found in the right lower lobe. The cause of death was determined to be "hemorrhagic, necrotizing enterocolitis secondary to anemic, hypotensive shock." DISCUSSION More than 600,000 people have development of pulmonary embolism each year in the United States. Eighty-nine percent of them survive the first hour of the illness. O f those who survive the first hour and receive appropriate treatment, 8% die. O f those who survive the first hour and do not receive appropriate treatment (usually because of lack of correct diagnosis), 30% die) Although veins that drain into the superior vena cava may be sources of thromboembolic disease, the emphasis of both diagnosis and treatment has been almost exclusively directed to veins of the lower extremities and pelvis. A study of patients with primary axillary and subclavian vein thrombosis found that 12% of these patients had development of pulmonary embolism) Axillary and subclavian vein
thrombosis has become more common in recent years with the increased use of indwelling central venous catheters. Although only 0.8% of patients with central venous catheters have clinical evidence of central venous thrombosis, venographic studies and autopsy studies have shown the true incidence to be far higher (up to 35% and 36.7%, respectively). 3-9 Anticoagulant therapy is the treatment of choice for most patients who have development of pulmonary embolism. Those for whom anticoagulation is contraindicated, who have recurrent emboli on anticoagulant therapy, or who have complications of anticoagulation require placement ofvena cava filters. Superior vena cava filter insertion or bidirectional vena cava filter insertion (in the superior and inferior vena cava) is rare. We have found only four previous reports) ,l°-12 In these cases, Greenfield filters were used. The patient described in this report had pulmonary embolism and a brachiocephalic venous thrombosis. Because a lower extremity source of emboli could not be excluded, bidirectional filter placement was performed. The Venatech-LGM filter introduction system is well suited to bidirectional vena cava filter placement. It is designed for use by either a femoral or a jugular approach. Two filters can be placed sequentially with opposite orientations through the same introducer in little more time than is required to place one filter.
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Fig. 3. Frontal (A) and lateral (B) views of chest demonstrate fikers in supracardiac and infracardiac positions. Superior vena cava flter is not fully expanded on frontal view. Computed tomography scan of chest showed superior vena cava to be compressed at this point by superior pulmonary vein. The risk of superior vena cava perforation and thrombosis, and the risk of superior vena cava filter migration, remain to be determined. These complications have not been described in the few patients in w h o m this procedure has been performed. In an experimental study, Langham et al. 13 placed Greenfield filters in the superior vena cava of 11 dogs and then introduced thromboemboli through the jugular or brachiocephalic veins. No pulmonary emboli occurred. Superior venacavograms obtained monthly for 3 months demonstrated continued caval patency in all animals. One animal sustained perforation of a brachiocephalic vein by a misplaced filter without clinical sequelae or autopsy evidence of bleeding. In conclusion, with the use of central venous lines, venous thrombosis in supracardiac veins is common and may become a source of pulmonary emboli. 14 These sources are not addressed by inferior vena cava filter placement. Bidirectional placement as illustrated here can be readily accomplished if a supracardiac source is suspected. Superior and inferior vena cava filter placement may be considered in patients with supracardiac deep venous thrombosis and indications for vena cava filter placement.
We gratefully acknowledge the efforts of John Roback, MD, in performing the postmortem examination. REFERENCES
1. Dalen JE, Alpert IS. Natural history of pulmonary embolism. Prog Cardiovasc Dis 1975;57:259-70. 2. Adams JT, DeWeese JA. "Effort" thrombosis of the axiUary and subclavian veins. J Trauma 1971;11:923-30. 3. Hoffman MJ, Greenfield LJ. Central venous septic thrombosis managed by superior vena cava Greenfield filter and venous thrombectomy: a case report. J VASC SURG 1986;4: 606-11. 4. Warden GD, Douglas MC, Wilmore W, Pniitt BA. Central venous thrombosis: a hazard of medical progress. J Trauma 1973;13:620-6. 5. Sitzmann JV, Townsend TR, Siler MC, Bartlett JG. Septic and technical complications of central venous catheterization. Ann Surg 1985;202:766-70. 6. Nordlund S, Thoren L. Catheter in the superior vena cava for parenteral feeding. Acta Clin Scand 1964;127:39-45. 7. Ryan JA Jr, Abel RM, Abbott WM, et al. Catheter complications in total parenteral nutrition: a prospective study of 200 consecutive patients. N Engl J Med 1974;290:757-61. 8. Padberg FT, Ruggiero J, Blackburn GL, Bistrian BR. Central venous catheterization for parenteral nutrition. Ann Surg 1981;193:264-70. 9. Axelson CK, Efsen F. Phlebography in long-term catheterization of the subclavian vein: a retrospective study in patients
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with severe gastrointestinal disorders. Scand Gastroenterol 1978;13:933-8. 10. Quang DB, Chartier P, Baron M, Picaud D. Mise en place du flitre de Greenfield dans la veine cava supdrieure. La Pressa Medicale 1985;14:1338-9. 11. Pals SO, Orchis DF, Mirris SE. Superior vena caval placement of a Kimray-Greenfield filter. Radiology 1987;165:385-6. 12. Owen EW, Schoettle GP, Harrington OB. Placement of a Greenfield filter in the superior vena cava. Ann Thorac Surg 1992;53:896-7.
JOURNAL OF VASCULAR SURGERY October 1995
13. Langham M, Etheridge JC, Crute SL, Greenfield H- Experimental superior vena caval placement of the Greenfield filter. J VAsc SURG 1985;2:794-8. 14. Sabiston DC. Pulmonary embolism. In: Sabiston DC, ed. Textbook of surgery. 14th ed., Philadelphia: WB Saunders~ 1991:1504.
Submitted March 8, 1995; accepted May 18, 1995.
Central venous catheters are frequently placed in the jugular or subclavian veins for h e m o d y n a m i c m o n i t o r i n g , parenteral alimentation, and chemotherapy. Catheter-induced venous thrombosis m a y be a source o f p u l m o n a r y emboli. W e describe a patient with left brachiocephalic venous thrombosis, acute p u l m o n a r y embolus, and a contraindication to anticoagulation in w h o m V e n a t e c h - L G M filters (Vena Tech Division, B. Braun Medical Inc., Evanston, I11.) were placed in the superior and inferior vena cava.
CASE REPORT A 75-year-old man with medical history significant for hypertension was admitted with worsening dysphagia and weight loss over a 3-month period. Workup included esophagraphy and computed tomography scanning, which revealed a 4 cm lesion at the gastroesophageal junction. Biopsy confirmed diagnosis of gastroesophageal junction adenocarcinoma, and the patient underwent esophagogastrectomy and splenectomy with placement of a jejunostomy tube. The postoperative course was remarkable for urinary retention and poor peripheral access necessitating placement of a central venous catheter. Multiple attempts at placement of a left-sided central venous line were unsuccessful. The left upper extremity was subsequently noted to be edematous, erythematous, and painful. Symptoms did not resolve with conservative treatment, and left subclavian Doppler study revealed a clot in the left jugular and subclavian veins and a clot in the proximal axillary and cephalic veins. There was also the suggestion of a fistula between the proximal subclavian artery and vein. Thoracic aortography with selective left subclavian arteriography was obtained; no evidence of arterial injury From the Department of Radiology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx. Reprint requests: Andrew Kerr, MD, Department of Radiology, Bronx Municipal Hospital Center, Pelham Parkway and Eastchester Road, Bronx, NY 10461. Copyright © 1995 by The Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter. 0741-5214/95/$5.00 + 0 24/4/66444
Fig. 1. Superior vena cavagrana demonstrates occlusion of left brachiocephalic vein.
was demonstrated. Immediately after the procedure, the patient had acute dyspnea and tachycardia. Room air arterial blood gas was p H = 7.44, P c o 2 = 3 3 , P o 2 = 62, oxygen saturation (Sat O2) = 93% (baseline pH = 7.43, Pco 2 = 45, Po 2 = 95, Sat 0 2 = 97%). Electrocardiography revealed sinus tachycardia at 130 beats/min; chest roentgenography did not show pulmonary vascular congestion. The presumptive diagnosis was acute pulmonary embolus, and emergency intubation was required. Inferior and superior venacavography was performed with use of a right femoral vein approach. Occlusion of the left innominate vein was present (Fig. 1), and thrombi in the inferior vena cava could not be excluded because the inferior vena cava study was limited by overlying bowel gas. Acute emboli were noted in the right pulmonary artery (Fig. 2). Subsequently, a Venatech-LGM vena cava filter was placed in an inverted position in the superior vena cava, and a second Venatech-LGM vena cava filter was deployed in the infrarenal inferior vena cava through the same introducer sheath (Fig. 3).
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Fig. 2. Later film from superior vena cava injection shows embolus in ascending branch of right pulmonary artery (arrow).
The patient tolerated the filter placements well and was extubated 1 day after the procedure. He was doing well until 17 days later when he died of an unrelated gastrointestinal bleed. At postmortem examination, both vena cava filters were completely expanded. No emboli were trapped in the tilters. A subacute embolus measuring 7 mm in diameter was found in the right middle lobe, and a subacute embolus measuring 2 mm in diameter was found in the right lower lobe. The cause of death was determined to be "hemorrhagic, necrotizing enterocolitis secondary to anemic, hypotensive shock." DISCUSSION More than 600,000 people have development of pulmonary embolism each year in the United States. Eighty-nine percent of them survive the first hour of the illness. O f those who survive the first hour and receive appropriate treatment, 8% die. O f those who survive the first hour and do not receive appropriate treatment (usually because of lack of correct diagnosis), 30% die) Although veins that drain into the superior vena cava may be sources of thromboembolic disease, the emphasis of both diagnosis and treatment has been almost exclusively directed to veins of the lower extremities and pelvis. A study of patients with primary axillary and subclavian vein thrombosis found that 12% of these patients had development of pulmonary embolism) Axillary and subclavian vein
thrombosis has become more common in recent years with the increased use of indwelling central venous catheters. Although only 0.8% of patients with central venous catheters have clinical evidence of central venous thrombosis, venographic studies and autopsy studies have shown the true incidence to be far higher (up to 35% and 36.7%, respectively). 3-9 Anticoagulant therapy is the treatment of choice for most patients who have development of pulmonary embolism. Those for whom anticoagulation is contraindicated, who have recurrent emboli on anticoagulant therapy, or who have complications of anticoagulation require placement ofvena cava filters. Superior vena cava filter insertion or bidirectional vena cava filter insertion (in the superior and inferior vena cava) is rare. We have found only four previous reports) ,l°-12 In these cases, Greenfield filters were used. The patient described in this report had pulmonary embolism and a brachiocephalic venous thrombosis. Because a lower extremity source of emboli could not be excluded, bidirectional filter placement was performed. The Venatech-LGM filter introduction system is well suited to bidirectional vena cava filter placement. It is designed for use by either a femoral or a jugular approach. Two filters can be placed sequentially with opposite orientations through the same introducer in little more time than is required to place one filter.
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Fig. 3. Frontal (A) and lateral (B) views of chest demonstrate fikers in supracardiac and infracardiac positions. Superior vena cava flter is not fully expanded on frontal view. Computed tomography scan of chest showed superior vena cava to be compressed at this point by superior pulmonary vein. The risk of superior vena cava perforation and thrombosis, and the risk of superior vena cava filter migration, remain to be determined. These complications have not been described in the few patients in w h o m this procedure has been performed. In an experimental study, Langham et al. 13 placed Greenfield filters in the superior vena cava of 11 dogs and then introduced thromboemboli through the jugular or brachiocephalic veins. No pulmonary emboli occurred. Superior venacavograms obtained monthly for 3 months demonstrated continued caval patency in all animals. One animal sustained perforation of a brachiocephalic vein by a misplaced filter without clinical sequelae or autopsy evidence of bleeding. In conclusion, with the use of central venous lines, venous thrombosis in supracardiac veins is common and may become a source of pulmonary emboli. 14 These sources are not addressed by inferior vena cava filter placement. Bidirectional placement as illustrated here can be readily accomplished if a supracardiac source is suspected. Superior and inferior vena cava filter placement may be considered in patients with supracardiac deep venous thrombosis and indications for vena cava filter placement.
We gratefully acknowledge the efforts of John Roback, MD, in performing the postmortem examination. REFERENCES
1. Dalen JE, Alpert IS. Natural history of pulmonary embolism. Prog Cardiovasc Dis 1975;57:259-70. 2. Adams JT, DeWeese JA. "Effort" thrombosis of the axiUary and subclavian veins. J Trauma 1971;11:923-30. 3. Hoffman MJ, Greenfield LJ. Central venous septic thrombosis managed by superior vena cava Greenfield filter and venous thrombectomy: a case report. J VASC SURG 1986;4: 606-11. 4. Warden GD, Douglas MC, Wilmore W, Pniitt BA. Central venous thrombosis: a hazard of medical progress. J Trauma 1973;13:620-6. 5. Sitzmann JV, Townsend TR, Siler MC, Bartlett JG. Septic and technical complications of central venous catheterization. Ann Surg 1985;202:766-70. 6. Nordlund S, Thoren L. Catheter in the superior vena cava for parenteral feeding. Acta Clin Scand 1964;127:39-45. 7. Ryan JA Jr, Abel RM, Abbott WM, et al. Catheter complications in total parenteral nutrition: a prospective study of 200 consecutive patients. N Engl J Med 1974;290:757-61. 8. Padberg FT, Ruggiero J, Blackburn GL, Bistrian BR. Central venous catheterization for parenteral nutrition. Ann Surg 1981;193:264-70. 9. Axelson CK, Efsen F. Phlebography in long-term catheterization of the subclavian vein: a retrospective study in patients
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with severe gastrointestinal disorders. Scand Gastroenterol 1978;13:933-8. 10. Quang DB, Chartier P, Baron M, Picaud D. Mise en place du flitre de Greenfield dans la veine cava supdrieure. La Pressa Medicale 1985;14:1338-9. 11. Pals SO, Orchis DF, Mirris SE. Superior vena caval placement of a Kimray-Greenfield filter. Radiology 1987;165:385-6. 12. Owen EW, Schoettle GP, Harrington OB. Placement of a Greenfield filter in the superior vena cava. Ann Thorac Surg 1992;53:896-7.
JOURNAL OF VASCULAR SURGERY October 1995
13. Langham M, Etheridge JC, Crute SL, Greenfield H- Experimental superior vena caval placement of the Greenfield filter. J VAsc SURG 1985;2:794-8. 14. Sabiston DC. Pulmonary embolism. In: Sabiston DC, ed. Textbook of surgery. 14th ed., Philadelphia: WB Saunders~ 1991:1504.
Submitted March 8, 1995; accepted May 18, 1995.