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Postlaparoscopic traumatic inferior vena caval thrombosis
DISEASE
Postlaparoscopic traumatic inferior vena caval thrombosis K a t h r y n E. Peck, M D , Jos~ T. B o n o a n , M D , a n d B u r k e A. C u n h a , MD, M i n e o l a a n d S t o n y B r o o k , N.Y.
Thrombosis of the inferior vena cava (IVC) is a rare disease. It has been reported in the literature in association with a variety of noninfectious diseases, particularly carcinoma of the kidney and liver, as well as abdominal trauma and percutaneous IVC filter placement. We report a case of IVC thrombosis in a young n o n p r e g n a n t patient after laparoscopic pelvic surgery. We believe it is the first case in th e literature of laparoscopic-induced IVC thrombosis. (Heart Lung ® 1998;27:279-82)
CASE
REPORT
A
28-year-old woman, gravida zero, with a long history of chronic pelvic pain was admitted to the Ambulatory Surgery Unit at WinthropUniversity Hospital for an elective explorative pelvic laparoscopy. Her surgical history included an exploratory laparoscopy of the pelvis, appendectomy, and left salpingo-oophorectomy approximately 10 years ago and an exploratory laparotomy 4 years ago. The patient continued to experience chronic pelvic pain without significant physical findings. A pelvic sonogram was performed before the present hospital admission and was found to be within normal limits. The patient reported that she had no history of pelvic inflammatory disease, uterine fibroids, sexually transmitted diseases, constipation, or diarrhea. At the time of hospital admission, her only medication consisted of birth control pills. Social history was significant for a halfpack-per-day use of tobacco. Admission laboratory studies including hemoglobin, hematocrit, white blood cell count, and electrolyte panel were all within normal limits.
From the Infectious Disease Division. Winthrop~University Hospital, Mineola,and the StateUniversityof NewYorkSchoolof Medicine.StonyBrook. Reprint requests:BurkeA. Cunha, MD, Chief, InfectiousDisease Division.Winthrop-UniversityHospital, Mineola.NY 11501 Copyright© 1998by Mosby,Inc. 0147-9563/98/$5.00+ 0 2/i/91154
HEART & L U N G VOL. 27, NO. 4
, ~,,
The explorative laparoscopy was complicated by laceration of the left common lilac artery and injury to the sigmoid colon. The patient underwent emergent repair of the artery by an end-to-end anastomosis and a resection of the damaged sigmold colon, with construction of a colostomy and a Hartmann's pouch. Findings at the time of the abdominal surgery were significant for dense pelvic and abdominal wall adhesions, a left retroperitoneal hematoma, and a right ovarian cyst. A right ovarian cystectomy was also performed during the surgical procedure. During the postoperative course the patient complained of pain and tingling in the left leg. The patient was given metronidazole, 500 mg intravenously (IV) every 8 hours, and suibactam-ampicillin 3 g (IV) every 6 hours. For the first 6 postoperative days, her temperatures were approximately 101.5°E At this time, gentamicin was added to the antibiotic regimen. On the seventh and eighth postoperative days, the maximum temperature was 102°F, and the Infectious Disease Service was contacted in consultation for the unresolving fevers. At this time, the patient had some mild abdominal discomfort but denied rigors, chills, sweats, chest pain, shortness of breath, and dysuria. Physical exam was significant only for moderate obesity. The colostomy was functioning satisfactorily, and the surgical wound sites appeared clean and intact. On the eighth postoperative day, the previously stated antibiotics were discontinued, and meropenem 1 g (IV) every 8 hours was started. At this time, the white blood cell
279
Table
Causes of inferior vena caval thrombosis Percutaneously-placed IVC filters Femoral vein catheterization Venous prosthetic devices Indwelling catheters Budd-Chiari syndrome Congenital anomalies of the IVC Aneurysms of the IVC Abdominal aortic aneurysm Beh~et's syndrome Antiphospholipid syndrome Retroperitoneal fibrosis Liver transplantation Malignant fibrous histiocytoma of the IVC Systemic amyloidosis Postpartum ovarian vein thrombosis Chronic pancreatitis Pancreatic cysts Pancreatic carcinoma Renal cell carcinoma Lymphoma Renal pelvic transitional cell carcinoma Pheochromocytoma Renal angiomyolipoma Testicular carcinoma Ovarian carcinoma Nephroblastoma Wilms' tumor Amebic hepatic abscess Adrenal neoplasms Hepatocellular carcinoma Blunt abdominal trauma Strenuous athletics Burns Ulcerative colitis Membranous lupus nephritis Acute staphylococcal osteomyelitis Protein C and S deficiencies Adapted from references4-6, 10.
count was 8.1 × 3000/mm 3, and the urine analysis was negative. Blood cultures were drawn but showed no growth. A computed tomography (CT) was performed of the abdomen and pelvis to rule out an intra-abdominal collection. CT of the abdomen demonstrated thrombosis. This extended cephalad, up to the region of the renal veins. Because of the CT findings of inferior vena canal (IVC) thrombosis, a heparin drip was started on the 10th postoperative day (1900 U/h),
280
and meropenem was continued. Over the course of the next 5 days, the patient became afebrile. After 5 days the patient was given warfarin 5 mg orally each day. DISCUSSION
IVC thrombosis is a rare disease. Review of the literature since 1987 shows that IVC thrombosis has been associated with a number of diseases, but not as a postoperative sequelae of laparoscopic surgery (Table). Recent reports have presented cases of deep venous thrombi of the legs secondary to laparoscopic cholecystectomy; but to our knowledge this is the first reported case of IVC thrombosis after laparoscopic surgery. I-3 In 1994, Chaudhuri et al 4 reported that 1VC thrombosis may be primary (14%) or can be secondary to conditions that apply external pressure (tumors and aortic aneurysms), extension of retroperitoneal tumors, hypercoaguable states, and diseases of the liver. In 1990, Novick et al 5 reported that the most common retroperitoneal tumor associated with IVC thrombosis is the renal cell carcinoma. The literature also contains well-documented reports of 1VC thrombosis associated with abdominal trauma. Because 1VC thrombosis is rare, the clinical features of this disease have yet to be clearly defined. 6 In 1990, Nagy et al 7 reported a case of IVC thrombosis after a motor vehicle accident in which the patient had a normal CT of the abdomen immediately after the injury and without any intraabdominal visceral injury. The patient, like ours, had a remarkable paucity of physical symptoms (only vague abdominal and back pain). In 1995, Takeuchi et al 6 reported 2 cases of trauma-associated (contused right lower lung and ruptured hepatic veins) IVC thrombosis in which the caval thrombi were detected by chance after routine abdominal CT scanning for postoperative evaluation. Thus it has been noted that caval obstruction may not necessarily cause leg edema; so the lack of this physical finding, as in our patient, cannot rule out the possibility of IVC thrombosis. Also of interest in the literature on trauma-associated IVC thrombosis is the Takeuchi et al 6 report that the delay between injury and presentation in 6 cases was 10 to 21 days. Our patient's IVC thrombosis was discovered on the 10th postoperative day. Furthermore, one of the postulated mechanisms of thrombosis in the Takeuchi et al 6 case (IVC thrombosis associated with a motor vehicle accident) is caval compression secondary to a retroperitoneal hematoma, probably of psoas muscle origin. Our patient also had a retroperitoneal hematoma, seen during the surgi-
JULY/AUGUST1998 HEART & LUNG
Fig. 1 CT scan of a b d o m e n and pelvis showing low attenuation centrally and enlargement of inferior vena cava (arrow), indicating IVC thrombosis.
cal procedure and also on the CT scan. However, Takeuchi et al 6 also note that their patient had a central venous catheter inserted into the left groin for 5 days. Femoral catheterization has been associated with IVC thrombosis in the literature. Endothelial injury of the venous wall secondary to compression or shearing forces seems to be the most widely postulated mechanism of IVC thrombosis related to trauma. 6 Septic thrombophlebitis of the IVC also has been reported, and this is thought to be initiated by bacterial injury of the venous endothelium. 8 Because the incidence of IVC thrombosis is so rare, the pathophysiological mechanisms of the disease have yet to be fully elucidated. CT scans have been shown to be of major diagnostic value. 9 However, Novick et al 5 note that a CT scan is unreliable in delineating the cephalad extent of a thrombus, and that inferior vena cavography has been most accurate in defining and assessing IVC thrombi. In cases where antegrade phlebography is insufficient because of complete caval obstruction, retrograde injection of the IVC may be used to define the distal limits of the thrombus. 5 However, vena cavography is invasive
HEART & LUNG VOL. 27, NO. 4
and carries the small risk of dislodging the thrombus. 4 Well-known risk factors for deep venous thrombosis (DVT) include advanced age, malignant tumors, hypercoaguable states, prior history of DVT, direct vessel injury, immobility, and obesity. 6 Our patient manifested the latter 2 risk factors. Whereas the incidence of DVT may be up to 250,000 per year (Nagy and Duarte7), thrombosis of the intra-abdominai great vessels is rare. 6 Management of IVC thrombosis has involved various modalities. Other cases of IVC thrombosis have been successfully treated like ours, with conservative medical management with heparin. 1° Thrombectomy, ligation of the 1VC followed by anticoagulation therapy, and thrombolytic therapy with use of urokinase have also been cited in the literature as case-specific means of treatment. 5
REFERENCES
1. Lord RV. Hugh TB, Coleman ML Doust BD. The incidence of deep venous thrombosis after laparoscopic cholecystectomy. Med l Aust 1996;165:402-3. 2. DraganicBD, Gani JS.The incidence of deepvenousthrombo-
281
3. 4. 5.
6.
sis after laparoscopic cholecystectomy. Med J Aust 1996;402:402-3. Patel MI, Hardman DT, Nicholls D, Fisher CM, Appleberg M. The incidence of deep venous thrombosis after laparoscopic cholecystectomy. Med J Aust 1996;164:652-4. Chaudhuri R, Malik I, Bingham ]B. Case of the month: a tightening of the belt. Brit J Radiol 1994;67:663-4. Novick AC, Kaye MC, Cosgrove DM, Angermeier K, Pontes JE, Montie JE, et al. ExperienCe with cardio-pulmonary bypass and deep hypothermic circulatory arrest in the management of retroperitoneal tumors with large vena caval thrombi. Ann Surg 1990;212:472-7. Takeuchi M, Maruyama K, Nakamura M, Chikusa H, Yoshida T, Muneyuki M, et al. Posttraumatic inferior vena caval thrombo-
7. 8. 9. 10.
sis: case report and review of the literature. J Trauma 1995;39:605-8. Nagy KK, Duarte B. Post-traumatic inferior vena caval thrombosis: case report. J Trauma 1990;30:218-21. Magee KP, Blanco JD, Graham JM. Massive septic pelvic thrombo-phlebitis. Obstet Gynecol 1993;82:662-4. Kniemeyer HW, Grabitz K, Buhl R, Wrist HJ, Sandmann W. Surgical treatment of septic deep venous thrombosis. Surgery 1995;118:49-53. John TG, Chalmers N, Redhead DN, Kumar S, Garden OJ. Case report: inferior vena caval thrombosis following severe liver trauma and peri-hepatic packing--early detection by intraoperative ultrasonography enabling treatment by percutaneous mechanical thrombectomy. Br J Radiol 1995;68:314-7.
AVAILABILITY OF JOURNAL BACK ISSUES As a service to our subscribers, copies of back issues of Heart & Lung®: The Journal of Acute and Critical Care for the preceding 5 years are maintained and are available for purchase from Mosby until inventory is depleted at a cost of $9.50 per issue. The following quantity discounts are available: 25% off on quantities of 12 to 23, and one-third off on quantities of 24 or more. Please write to Mosby, Inc., Subscription Services, 11830 Wesfline Industrial Dr., St. Louis, MO 63146-3318, or call (800)453-4351 or (314)453-4351 for information on availability of particular issues. If unavailable from the publisher, photocopies of complete issues may be purchased from UMI, 300 N. Zeeb Rd., Ann Arbor, MI 48106, (313)761-4700.
282
JULY/AUGUST1998 HEART & LUNG
Postlaparoscopic traumatic inferior vena caval thrombosis K a t h r y n E. Peck, M D , Jos~ T. B o n o a n , M D , a n d B u r k e A. C u n h a , MD, M i n e o l a a n d S t o n y B r o o k , N.Y.
Thrombosis of the inferior vena cava (IVC) is a rare disease. It has been reported in the literature in association with a variety of noninfectious diseases, particularly carcinoma of the kidney and liver, as well as abdominal trauma and percutaneous IVC filter placement. We report a case of IVC thrombosis in a young n o n p r e g n a n t patient after laparoscopic pelvic surgery. We believe it is the first case in th e literature of laparoscopic-induced IVC thrombosis. (Heart Lung ® 1998;27:279-82)
CASE
REPORT
A
28-year-old woman, gravida zero, with a long history of chronic pelvic pain was admitted to the Ambulatory Surgery Unit at WinthropUniversity Hospital for an elective explorative pelvic laparoscopy. Her surgical history included an exploratory laparoscopy of the pelvis, appendectomy, and left salpingo-oophorectomy approximately 10 years ago and an exploratory laparotomy 4 years ago. The patient continued to experience chronic pelvic pain without significant physical findings. A pelvic sonogram was performed before the present hospital admission and was found to be within normal limits. The patient reported that she had no history of pelvic inflammatory disease, uterine fibroids, sexually transmitted diseases, constipation, or diarrhea. At the time of hospital admission, her only medication consisted of birth control pills. Social history was significant for a halfpack-per-day use of tobacco. Admission laboratory studies including hemoglobin, hematocrit, white blood cell count, and electrolyte panel were all within normal limits.
From the Infectious Disease Division. Winthrop~University Hospital, Mineola,and the StateUniversityof NewYorkSchoolof Medicine.StonyBrook. Reprint requests:BurkeA. Cunha, MD, Chief, InfectiousDisease Division.Winthrop-UniversityHospital, Mineola.NY 11501 Copyright© 1998by Mosby,Inc. 0147-9563/98/$5.00+ 0 2/i/91154
HEART & L U N G VOL. 27, NO. 4
, ~,,
The explorative laparoscopy was complicated by laceration of the left common lilac artery and injury to the sigmoid colon. The patient underwent emergent repair of the artery by an end-to-end anastomosis and a resection of the damaged sigmold colon, with construction of a colostomy and a Hartmann's pouch. Findings at the time of the abdominal surgery were significant for dense pelvic and abdominal wall adhesions, a left retroperitoneal hematoma, and a right ovarian cyst. A right ovarian cystectomy was also performed during the surgical procedure. During the postoperative course the patient complained of pain and tingling in the left leg. The patient was given metronidazole, 500 mg intravenously (IV) every 8 hours, and suibactam-ampicillin 3 g (IV) every 6 hours. For the first 6 postoperative days, her temperatures were approximately 101.5°E At this time, gentamicin was added to the antibiotic regimen. On the seventh and eighth postoperative days, the maximum temperature was 102°F, and the Infectious Disease Service was contacted in consultation for the unresolving fevers. At this time, the patient had some mild abdominal discomfort but denied rigors, chills, sweats, chest pain, shortness of breath, and dysuria. Physical exam was significant only for moderate obesity. The colostomy was functioning satisfactorily, and the surgical wound sites appeared clean and intact. On the eighth postoperative day, the previously stated antibiotics were discontinued, and meropenem 1 g (IV) every 8 hours was started. At this time, the white blood cell
279
Table
Causes of inferior vena caval thrombosis Percutaneously-placed IVC filters Femoral vein catheterization Venous prosthetic devices Indwelling catheters Budd-Chiari syndrome Congenital anomalies of the IVC Aneurysms of the IVC Abdominal aortic aneurysm Beh~et's syndrome Antiphospholipid syndrome Retroperitoneal fibrosis Liver transplantation Malignant fibrous histiocytoma of the IVC Systemic amyloidosis Postpartum ovarian vein thrombosis Chronic pancreatitis Pancreatic cysts Pancreatic carcinoma Renal cell carcinoma Lymphoma Renal pelvic transitional cell carcinoma Pheochromocytoma Renal angiomyolipoma Testicular carcinoma Ovarian carcinoma Nephroblastoma Wilms' tumor Amebic hepatic abscess Adrenal neoplasms Hepatocellular carcinoma Blunt abdominal trauma Strenuous athletics Burns Ulcerative colitis Membranous lupus nephritis Acute staphylococcal osteomyelitis Protein C and S deficiencies Adapted from references4-6, 10.
count was 8.1 × 3000/mm 3, and the urine analysis was negative. Blood cultures were drawn but showed no growth. A computed tomography (CT) was performed of the abdomen and pelvis to rule out an intra-abdominal collection. CT of the abdomen demonstrated thrombosis. This extended cephalad, up to the region of the renal veins. Because of the CT findings of inferior vena canal (IVC) thrombosis, a heparin drip was started on the 10th postoperative day (1900 U/h),
280
and meropenem was continued. Over the course of the next 5 days, the patient became afebrile. After 5 days the patient was given warfarin 5 mg orally each day. DISCUSSION
IVC thrombosis is a rare disease. Review of the literature since 1987 shows that IVC thrombosis has been associated with a number of diseases, but not as a postoperative sequelae of laparoscopic surgery (Table). Recent reports have presented cases of deep venous thrombi of the legs secondary to laparoscopic cholecystectomy; but to our knowledge this is the first reported case of IVC thrombosis after laparoscopic surgery. I-3 In 1994, Chaudhuri et al 4 reported that 1VC thrombosis may be primary (14%) or can be secondary to conditions that apply external pressure (tumors and aortic aneurysms), extension of retroperitoneal tumors, hypercoaguable states, and diseases of the liver. In 1990, Novick et al 5 reported that the most common retroperitoneal tumor associated with IVC thrombosis is the renal cell carcinoma. The literature also contains well-documented reports of 1VC thrombosis associated with abdominal trauma. Because 1VC thrombosis is rare, the clinical features of this disease have yet to be clearly defined. 6 In 1990, Nagy et al 7 reported a case of IVC thrombosis after a motor vehicle accident in which the patient had a normal CT of the abdomen immediately after the injury and without any intraabdominal visceral injury. The patient, like ours, had a remarkable paucity of physical symptoms (only vague abdominal and back pain). In 1995, Takeuchi et al 6 reported 2 cases of trauma-associated (contused right lower lung and ruptured hepatic veins) IVC thrombosis in which the caval thrombi were detected by chance after routine abdominal CT scanning for postoperative evaluation. Thus it has been noted that caval obstruction may not necessarily cause leg edema; so the lack of this physical finding, as in our patient, cannot rule out the possibility of IVC thrombosis. Also of interest in the literature on trauma-associated IVC thrombosis is the Takeuchi et al 6 report that the delay between injury and presentation in 6 cases was 10 to 21 days. Our patient's IVC thrombosis was discovered on the 10th postoperative day. Furthermore, one of the postulated mechanisms of thrombosis in the Takeuchi et al 6 case (IVC thrombosis associated with a motor vehicle accident) is caval compression secondary to a retroperitoneal hematoma, probably of psoas muscle origin. Our patient also had a retroperitoneal hematoma, seen during the surgi-
JULY/AUGUST1998 HEART & LUNG
Fig. 1 CT scan of a b d o m e n and pelvis showing low attenuation centrally and enlargement of inferior vena cava (arrow), indicating IVC thrombosis.
cal procedure and also on the CT scan. However, Takeuchi et al 6 also note that their patient had a central venous catheter inserted into the left groin for 5 days. Femoral catheterization has been associated with IVC thrombosis in the literature. Endothelial injury of the venous wall secondary to compression or shearing forces seems to be the most widely postulated mechanism of IVC thrombosis related to trauma. 6 Septic thrombophlebitis of the IVC also has been reported, and this is thought to be initiated by bacterial injury of the venous endothelium. 8 Because the incidence of IVC thrombosis is so rare, the pathophysiological mechanisms of the disease have yet to be fully elucidated. CT scans have been shown to be of major diagnostic value. 9 However, Novick et al 5 note that a CT scan is unreliable in delineating the cephalad extent of a thrombus, and that inferior vena cavography has been most accurate in defining and assessing IVC thrombi. In cases where antegrade phlebography is insufficient because of complete caval obstruction, retrograde injection of the IVC may be used to define the distal limits of the thrombus. 5 However, vena cavography is invasive
HEART & LUNG VOL. 27, NO. 4
and carries the small risk of dislodging the thrombus. 4 Well-known risk factors for deep venous thrombosis (DVT) include advanced age, malignant tumors, hypercoaguable states, prior history of DVT, direct vessel injury, immobility, and obesity. 6 Our patient manifested the latter 2 risk factors. Whereas the incidence of DVT may be up to 250,000 per year (Nagy and Duarte7), thrombosis of the intra-abdominai great vessels is rare. 6 Management of IVC thrombosis has involved various modalities. Other cases of IVC thrombosis have been successfully treated like ours, with conservative medical management with heparin. 1° Thrombectomy, ligation of the 1VC followed by anticoagulation therapy, and thrombolytic therapy with use of urokinase have also been cited in the literature as case-specific means of treatment. 5
REFERENCES
1. Lord RV. Hugh TB, Coleman ML Doust BD. The incidence of deep venous thrombosis after laparoscopic cholecystectomy. Med l Aust 1996;165:402-3. 2. DraganicBD, Gani JS.The incidence of deepvenousthrombo-
281
3. 4. 5.
6.
sis after laparoscopic cholecystectomy. Med J Aust 1996;402:402-3. Patel MI, Hardman DT, Nicholls D, Fisher CM, Appleberg M. The incidence of deep venous thrombosis after laparoscopic cholecystectomy. Med J Aust 1996;164:652-4. Chaudhuri R, Malik I, Bingham ]B. Case of the month: a tightening of the belt. Brit J Radiol 1994;67:663-4. Novick AC, Kaye MC, Cosgrove DM, Angermeier K, Pontes JE, Montie JE, et al. ExperienCe with cardio-pulmonary bypass and deep hypothermic circulatory arrest in the management of retroperitoneal tumors with large vena caval thrombi. Ann Surg 1990;212:472-7. Takeuchi M, Maruyama K, Nakamura M, Chikusa H, Yoshida T, Muneyuki M, et al. Posttraumatic inferior vena caval thrombo-
7. 8. 9. 10.
sis: case report and review of the literature. J Trauma 1995;39:605-8. Nagy KK, Duarte B. Post-traumatic inferior vena caval thrombosis: case report. J Trauma 1990;30:218-21. Magee KP, Blanco JD, Graham JM. Massive septic pelvic thrombo-phlebitis. Obstet Gynecol 1993;82:662-4. Kniemeyer HW, Grabitz K, Buhl R, Wrist HJ, Sandmann W. Surgical treatment of septic deep venous thrombosis. Surgery 1995;118:49-53. John TG, Chalmers N, Redhead DN, Kumar S, Garden OJ. Case report: inferior vena caval thrombosis following severe liver trauma and peri-hepatic packing--early detection by intraoperative ultrasonography enabling treatment by percutaneous mechanical thrombectomy. Br J Radiol 1995;68:314-7.
AVAILABILITY OF JOURNAL BACK ISSUES As a service to our subscribers, copies of back issues of Heart & Lung®: The Journal of Acute and Critical Care for the preceding 5 years are maintained and are available for purchase from Mosby until inventory is depleted at a cost of $9.50 per issue. The following quantity discounts are available: 25% off on quantities of 12 to 23, and one-third off on quantities of 24 or more. Please write to Mosby, Inc., Subscription Services, 11830 Wesfline Industrial Dr., St. Louis, MO 63146-3318, or call (800)453-4351 or (314)453-4351 for information on availability of particular issues. If unavailable from the publisher, photocopies of complete issues may be purchased from UMI, 300 N. Zeeb Rd., Ann Arbor, MI 48106, (313)761-4700.
282
JULY/AUGUST1998 HEART & LUNG