- Email: [email protected]
Treatment of an Acute Limb Due to Inferior Vena Cava Filter Thrombosis
JACC: CARDIOVASCULAR INTERVENTIONS
VOL.
ª 2017 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
-, NO. -, 2017
ISSN 1936-8798/$36.00
PUBLISHED BY ELSEVIER
http://dx.doi.org/10.1016/j.jcin.2017.06.041
IMAGES IN INTERVENTION
Treatment of an Acute Limb due to Inferior Vena Cava Filter Thrombosis Michael N. Young, MD, Mazen Albaghdadi, MD, MS, Rasha Al-Bawardy, MD, Jorge Borges, MD, MPH, PHD, Kenneth Rosenfield, MD, MHCDS
A
55-year-old man presented with profound
anticoagulation, prompting placement of a retriev-
unilateral
Approxi-
able inferior vena cava (IVC) filter. On this admission,
mately 1 month before, he had suffered a
ultrasound evaluation revealed extensive bilateral
pulmonary embolism complicated by bleeding on
deep venous thromboses (Figure 1). On examination,
right
leg
swelling.
F I G U R E 1 Bilateral Proximal Deep Venous Thromboses
Venous duplex ultrasound on hospital admission revealed right greater than left deep venous thromboses in the proximal iliofemoral venous systems. þ signs indicate vein measurements with external transducer compression. 2 ¼ 0.78 cm (left common femoral vein). 3 ¼ 1.41 cm (right common femoral vein). 4 ¼ 0.98 cm (right greater saphenous vein. CFV ¼ common femoral vein; GSV ¼ greater saphenous vein; non comp ¼ non-compressible; part comp ¼ partially compressible. See Online Video 1.
From the Fireman Vascular Center, Massachusetts General Hospital, Boston, Massachusetts. Dr. Rosenfield has served on the scientific advisory board of and as a consultant for Angiodynamics, Abbott Vascular, Amgen, Cardinal Health, Inspire MD, Silk Road Medical, Surmodics, Thrombolex, Volcano-Philips, and University of Maryland; has received institutional research grant support from Angiodynamics, Atrium-Getinage, Lutonix-BARD, National Institutes of Health, and Inari Medical; has served on the board of directors for VIVA; has served as the president of the Society for Cardiovascular Angiography and Interventions; and has served as the president of the National PERT Consortium. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received May 30, 2017; revised manuscript received June 10, 2017, accepted June 20, 2017.
2
Young et al.
JACC: CARDIOVASCULAR INTERVENTIONS VOL.
-, NO. -, 2017 - 2017:-–-
Endovascular Therapy for IVC Filter Occlusion
F I G U R E 2 Initial Percutaneous Approach to Inferior Vena Cava Filter Thrombosis
Diagnostic venogram showed a completely thrombosed filter device in the inferior vena cava (left). Vacuum-assisted thrombectomy was initially performed above the filter, followed by device retrieval using a 10-mm gooseneck snare (right). See Online Video 2.
the patient exhibited diminished sensation and ab-
circuit. Venography confirmed complete IVC filter
sent pedal pulses of the right foot consistent with
thrombosis (Online Video 1) extending inferiorly
phlegmasia. Following an emergent multidisciplinary
into the bilateral iliofemoral venous systems. We
evaluation by vascular surgery and medicine, we pro-
performed vacuum-assisted thrombectomy (Online
ceeded with IVC filter removal and catheter-based
Video 2) above the filter using an AngioVac Can-
thrombectomy.
nula (AngioDynamics, Latham, New York). The filter
First, we placed 26-F and 15-F sheaths in the
was subsequently extracted using a 4-F 10-mm
right and left internal jugular veins, respectively,
gooseneck snare in tandem with a 5-F AL1 cath-
through which we initiated a venovenous bypass
eter (Figure 2).
F I G U R E 3 Treatment of the Right Iliofemoral Venous System
Catheter techniques used for venous thromboembolectomy: (A) vacuum-assisted filtration of the right iliofemoral veins; (B) maceration of recalcitrant thrombus using an oscillating wire under active suction; and (C) balloon venoplasty followed by pullback under active suction. See Online Video 3.
JACC: CARDIOVASCULAR INTERVENTIONS VOL.
-, NO. -, 2017
- 2017:-–-
Young et al. Endovascular Therapy for IVC Filter Occlusion
F I G U R E 4 Restored Patency of the Iliofemoral Venous System and Inferior Vena Cava
Completion venography demonstrated significant debulking of clot with restored patency and inflow as shown: (A) right iliofemoral venous system; (B) left iliofemoral venous system; and (C) proximal iliac bifurcation and inferior vena cava. See Online Video 4.
F I G U R E 5 Percutaneously-Extracted Thrombi and Retrievable Filter Device
Representative images of large volume thrombi extracted into recipient canisters (top and bottom left) and an externalized inferior vena cava filter (bottom right).
3
4
Young et al.
JACC: CARDIOVASCULAR INTERVENTIONS VOL.
-, NO. -, 2017 - 2017:-–-
Endovascular Therapy for IVC Filter Occlusion
F I G U R E 6 Complete Resolution of Right Lower Extremity Edema and Phlegmasia
Vacuum filtration was then performed from the IVC to the right iliofemoral venous system. Adjunctive techniques to debulk thrombus included: 1) clot maceration (Online Video 3) using a rotational CleanerXT wire (Argon Medical Devices, Inc., Plano, Texas); 2) balloon venoplasty with 10- and 12-mm catheters; and 3) mechanical embolectomy via active balloon catheter pullback under proximal suction by the AngioVac device (Figure 3). We repeated vacuum filtration in the left iliofemoral system. Completion venography (Online Video 4) demonstrated excellent angiographic
results
(Figure
4).
Following
clot
extraction (Figure 5), the swelling of the right leg resolved (Figure 6), pedal pulses and sensation of the foot normalized, and the patient was successfully discharged to a rehabilitation facility. In this case of lower extremity phlegmasia due to thrombotic IVC filter occlusion, we
show
that
vacuum-assisted thrombectomy in tandem with a venovenous bypass circuit is feasible and effective. Extracorporeal bypass allows for externalization and filtration of thrombus through the AngioVac device. Meanwhile, the reinfusion cannula minimizes central blood loss and permits continued vacuum-assisted filtration (1,2).
ADDRESS FOR CORRESPONDENCE: Dr. Michael N. Physical appearance of the bilateral lower extremities (top) before and
Young, Massachusetts General Hospital, Harvard Medical
(bottom) after percutaneous venous thromboembolectomy.
School, 55 Fruit Street, GRB8-852E, Boston, Massachusetts 02114. E-mail: [email protected].
REFERENCES 1. Golowa Y, Warhit M, Matsunaga F, Cynamon J. Catheter directed interventions for inferior vena cava
with a novel device. Catheter Cardiovasc Interv 2015;86:E81–7.
thrombosis. Cardiovasc Diagn Ther 2016;6:612–22. 2. Donaldson CW, Baker JN, Narayan RL, et al. Thrombectomy using suction filtration and
KEY WORDS inferior vena cava filter,
veno-venous bypass: single center experience
percutaneous thrombectomy, thrombosis
AP PE NDIX For supplemental videos and their legends, please see the online version of this article.
VOL.
ª 2017 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
-, NO. -, 2017
ISSN 1936-8798/$36.00
PUBLISHED BY ELSEVIER
http://dx.doi.org/10.1016/j.jcin.2017.06.041
IMAGES IN INTERVENTION
Treatment of an Acute Limb due to Inferior Vena Cava Filter Thrombosis Michael N. Young, MD, Mazen Albaghdadi, MD, MS, Rasha Al-Bawardy, MD, Jorge Borges, MD, MPH, PHD, Kenneth Rosenfield, MD, MHCDS
A
55-year-old man presented with profound
anticoagulation, prompting placement of a retriev-
unilateral
Approxi-
able inferior vena cava (IVC) filter. On this admission,
mately 1 month before, he had suffered a
ultrasound evaluation revealed extensive bilateral
pulmonary embolism complicated by bleeding on
deep venous thromboses (Figure 1). On examination,
right
leg
swelling.
F I G U R E 1 Bilateral Proximal Deep Venous Thromboses
Venous duplex ultrasound on hospital admission revealed right greater than left deep venous thromboses in the proximal iliofemoral venous systems. þ signs indicate vein measurements with external transducer compression. 2 ¼ 0.78 cm (left common femoral vein). 3 ¼ 1.41 cm (right common femoral vein). 4 ¼ 0.98 cm (right greater saphenous vein. CFV ¼ common femoral vein; GSV ¼ greater saphenous vein; non comp ¼ non-compressible; part comp ¼ partially compressible. See Online Video 1.
From the Fireman Vascular Center, Massachusetts General Hospital, Boston, Massachusetts. Dr. Rosenfield has served on the scientific advisory board of and as a consultant for Angiodynamics, Abbott Vascular, Amgen, Cardinal Health, Inspire MD, Silk Road Medical, Surmodics, Thrombolex, Volcano-Philips, and University of Maryland; has received institutional research grant support from Angiodynamics, Atrium-Getinage, Lutonix-BARD, National Institutes of Health, and Inari Medical; has served on the board of directors for VIVA; has served as the president of the Society for Cardiovascular Angiography and Interventions; and has served as the president of the National PERT Consortium. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received May 30, 2017; revised manuscript received June 10, 2017, accepted June 20, 2017.
2
Young et al.
JACC: CARDIOVASCULAR INTERVENTIONS VOL.
-, NO. -, 2017 - 2017:-–-
Endovascular Therapy for IVC Filter Occlusion
F I G U R E 2 Initial Percutaneous Approach to Inferior Vena Cava Filter Thrombosis
Diagnostic venogram showed a completely thrombosed filter device in the inferior vena cava (left). Vacuum-assisted thrombectomy was initially performed above the filter, followed by device retrieval using a 10-mm gooseneck snare (right). See Online Video 2.
the patient exhibited diminished sensation and ab-
circuit. Venography confirmed complete IVC filter
sent pedal pulses of the right foot consistent with
thrombosis (Online Video 1) extending inferiorly
phlegmasia. Following an emergent multidisciplinary
into the bilateral iliofemoral venous systems. We
evaluation by vascular surgery and medicine, we pro-
performed vacuum-assisted thrombectomy (Online
ceeded with IVC filter removal and catheter-based
Video 2) above the filter using an AngioVac Can-
thrombectomy.
nula (AngioDynamics, Latham, New York). The filter
First, we placed 26-F and 15-F sheaths in the
was subsequently extracted using a 4-F 10-mm
right and left internal jugular veins, respectively,
gooseneck snare in tandem with a 5-F AL1 cath-
through which we initiated a venovenous bypass
eter (Figure 2).
F I G U R E 3 Treatment of the Right Iliofemoral Venous System
Catheter techniques used for venous thromboembolectomy: (A) vacuum-assisted filtration of the right iliofemoral veins; (B) maceration of recalcitrant thrombus using an oscillating wire under active suction; and (C) balloon venoplasty followed by pullback under active suction. See Online Video 3.
JACC: CARDIOVASCULAR INTERVENTIONS VOL.
-, NO. -, 2017
- 2017:-–-
Young et al. Endovascular Therapy for IVC Filter Occlusion
F I G U R E 4 Restored Patency of the Iliofemoral Venous System and Inferior Vena Cava
Completion venography demonstrated significant debulking of clot with restored patency and inflow as shown: (A) right iliofemoral venous system; (B) left iliofemoral venous system; and (C) proximal iliac bifurcation and inferior vena cava. See Online Video 4.
F I G U R E 5 Percutaneously-Extracted Thrombi and Retrievable Filter Device
Representative images of large volume thrombi extracted into recipient canisters (top and bottom left) and an externalized inferior vena cava filter (bottom right).
3
4
Young et al.
JACC: CARDIOVASCULAR INTERVENTIONS VOL.
-, NO. -, 2017 - 2017:-–-
Endovascular Therapy for IVC Filter Occlusion
F I G U R E 6 Complete Resolution of Right Lower Extremity Edema and Phlegmasia
Vacuum filtration was then performed from the IVC to the right iliofemoral venous system. Adjunctive techniques to debulk thrombus included: 1) clot maceration (Online Video 3) using a rotational CleanerXT wire (Argon Medical Devices, Inc., Plano, Texas); 2) balloon venoplasty with 10- and 12-mm catheters; and 3) mechanical embolectomy via active balloon catheter pullback under proximal suction by the AngioVac device (Figure 3). We repeated vacuum filtration in the left iliofemoral system. Completion venography (Online Video 4) demonstrated excellent angiographic
results
(Figure
4).
Following
clot
extraction (Figure 5), the swelling of the right leg resolved (Figure 6), pedal pulses and sensation of the foot normalized, and the patient was successfully discharged to a rehabilitation facility. In this case of lower extremity phlegmasia due to thrombotic IVC filter occlusion, we
show
that
vacuum-assisted thrombectomy in tandem with a venovenous bypass circuit is feasible and effective. Extracorporeal bypass allows for externalization and filtration of thrombus through the AngioVac device. Meanwhile, the reinfusion cannula minimizes central blood loss and permits continued vacuum-assisted filtration (1,2).
ADDRESS FOR CORRESPONDENCE: Dr. Michael N. Physical appearance of the bilateral lower extremities (top) before and
Young, Massachusetts General Hospital, Harvard Medical
(bottom) after percutaneous venous thromboembolectomy.
School, 55 Fruit Street, GRB8-852E, Boston, Massachusetts 02114. E-mail: [email protected].
REFERENCES 1. Golowa Y, Warhit M, Matsunaga F, Cynamon J. Catheter directed interventions for inferior vena cava
with a novel device. Catheter Cardiovasc Interv 2015;86:E81–7.
thrombosis. Cardiovasc Diagn Ther 2016;6:612–22. 2. Donaldson CW, Baker JN, Narayan RL, et al. Thrombectomy using suction filtration and
KEY WORDS inferior vena cava filter,
veno-venous bypass: single center experience
percutaneous thrombectomy, thrombosis
AP PE NDIX For supplemental videos and their legends, please see the online version of this article.