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Vena cava umbrella placement
Vena Cava Umbrella Placement Its Place in the Over-All
Jefferson
Management
F. Ray, III, MD, Marshfield,
William 0. Myers, MD, FAG, Ben Ft. Lawton,
Richard D. Sautter,
Wisconsin Wisconsin
MD, FACS, Marshfield,
Wisconsin
Surgical procedures in the infrarenal vena cava to protect against recurrence of pulmonary emboli despite adequate heparinization have evolved from ligation with silk [I], construction of an intracaval grid of silk suture material [2], and plication by Teflon@ clip [3], silk sutures [4], or stainless steel staples [5], to the transvenous placement of an intracaval silicone rubber webbed umbrella f&13].
This latter operation introduced by Mobin[iddin et al [6] in 1967 was immediately attractive because (1) a general anesthetic is not used; (2) it does not affect cardiac output; (3) it is not traumatic and is usually easily performed; (4) it promises low morbidity and mortality. This is a report of two consecutive years’ experience, March 1971 to March 1973, and includes all caval umbrella placements ever performed at the Marshfield Clinic. The effectiveness of the filter, morbidity, and complications are presented. The over-all role of umbrella placement in the management, of thromboembolic disease is discussed in the light of one year’s review, March 1971 to March 1972, of all documented thromboemboli that occurred at the Clinic.
From the Marshfield Clinic and Marshfield Clinic Foundation for Medical Research and Education, Marshfield, Wisconsin. Reprint requests should be addressed to Dr Ray, 630 South Central Avenue, Marshfield. Wisconsin 54449.
Volume 127, May 1974
Disease
Wisconsin
Marshfield,
MD, FACS, Marshfield,
of Thromboembolic
Material
and Methods
Sixteen patients, ten men and six women, underwent, seventeen attempts at transvenous caval or !liac vein interruption with the umbrella filter. In patient 6 the unbrella was purposefully placed in the right iliac vein, and in patient 5 the umbrella could not be placed because the superior vena cava was obstructed. The age range was forty-eight to seventy-six years, with an average of sixty-two. Ten of the patients had undergone recent surgery and three had evidence of congestive heart failure. Other risk factors were cancer in four, traama in one, and thrombophlebitis in four. Some patients had more than one risk factor. The diagnosis of pulmonary embolism was confirmed by pulmonary angiography in fifteen of the sixteen patients. Lower extremity vent,)grams were taken in nine patients. Eight venograms confirmed the presence of thrombophlebitis and one, in p&ient 5, did not. In eleven patients the indication for caval umbrella placement was recurrent pulmonary embolism despite adequate anticoagulation with heparin. In four patients heparin therapy was contraindicated. A pcatentially iethal 20 cm clot in the leg, attached only distally and floating in the deep femoral vein of the thigh, was another indication. In one instance of threatened migration of the filter, a second filter was positioned above the first IO engage both filters, fixing the spokes into the caval wall to prevent further migration. Follow-up study of patients from one to twenty-four months has been 100 per cent with letters and office visits and is complete to March 1973.
545
2
:: OI
with Vena Cava Umbrella
M, 65
F, 60
M, 54
M, 57
M, 48
F, 65
M, 69
F, 59
M, 71
F, 76
4
5
6
7
8
9
10
11
12
13
M, 68
F, 62
M, 66
M, 54
3
of left hip
Post left knee surgery (synovectomy and debridement) Post reoperation for coronary artery disease (triple vein grafts and direct mammary bypass); Vineberg implant in 1968 Congestive heart failure with recurring pulmonary emboli; bilateral pleural effusion Small bowel obstruction; emboli, recurrent, on heparin therapy Carcinomatosis (adenocarcinoma) most likely from biliary tree Congestive heart failure; atrial fibrillation; diabetes; parkinsonism; alcoholism; small emboli for 3 weeks prior to admission Recurrent pulmonary embolism, documented with angiography 1969 Recurrent pulmonary embolus, documented angiographically; post triple coronary bypass complicated by mediastinitis Post esophagogastrectomy for adenocarcinoma Recurrent pulmonary embolism; phlebitis since age 25
Post fusion
Post excision of lower lip carcinoma and right radical neck dissection Post vagectomy and pyloroplasty; abdominal wound infection; pulmonary embolus Post threatened migration Accident, burns (third degree) of trunk, perineum, thighs, penis Squamous cell carcinoma of the esophagus
M, 69
2
hemorrhage
Subarachnoid
F, 57
1
Preoperative Clinical Diagnosis
Two Year Experience
Sex and Age (yr)
I
Patient Number
TABLE at the Marshfield
well; 7
well: 6
well; 6
Alive, doing
Alive, doing
Alive, doing
None
None
Positive, right
Not done
Positive, right
Positive,
Positive,
Not done
Not done
Not done
left and
left and
left
left
Inability to pass eustachian valve; patient positioned with right side up; catheter passed easily
None
None
None
None
Small right internal jugular vein; left internal jugular vein used None
None
well; 19 well; 17
Alive, doing Alive, doing
well; 1 well
Alive, doing None
doing well; 1
well; 1
Alive, doing
Alive,
Alive, doing
Died (12-3-72) of carcinomatosis; 2 Alive, doing well; 5
well; 19
Alive, doing
None
None
None
Left leg, 3+ edema
None
None
well; 7
Alive, doing None
None None
Alive, doing well; 11 None
Positive, left and right Positive, left and right Negative, left; positive, right
Died (1-18-72) 3 months after esophagogastrectomy
None
Superior vena caval obstruction secondary to carcinoma (squamous cell) of esophagus and radiation therapy None
Venograms taken; no clots seen in either extremity
above
New filter None
Not done Not done
placed
Right leg, l+ edema; left leg,
well; 23
Umbrella loose in vena cava; threatened migration
Alive, doing
None
Positive, left; negative, right Not done
Alive, doing well; 24
Left leg, 2+ edema None
Postoperative Edema
Current Status and Length of Follow-Up Study (mo)
None
Difficulty and Surgical Complications of Umbrella Placement
Clinic
Not done
Lower Extremity Venography
Placement
z Y 2 ar
Figure 1. F/at p/ate of abdomen in patient 3 taken severa/ days after placement of the second fitter showing the two filfers fixed in the infrarenal vena cava.
Figure 2. Bilateral venograms revealing clot in deep femoral system in the right thigh of patient 8.
Results
bolization of the filter to the heart. (Figure i .) This patient also had angiographic c,onf irmat.ion of the position of both renal veins 10 insure plat,ement of the filter below them [ 141.
The resu1t.s are summarized in Table I. Mortaiir? There was no mortality associated with filter placement. As of March 1973, fourteen of the patients are alive. The deaths, in patients 5 and 11, were due to progression of the underlying malignancy. Morbidit>. Recurrent embolism: There was one instance of recurrent pulmonary embolism, documented hy pulmonary angiography, which occurred four months postoperatively in patient 2. The umbrella filter was seen to be firmly in place at the time of recurrent embolism. This patient is now alive twenty-four months postoperatively and doing well. He has been on Coumadin@ therapy during this period. Filter migration: In patient 3 migration of the filter threatened. The filter was seen to be wobbly on fluoroscopy, with the prongs on one side of the filter not fully engaging the vena cava, thereby allowing the umbrella to tilt and wobble in the vena cava; also, it was two vertebral bodies above its original site of placement. This was managed by immediately placing another filter above the first and. with cautious manipulation, firm fixation of both filters was achieved, thereby preventing em-
Volume
127,May
1974
Edema
and sta.sis dermatitis
o/ file tstrenzitir~.s:
Thirteen patients have no edema. Threci ot’ the sixteen patients have moderate to severe edema of one or both extremities. (Figure 2.) ‘l’his edema has been controlled at least partially with ,Johst stockings. No ulceration of the legs is present. Retroperitoneal bleeding: We have observed one instance, in patient 16, of’ ret~roperitoneal bleeding with a fall in the hematocrit f’r’.)m 43 to 35 per cent associated with transient ileus. Transfusion was not required. Misplacement of the filter: There were no misplaced filters. The filter was purposefully placed in the right iliac vein in patient 6 hecause it was helieved that this might prevent thromboemboli and also that it would not predispose the pat.ient to hlateral edema of the lower extremities. Since edema has not been a problem, we now routine11 place the umbrella, in the inferior vena cava. Perforation of the duodenal rcaii: \I,-? have not, encountered this complication [ 151. Wound complications: All wounds have healed per primum and there have heen no inf’ect.ions.
547
Ray et al
Impossible or difficult filter placement: It was impossible to place the filter in patient 5 because of obstruction of the superior vena cava. The patient had received hyperalimentation via both subclavian veins. It is believed the superior vena cava was the site of origin of the emboli. Patient 12 had placement of a 28 mm filter, which was extremely difficult because of its tootight fit in the loading capsule. The Edwards Laboratories has acknowledged that other surgeons have experienced difficulty with the unloading of the 28 mm filter. Subsequent to this difficult placement, we have preferred not to use the 28 mm filter and are awaiting a retooling of the loading capsule, which the Edwards Laboratories has acknowledged is advisable and is now being done. Placement of the filter was difficult in patient 17 because the capsule continuously stopped at the eustachian valve and would not advance further. Multiple attempts at maneuvering past the valve were unsuccessful. When the patient’s position was changed to a 45 degree right-side-up position, however, the filter slid easily past the eustachian valve. Comments The mainstay of treatment of pulmonary embolization remains intravenous heparin therapy, As seen from the clinical profile, this group of patients with placement of vena cava umbrellas had re-embolization during heparin therapy (twelve patients) or had contraindications to heparin therapy (four patients). Indications for umbrella placement include (1) angiographically confirmed recurrent pulmonary emboli despite anticoagulation with venographic confirmation of thrombi in the lower part of the body, (2) contraindications to anticoagulant therapy with angiographically confirmed massive or submassive pulmonary emboli with venographic confirmation of thrombi in the lower part of the body, (3) venographic evidence of potentially lethal thrombus in a patient with angiographically confirmed pulmonary emboli, (4) threatened migration, to trap another previously placed filter unstable on fluoroscopy. No umbrella has been placed prophylactically, that is, in a patient who does not yet have pulmonary emboli [17]; the operation has been performed almost exclusively in patients meeting the foregoing criteria and, as seen in their clinical profile (Table I), in patients who were considered likely to die from another pulmonary embolus [16].
548
The priorities of management of patients with massive pulmonary thromboemboli include (1) immediate intravenous dose of 100 mg of heparin, (2) assisted extracorporeal circulation, (3) fibrinolytic therapy, (4) caval umbrella, (5) heparin for five days and Coumadin for three months. As fibrinolytic therapy is not available to the clinician, caval umbrella placement assumes the third priority [17]; if the patient is not in profound shock and thus not a candidate for assisted circulation, caval umbrella placement assumes the second priority. Does this second priority mean that many patients will be candidates for umbrella placement? We think not, based on the following one year review of all patients with demonstrated pulmonary thromboembolism at the Marshfield Clinic. From March 1971 to March 1972 there were twenty-one patients with confirmed (in nineteen by angiograms and in two by postmortem examinations) massive pulmonary emboli involving more than 50 per cent of the pulmonary circulation; there were forty patients with documented lesser emboli involving less than 50 per cent of the pulmonary circulation. Thus, in one year’s experience with sixty-one patients with documented emboli, only six received caval umbrella interruption. Would patients not receiving umbrella interruption have fared better with the operation than they did with heparin therapy alone? Of the fiftyfive patients not receiving an umbrella, fifty-three had heparin therapy. Fifty of the fifty-five patients left the hospital alive. In the entire group of sixty-one patients six died, five with massive emboli and one patient with less than massive emboli. Five of the deaths occurred in patients not receiving umbrellas and one death occurred in a patient in whom the umbrella could not be placed (patient 5). It is interesting to note that this death was not due to recurrent pulmonary embolization but was due to progression of the underlying malignancy. Of the five patients not receiving umbrellas who died, only one could have been considered a candidate for umbrella placement in retrospective analysis. This patient was a seventy-two year old woman with a prior cerebrovascular accident who died fifteen minutes after a second pulmonary embolization. She should, we believe now, have received a caval umbrella. The three other deaths in the patients with massive emboli were due primarily to severe intercurrent disease, disseminated intravascular coagulation, gastrointestinal bleeding, and pulmonary insufficiency secondary to radiation fibrosis (Hodgkin’s disease). The sole death in
The American Journal of Surgery
C:ava Umbrella
Vena
the group of patients with less than massive emboli was due to multiple systemic emboli originating from intracardiac thrombus material in a patient with a primary cardiomyopathy and congestive heart failure. Thus, of sixty-one patients with documented pulmonary emboli at the Marshfield Clinic from March 1971 to March 1972, six had umbrella placement. Of the remaining fifty-five patients, only one could be identified who, in retrospect, would have benefited from caval umbrella placement. We conclude that umbrella placement has a definite role in the management of patients with thromboembolic disease but that only 10 to 15 per cent of patients with documented thromboemboli are candidates for the operation. This figure, which we believe to be reasonable, is high according to Hirsh [a]. He believes that operations to trap emboli from the lower portion of the body are rarely indicated [ 181. As we have stated previously, the diagnosis of pulmonary embolism should be confirmed by pulmonary angiography [ 191. Radioisotopic lung scanning is a good screening procedure, but prior to operation a precise diagnosis is required. In all but one of our patients the diagnosis was confirmed by pulmonary arteriography. Venography is the most valuable adjunctive study in patients with pulmonary thromboemboli [20]. Venography was performed in nine patients. In one case, patient 5, no thrombi were seen in either lower extremity. Believing that the venogram was in error, we decided to perform a caval filter placement. At operation the filter could not be placed because the superior vena cava was obstructed with clot and was thought to be the probable source of emboli. In patient 6, the filter was placed purposefully in the right iliac vein as the right leg was seen to be the site of potentially embolizing thrombotic material. In patient 12, venography revealed a potentially lethal floating clot, 20 cm by 1.5 cm, in the left deep femoral vein attached only distally. This patient had not been on heparin therapy but because of the ominous venogram umbrella placement was carried out. We currently believe that bilateral venography of the lower extremities should probably be performed in all patients considered for umbrella placement. The accuracy of impedance plethysmography and Doppler ultrasound detection is good, and these tests [2I,22] have been employed as screening tests in many of our patients; however, venography remains the most accurate means
Volume
127, May
1974
TABLE
II
Flow Sheet of Management of Patients with Suspected Pulmonary Embolism
Positive screening test for venous thrombosis -IITS scan -Doppler ultrasound evaluation -Impedance plethysmograph
Symptoms
of massive embolus
I / /
.
4 +
Pulmonary
scan 7’
+ Pulmonary
arteriogram
‘----A Venograms
(bilateral)
----Yb
A/--Potentially
lethal
thrombi
No thrombi or Nonlethal thrombi
I
Venous interruption (Local anesthetic) -Mobin-Uddin umbrella -Femoral vein plication
+--
Anticoagulants -Heparin -Coumadin
of identifying clots in the deep venous system of the legs [20]. Our method of management of patients with suspected pulmonary emboli is summarized in Table II. The preferred order of diagnostic study is (1) noninvasive studies, including lung scan, impedance plethysmography, and Doppler ultrasound evaluation, and (2) invasive studies, including pulmonary arteriography (with pulmonary artery pressure and pulmonary artery mixed venous oxygen saturation), postangiographic evaluation of kidneys, ureters, and bladder to detect unsuspected renal disease, and venography of both lower extremities. After the tests a dl?cision regarding umbrella placement is made. We have been impressed with the extremely uncomplicated postoperative course of all of the patients; patients have been returned to .their room and have required minimal or no special care or monitoring. The most critically ill patient, patient 8, had undergone triple vein graft and direct left internal mammary bypass to the left anterior descending coronary artery seven days previously and was virtually moribund with hypotension to 90 mm Hg systolic, tachycardia of 120 beats per minute, and tachypnea of 38 respirations per minute. (Figures 3 and 4.) Pulmonary artery oxygen saturation was 43 per cent at the time of filter placement. Over the next eight hours he improved markedly with pulmonary artery oxygen saturation qf 72 per cent six hours postoperatively. A
549
Ray et
al
general anesthetic in this patient would have led to complete cardiovascular collapse and would have necessitated prolonged extracorporeal cardiopulmonary bypass [23]. Since 1970, embolectomy has not been performed because prolonged bypass alone is believed to offer the patient optimal chance of survival by allowing endogenous fibrinolytic resolution of the embolus [24]. In this case, placement of the filter under local anesthesia did not further jeopardize the cardiac output and presumably allowed sufficient time for i&e intrinsic fibrinolytic system to lyse the clots. The patient continues to do well seven months postoperatively and has returned to work. Summary
Figure 3. Pulmonary angiogram in patient 8 confirming massive thromboemboli after triple aortocoronary vein grafts and direct mammary artery bypass graft.
A series of patients who underwent placement of a vena cava umbrella is presented. Morbidity was minimal and there was no mortality related to umbrella filter placement per se. One patient had a nonfatal episode of recurrent embolization. The role of umbrella placement in the over-all management of thromboembolic disease is discussed and it is concluded that only 10 to 15 per cent of patients with documented pulmonary emboli will be candidates for umbrella placement. References
Figure 4. Venogram in patient 8 demonstrating occlusion of two of three deep veins in the area of the right calf wfth a clot visible in one of deep veins.
550
1. Ochsner A, DeBakey ME: Thrombophlebitis and phlebothrombosis, chap &, p 1. Lewis’ System of Surgery, vol 12. Hagerstown, Maryland, Lewis, 1932. DeWeese MS, Hunter DC: A vena cava filter for the prevention of pulmonary emboli. Bull Sot Int Chir 17: 17, 1958. Moretz WH, Rhode CM, Shepherd MH: Prevention of pulmonary emboli by partial occlusion of the inferior vena cava. Am Surg25: 617, 1959. Spencer FC, Quattlebaum JK, Quattlebaum JK Jr, Sharp EH. Jude JR: Plication of the inferior vena cava for pulmonary embolism: a report of 20 cases. Ann Surg 155: 827. 1962. 5. Ravitch MM. Snodgrass E, McEnany T, Rivarola A: Compartmentation of the vena cava with the mechanical stapler. Surg Gynecol Obstet 122: 561, 1966. 6. Mobin-Uddin K, Smith PE, Martinez LO, Lombard0 C, Jude JR: A vena caval filter for the prevention of pulmonary embolus. Surg Forum 18: 209, 1967. 7. Mobin-Uddin K, McLean R. Bolooki H, Jude JR: Caval interruption for prevention of pulmonary embolism: long term results of a new method. Arch Surg 99: 711, 1969. a. Mobin-Uddin K, Callard GM, Bolooki H. et al: Transvenous caval interruption with umbrella filter. N Engl J Med 286: 55, 1972. 9. Orvald TO, Callard GM, Jude JR: Prevention of pulmonary embolus with vena cava umbrella results in 1.50 patients. Ann Thorac Surg 15: 196, 1973. 10. Mobin-Uddin K, Tringle JK. Bryant LR: Present status of the inferior vena cava umbrella filter. Surgery70: 914, 1971. 11. Beller BM, Talley RC, Lawrence JL: Nonsurgical inferior vena cava obstruction for prevention of pulmonary emboli. JAMA 220: 973, 1972. 12. Crane C: The Mobin-Uddin inferior vena cava filter. Arch
The American Journal of Surgery
vena
surg 103: 661, 1971. 13. Mobin-Uddin K, Bolooki H. Jude JR: intravenous caval interruption for pulmonary embolism in cardiac disease. Circu/&ion41 and 42 suppl2: 152, 1970. 14. Sautter RD. Myers WO, Lawton BR: Experience with vena cava filter migration. JAMA 219: 1217, 1972. 15. Irvin GL III: Duodenal perforation with a vena caval umbrella. Am Surg 38: 635, 1972. 16. Sautter RD. Ray JF III, Myers WO: Massive Pulmonary Thromboembolism-Fibrinolytic Therapy. Saunders, in press. 17. Fullen WD. Miller EH, Steele WF, McDonough JJ: Prophylactic vena caval interruption in hip fractures. J Trauma 13: 403, 1973. 18. Hirsh J: Personal communication, Hamilton, Ontario, Canada, April, 1973.
Volume 127, May 1974
i;ava
Umbrella
19. Sautter RD, Fletcher FW, Ousley JL, Wenze FJ: Extremely rapid resolution of a pulmonary embolus: report of a case. Dis Chesf52: 825. 1967. 20. Williams WJ (ed): Venography.
Circulation 47: 220. 1973
21. Wheeler HB, Pearson D, O’Connell D, M&lick SC: impedance phlebography. Arch Surg 104: 164, 1972. 22. Strandness DE, Sumner DS: Ultrasonic velocity detector in the diagnosis elf thrombophlebitis. Arch Surg 104: 180. 1972. 23. Gazzaniga AB, Cahill JL, Replogle RL, Tilney NL: Changes in blood volume and renal function following ligation of the inferior vena cava. Surgery62: 417, 1967 24. Sautter RD, Myers WO, Ray JF III, Wenzel FJ: Relationship of fibrinolytic system to thrombotic phenomena in the postoperative patient. Arch Surg 107: 292. 1973.
551
Jefferson
Management
F. Ray, III, MD, Marshfield,
William 0. Myers, MD, FAG, Ben Ft. Lawton,
Richard D. Sautter,
Wisconsin Wisconsin
MD, FACS, Marshfield,
Wisconsin
Surgical procedures in the infrarenal vena cava to protect against recurrence of pulmonary emboli despite adequate heparinization have evolved from ligation with silk [I], construction of an intracaval grid of silk suture material [2], and plication by Teflon@ clip [3], silk sutures [4], or stainless steel staples [5], to the transvenous placement of an intracaval silicone rubber webbed umbrella f&13].
This latter operation introduced by Mobin[iddin et al [6] in 1967 was immediately attractive because (1) a general anesthetic is not used; (2) it does not affect cardiac output; (3) it is not traumatic and is usually easily performed; (4) it promises low morbidity and mortality. This is a report of two consecutive years’ experience, March 1971 to March 1973, and includes all caval umbrella placements ever performed at the Marshfield Clinic. The effectiveness of the filter, morbidity, and complications are presented. The over-all role of umbrella placement in the management, of thromboembolic disease is discussed in the light of one year’s review, March 1971 to March 1972, of all documented thromboemboli that occurred at the Clinic.
From the Marshfield Clinic and Marshfield Clinic Foundation for Medical Research and Education, Marshfield, Wisconsin. Reprint requests should be addressed to Dr Ray, 630 South Central Avenue, Marshfield. Wisconsin 54449.
Volume 127, May 1974
Disease
Wisconsin
Marshfield,
MD, FACS, Marshfield,
of Thromboembolic
Material
and Methods
Sixteen patients, ten men and six women, underwent, seventeen attempts at transvenous caval or !liac vein interruption with the umbrella filter. In patient 6 the unbrella was purposefully placed in the right iliac vein, and in patient 5 the umbrella could not be placed because the superior vena cava was obstructed. The age range was forty-eight to seventy-six years, with an average of sixty-two. Ten of the patients had undergone recent surgery and three had evidence of congestive heart failure. Other risk factors were cancer in four, traama in one, and thrombophlebitis in four. Some patients had more than one risk factor. The diagnosis of pulmonary embolism was confirmed by pulmonary angiography in fifteen of the sixteen patients. Lower extremity vent,)grams were taken in nine patients. Eight venograms confirmed the presence of thrombophlebitis and one, in p&ient 5, did not. In eleven patients the indication for caval umbrella placement was recurrent pulmonary embolism despite adequate anticoagulation with heparin. In four patients heparin therapy was contraindicated. A pcatentially iethal 20 cm clot in the leg, attached only distally and floating in the deep femoral vein of the thigh, was another indication. In one instance of threatened migration of the filter, a second filter was positioned above the first IO engage both filters, fixing the spokes into the caval wall to prevent further migration. Follow-up study of patients from one to twenty-four months has been 100 per cent with letters and office visits and is complete to March 1973.
545
2
:: OI
with Vena Cava Umbrella
M, 65
F, 60
M, 54
M, 57
M, 48
F, 65
M, 69
F, 59
M, 71
F, 76
4
5
6
7
8
9
10
11
12
13
M, 68
F, 62
M, 66
M, 54
3
of left hip
Post left knee surgery (synovectomy and debridement) Post reoperation for coronary artery disease (triple vein grafts and direct mammary bypass); Vineberg implant in 1968 Congestive heart failure with recurring pulmonary emboli; bilateral pleural effusion Small bowel obstruction; emboli, recurrent, on heparin therapy Carcinomatosis (adenocarcinoma) most likely from biliary tree Congestive heart failure; atrial fibrillation; diabetes; parkinsonism; alcoholism; small emboli for 3 weeks prior to admission Recurrent pulmonary embolism, documented with angiography 1969 Recurrent pulmonary embolus, documented angiographically; post triple coronary bypass complicated by mediastinitis Post esophagogastrectomy for adenocarcinoma Recurrent pulmonary embolism; phlebitis since age 25
Post fusion
Post excision of lower lip carcinoma and right radical neck dissection Post vagectomy and pyloroplasty; abdominal wound infection; pulmonary embolus Post threatened migration Accident, burns (third degree) of trunk, perineum, thighs, penis Squamous cell carcinoma of the esophagus
M, 69
2
hemorrhage
Subarachnoid
F, 57
1
Preoperative Clinical Diagnosis
Two Year Experience
Sex and Age (yr)
I
Patient Number
TABLE at the Marshfield
well; 7
well: 6
well; 6
Alive, doing
Alive, doing
Alive, doing
None
None
Positive, right
Not done
Positive, right
Positive,
Positive,
Not done
Not done
Not done
left and
left and
left
left
Inability to pass eustachian valve; patient positioned with right side up; catheter passed easily
None
None
None
None
Small right internal jugular vein; left internal jugular vein used None
None
well; 19 well; 17
Alive, doing Alive, doing
well; 1 well
Alive, doing None
doing well; 1
well; 1
Alive, doing
Alive,
Alive, doing
Died (12-3-72) of carcinomatosis; 2 Alive, doing well; 5
well; 19
Alive, doing
None
None
None
Left leg, 3+ edema
None
None
well; 7
Alive, doing None
None None
Alive, doing well; 11 None
Positive, left and right Positive, left and right Negative, left; positive, right
Died (1-18-72) 3 months after esophagogastrectomy
None
Superior vena caval obstruction secondary to carcinoma (squamous cell) of esophagus and radiation therapy None
Venograms taken; no clots seen in either extremity
above
New filter None
Not done Not done
placed
Right leg, l+ edema; left leg,
well; 23
Umbrella loose in vena cava; threatened migration
Alive, doing
None
Positive, left; negative, right Not done
Alive, doing well; 24
Left leg, 2+ edema None
Postoperative Edema
Current Status and Length of Follow-Up Study (mo)
None
Difficulty and Surgical Complications of Umbrella Placement
Clinic
Not done
Lower Extremity Venography
Placement
z Y 2 ar
Figure 1. F/at p/ate of abdomen in patient 3 taken severa/ days after placement of the second fitter showing the two filfers fixed in the infrarenal vena cava.
Figure 2. Bilateral venograms revealing clot in deep femoral system in the right thigh of patient 8.
Results
bolization of the filter to the heart. (Figure i .) This patient also had angiographic c,onf irmat.ion of the position of both renal veins 10 insure plat,ement of the filter below them [ 141.
The resu1t.s are summarized in Table I. Mortaiir? There was no mortality associated with filter placement. As of March 1973, fourteen of the patients are alive. The deaths, in patients 5 and 11, were due to progression of the underlying malignancy. Morbidit>. Recurrent embolism: There was one instance of recurrent pulmonary embolism, documented hy pulmonary angiography, which occurred four months postoperatively in patient 2. The umbrella filter was seen to be firmly in place at the time of recurrent embolism. This patient is now alive twenty-four months postoperatively and doing well. He has been on Coumadin@ therapy during this period. Filter migration: In patient 3 migration of the filter threatened. The filter was seen to be wobbly on fluoroscopy, with the prongs on one side of the filter not fully engaging the vena cava, thereby allowing the umbrella to tilt and wobble in the vena cava; also, it was two vertebral bodies above its original site of placement. This was managed by immediately placing another filter above the first and. with cautious manipulation, firm fixation of both filters was achieved, thereby preventing em-
Volume
127,May
1974
Edema
and sta.sis dermatitis
o/ file tstrenzitir~.s:
Thirteen patients have no edema. Threci ot’ the sixteen patients have moderate to severe edema of one or both extremities. (Figure 2.) ‘l’his edema has been controlled at least partially with ,Johst stockings. No ulceration of the legs is present. Retroperitoneal bleeding: We have observed one instance, in patient 16, of’ ret~roperitoneal bleeding with a fall in the hematocrit f’r’.)m 43 to 35 per cent associated with transient ileus. Transfusion was not required. Misplacement of the filter: There were no misplaced filters. The filter was purposefully placed in the right iliac vein in patient 6 hecause it was helieved that this might prevent thromboemboli and also that it would not predispose the pat.ient to hlateral edema of the lower extremities. Since edema has not been a problem, we now routine11 place the umbrella, in the inferior vena cava. Perforation of the duodenal rcaii: \I,-? have not, encountered this complication [ 151. Wound complications: All wounds have healed per primum and there have heen no inf’ect.ions.
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Ray et al
Impossible or difficult filter placement: It was impossible to place the filter in patient 5 because of obstruction of the superior vena cava. The patient had received hyperalimentation via both subclavian veins. It is believed the superior vena cava was the site of origin of the emboli. Patient 12 had placement of a 28 mm filter, which was extremely difficult because of its tootight fit in the loading capsule. The Edwards Laboratories has acknowledged that other surgeons have experienced difficulty with the unloading of the 28 mm filter. Subsequent to this difficult placement, we have preferred not to use the 28 mm filter and are awaiting a retooling of the loading capsule, which the Edwards Laboratories has acknowledged is advisable and is now being done. Placement of the filter was difficult in patient 17 because the capsule continuously stopped at the eustachian valve and would not advance further. Multiple attempts at maneuvering past the valve were unsuccessful. When the patient’s position was changed to a 45 degree right-side-up position, however, the filter slid easily past the eustachian valve. Comments The mainstay of treatment of pulmonary embolization remains intravenous heparin therapy, As seen from the clinical profile, this group of patients with placement of vena cava umbrellas had re-embolization during heparin therapy (twelve patients) or had contraindications to heparin therapy (four patients). Indications for umbrella placement include (1) angiographically confirmed recurrent pulmonary emboli despite anticoagulation with venographic confirmation of thrombi in the lower part of the body, (2) contraindications to anticoagulant therapy with angiographically confirmed massive or submassive pulmonary emboli with venographic confirmation of thrombi in the lower part of the body, (3) venographic evidence of potentially lethal thrombus in a patient with angiographically confirmed pulmonary emboli, (4) threatened migration, to trap another previously placed filter unstable on fluoroscopy. No umbrella has been placed prophylactically, that is, in a patient who does not yet have pulmonary emboli [17]; the operation has been performed almost exclusively in patients meeting the foregoing criteria and, as seen in their clinical profile (Table I), in patients who were considered likely to die from another pulmonary embolus [16].
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The priorities of management of patients with massive pulmonary thromboemboli include (1) immediate intravenous dose of 100 mg of heparin, (2) assisted extracorporeal circulation, (3) fibrinolytic therapy, (4) caval umbrella, (5) heparin for five days and Coumadin for three months. As fibrinolytic therapy is not available to the clinician, caval umbrella placement assumes the third priority [17]; if the patient is not in profound shock and thus not a candidate for assisted circulation, caval umbrella placement assumes the second priority. Does this second priority mean that many patients will be candidates for umbrella placement? We think not, based on the following one year review of all patients with demonstrated pulmonary thromboembolism at the Marshfield Clinic. From March 1971 to March 1972 there were twenty-one patients with confirmed (in nineteen by angiograms and in two by postmortem examinations) massive pulmonary emboli involving more than 50 per cent of the pulmonary circulation; there were forty patients with documented lesser emboli involving less than 50 per cent of the pulmonary circulation. Thus, in one year’s experience with sixty-one patients with documented emboli, only six received caval umbrella interruption. Would patients not receiving umbrella interruption have fared better with the operation than they did with heparin therapy alone? Of the fiftyfive patients not receiving an umbrella, fifty-three had heparin therapy. Fifty of the fifty-five patients left the hospital alive. In the entire group of sixty-one patients six died, five with massive emboli and one patient with less than massive emboli. Five of the deaths occurred in patients not receiving umbrellas and one death occurred in a patient in whom the umbrella could not be placed (patient 5). It is interesting to note that this death was not due to recurrent pulmonary embolization but was due to progression of the underlying malignancy. Of the five patients not receiving umbrellas who died, only one could have been considered a candidate for umbrella placement in retrospective analysis. This patient was a seventy-two year old woman with a prior cerebrovascular accident who died fifteen minutes after a second pulmonary embolization. She should, we believe now, have received a caval umbrella. The three other deaths in the patients with massive emboli were due primarily to severe intercurrent disease, disseminated intravascular coagulation, gastrointestinal bleeding, and pulmonary insufficiency secondary to radiation fibrosis (Hodgkin’s disease). The sole death in
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the group of patients with less than massive emboli was due to multiple systemic emboli originating from intracardiac thrombus material in a patient with a primary cardiomyopathy and congestive heart failure. Thus, of sixty-one patients with documented pulmonary emboli at the Marshfield Clinic from March 1971 to March 1972, six had umbrella placement. Of the remaining fifty-five patients, only one could be identified who, in retrospect, would have benefited from caval umbrella placement. We conclude that umbrella placement has a definite role in the management of patients with thromboembolic disease but that only 10 to 15 per cent of patients with documented thromboemboli are candidates for the operation. This figure, which we believe to be reasonable, is high according to Hirsh [a]. He believes that operations to trap emboli from the lower portion of the body are rarely indicated [ 181. As we have stated previously, the diagnosis of pulmonary embolism should be confirmed by pulmonary angiography [ 191. Radioisotopic lung scanning is a good screening procedure, but prior to operation a precise diagnosis is required. In all but one of our patients the diagnosis was confirmed by pulmonary arteriography. Venography is the most valuable adjunctive study in patients with pulmonary thromboemboli [20]. Venography was performed in nine patients. In one case, patient 5, no thrombi were seen in either lower extremity. Believing that the venogram was in error, we decided to perform a caval filter placement. At operation the filter could not be placed because the superior vena cava was obstructed with clot and was thought to be the probable source of emboli. In patient 6, the filter was placed purposefully in the right iliac vein as the right leg was seen to be the site of potentially embolizing thrombotic material. In patient 12, venography revealed a potentially lethal floating clot, 20 cm by 1.5 cm, in the left deep femoral vein attached only distally. This patient had not been on heparin therapy but because of the ominous venogram umbrella placement was carried out. We currently believe that bilateral venography of the lower extremities should probably be performed in all patients considered for umbrella placement. The accuracy of impedance plethysmography and Doppler ultrasound detection is good, and these tests [2I,22] have been employed as screening tests in many of our patients; however, venography remains the most accurate means
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TABLE
II
Flow Sheet of Management of Patients with Suspected Pulmonary Embolism
Positive screening test for venous thrombosis -IITS scan -Doppler ultrasound evaluation -Impedance plethysmograph
Symptoms
of massive embolus
I / /
.
4 +
Pulmonary
scan 7’
+ Pulmonary
arteriogram
‘----A Venograms
(bilateral)
----Yb
A/--Potentially
lethal
thrombi
No thrombi or Nonlethal thrombi
I
Venous interruption (Local anesthetic) -Mobin-Uddin umbrella -Femoral vein plication
+--
Anticoagulants -Heparin -Coumadin
of identifying clots in the deep venous system of the legs [20]. Our method of management of patients with suspected pulmonary emboli is summarized in Table II. The preferred order of diagnostic study is (1) noninvasive studies, including lung scan, impedance plethysmography, and Doppler ultrasound evaluation, and (2) invasive studies, including pulmonary arteriography (with pulmonary artery pressure and pulmonary artery mixed venous oxygen saturation), postangiographic evaluation of kidneys, ureters, and bladder to detect unsuspected renal disease, and venography of both lower extremities. After the tests a dl?cision regarding umbrella placement is made. We have been impressed with the extremely uncomplicated postoperative course of all of the patients; patients have been returned to .their room and have required minimal or no special care or monitoring. The most critically ill patient, patient 8, had undergone triple vein graft and direct left internal mammary bypass to the left anterior descending coronary artery seven days previously and was virtually moribund with hypotension to 90 mm Hg systolic, tachycardia of 120 beats per minute, and tachypnea of 38 respirations per minute. (Figures 3 and 4.) Pulmonary artery oxygen saturation was 43 per cent at the time of filter placement. Over the next eight hours he improved markedly with pulmonary artery oxygen saturation qf 72 per cent six hours postoperatively. A
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general anesthetic in this patient would have led to complete cardiovascular collapse and would have necessitated prolonged extracorporeal cardiopulmonary bypass [23]. Since 1970, embolectomy has not been performed because prolonged bypass alone is believed to offer the patient optimal chance of survival by allowing endogenous fibrinolytic resolution of the embolus [24]. In this case, placement of the filter under local anesthesia did not further jeopardize the cardiac output and presumably allowed sufficient time for i&e intrinsic fibrinolytic system to lyse the clots. The patient continues to do well seven months postoperatively and has returned to work. Summary
Figure 3. Pulmonary angiogram in patient 8 confirming massive thromboemboli after triple aortocoronary vein grafts and direct mammary artery bypass graft.
A series of patients who underwent placement of a vena cava umbrella is presented. Morbidity was minimal and there was no mortality related to umbrella filter placement per se. One patient had a nonfatal episode of recurrent embolization. The role of umbrella placement in the over-all management of thromboembolic disease is discussed and it is concluded that only 10 to 15 per cent of patients with documented pulmonary emboli will be candidates for umbrella placement. References
Figure 4. Venogram in patient 8 demonstrating occlusion of two of three deep veins in the area of the right calf wfth a clot visible in one of deep veins.
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1. Ochsner A, DeBakey ME: Thrombophlebitis and phlebothrombosis, chap &, p 1. Lewis’ System of Surgery, vol 12. Hagerstown, Maryland, Lewis, 1932. DeWeese MS, Hunter DC: A vena cava filter for the prevention of pulmonary emboli. Bull Sot Int Chir 17: 17, 1958. Moretz WH, Rhode CM, Shepherd MH: Prevention of pulmonary emboli by partial occlusion of the inferior vena cava. Am Surg25: 617, 1959. Spencer FC, Quattlebaum JK, Quattlebaum JK Jr, Sharp EH. Jude JR: Plication of the inferior vena cava for pulmonary embolism: a report of 20 cases. Ann Surg 155: 827. 1962. 5. Ravitch MM. Snodgrass E, McEnany T, Rivarola A: Compartmentation of the vena cava with the mechanical stapler. Surg Gynecol Obstet 122: 561, 1966. 6. Mobin-Uddin K, Smith PE, Martinez LO, Lombard0 C, Jude JR: A vena caval filter for the prevention of pulmonary embolus. Surg Forum 18: 209, 1967. 7. Mobin-Uddin K, McLean R. Bolooki H, Jude JR: Caval interruption for prevention of pulmonary embolism: long term results of a new method. Arch Surg 99: 711, 1969. a. Mobin-Uddin K, Callard GM, Bolooki H. et al: Transvenous caval interruption with umbrella filter. N Engl J Med 286: 55, 1972. 9. Orvald TO, Callard GM, Jude JR: Prevention of pulmonary embolus with vena cava umbrella results in 1.50 patients. Ann Thorac Surg 15: 196, 1973. 10. Mobin-Uddin K, Tringle JK. Bryant LR: Present status of the inferior vena cava umbrella filter. Surgery70: 914, 1971. 11. Beller BM, Talley RC, Lawrence JL: Nonsurgical inferior vena cava obstruction for prevention of pulmonary emboli. JAMA 220: 973, 1972. 12. Crane C: The Mobin-Uddin inferior vena cava filter. Arch
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surg 103: 661, 1971. 13. Mobin-Uddin K, Bolooki H. Jude JR: intravenous caval interruption for pulmonary embolism in cardiac disease. Circu/&ion41 and 42 suppl2: 152, 1970. 14. Sautter RD. Myers WO, Lawton BR: Experience with vena cava filter migration. JAMA 219: 1217, 1972. 15. Irvin GL III: Duodenal perforation with a vena caval umbrella. Am Surg 38: 635, 1972. 16. Sautter RD. Ray JF III, Myers WO: Massive Pulmonary Thromboembolism-Fibrinolytic Therapy. Saunders, in press. 17. Fullen WD. Miller EH, Steele WF, McDonough JJ: Prophylactic vena caval interruption in hip fractures. J Trauma 13: 403, 1973. 18. Hirsh J: Personal communication, Hamilton, Ontario, Canada, April, 1973.
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19. Sautter RD, Fletcher FW, Ousley JL, Wenze FJ: Extremely rapid resolution of a pulmonary embolus: report of a case. Dis Chesf52: 825. 1967. 20. Williams WJ (ed): Venography.
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21. Wheeler HB, Pearson D, O’Connell D, M&lick SC: impedance phlebography. Arch Surg 104: 164, 1972. 22. Strandness DE, Sumner DS: Ultrasonic velocity detector in the diagnosis elf thrombophlebitis. Arch Surg 104: 180. 1972. 23. Gazzaniga AB, Cahill JL, Replogle RL, Tilney NL: Changes in blood volume and renal function following ligation of the inferior vena cava. Surgery62: 417, 1967 24. Sautter RD, Myers WO, Ray JF III, Wenzel FJ: Relationship of fibrinolytic system to thrombotic phenomena in the postoperative patient. Arch Surg 107: 292. 1973.
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