Rheolytic Thrombectomy After Inferior Vena Cava Filter Placement to Treat Caval Thrombosis

Abstract

Venous thromboembolic disease (VTE), including deep vein thrombosis and pulmonary embolus, is a frequent occurrence in clinical medicine. Isolated inferior vena cava (IVC) thrombus, however, is a rare finding. Current treatment options for VTE include long-term anticoagulation, thrombolytic therapy, surgical thrombectomy, percutaneous reduction of thrombus burden, or a combination of these modalities. We describe a case of IVC thrombosis, which, after deployment of an IVC filter for distal embolization protection, was effectively treated with rheolytic thrombectomy.

VASCULAR DISEASE MANAGEMENT 2011;8(9):E153–E154

_____________________________________________

Introduction

VTE is a commonly encountered syndrome affecting more than 350,000 people annually in the United States.¹ Thrombosis involving only the IVC is an exceedingly rare phenomenon. We present a case of IVC thrombus treated by rheolytic thrombectomy after IVC filter placement for distal embolization protection. 

Case Report

An 84-year-old male was admitted to the hospital for acute onset of sharp, substernal chest pain and dyspnea. A positive D-dimer test performed in the emergency room prompted further evaluation with computed tomography angiography (CTA) of the chest to evaluate for pulmonary embolus, which confirmed a right upper lobe pulmonary embolus. The patient was initiated on intravenous heparin therapy, and admitted for further work-up. Bilateral lower extremity venous doppler ultrasound was unremarkable for deep vein thrombosis.

The patient had undergone elective percutaneous coronary intervention 2 weeks prior to presentation with bare metal stent placement to the left circumflex artery, and had recently noted episodes of blood-tinged stool on dual antiplatelet therapy. Based on the diagnosis of pulmonary embolus with gastrointestinal bleeding, the decision was made to implant an IVC filter. 

Treatment

Preceding IVC filter placement, a venogram showed a large filling defect, consistent with a large thrombus, primarily adherent to the medial aspect of the IVC at the origin of the left renal vein (Figure 1). The superior portion of the thrombus had a mobile appearance which was concerning for impending rupture and embolization. A retrievable IVC filter (Celect, Cook Medical, Bloomington, Indiana) was successfully placed between the thrombus and the IVC-right atrial junction (Figure 2). Subsequent to IVC filter deployment, rheolytic thrombectomy (AngioJet, Medrad, Inc., Minneapolis, Minnesota) was performed with 5 consecutive passes within the IVC with significant reduction of thrombotic burden (Figure 3). Final venogram showed a very small residual adherent thrombus without evidence of a mobile component (Figure 4). The patient eventually underwent colonoscopy, which divulged stage 1 colon cancer involving the cecum and consequently, underwent successful partial colectomy with an uncomplicated recovery.

Conclusion

IVC thrombosis, although rare, can occur in malignancy, trauma, compression, or by iatrogenic causes such as IVC filters.² Treatment options include surgical thrombectomy, catheter-directed thrombolytic therapy, percutaneous thrombectomy, or a combination of these modalities.³ Rheolytic thrombectomy, often used in conjunction with thrombolytic therapy, has demonstrated efficacy in treatment of massive pulmonary embolism.⁴ However, in the presence of large thrombotic burden above the level of the renal veins with a mobile fragment, the optimal treatment strategy is unclear.  We describe a patient with a large IVC thrombus that was restricted by recent gastrointestinal bleeding. This prompted IVC filter placement above the level of renal veins for distal embolization protection against large fragments of clot, while undergoing rheolytic thrombectomy to effectively debulk the amount of thrombus. Percutaneous thrombectomy continues to emerge as a viable option in the treatment of VTE. 

References

1. Office of the Surgeon General (US); National Heart, Lung, and Blood Institute (US). The Surgeon General's Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism. September 2008. https://www.surgeongeneral.gov/topics/deepvein/
2. Rigatelli G, Cardaioli P, Roncon L, et al. Combined percutaneous aspiration thrombectomy and rheolytic thrombectomy in massive subacute vena cava thrombosis with IVC filter occlusion. J Endovasc Ther 2006 Jun;13(3):373–376.
3. Biuckians A, Meier G 3rd. Treatment of lower extremity acute deep vein thrombosis: Role of mechanical thrombectomy. Vascular 2007 Sep–Oct;15(5):297–303. 
4. Chauhan MS, Kawamura A. Percutaneous rheolytic thrombectomy for large pulmonary embolism: A promising treatment option. Catheter Cardiovasc Interv 2007 Jul;70(1):121–128.

_____________________________________________

From the Deborah Heart and Lung Center, Browns Mills, New Jersey.
The authors report no conflicts of interest regarding the content herein.
Manuscript submitted June 17, 2011, final version accepted July 6, 2011.
Address for correspondence: Dr. Jon C. George, MD, Deborah Heart and Lung Center, Interventional Cardiology and Endovascular Medicine, 200 Trenton Road, Browns Mills, NJ 08015 E-mail: jcgeorgemd@hotmail.com