Etiology and treatment of acute inferior vena cava thrombosis

Endovascular release of an Adams-DeWeese clip and iliocaval reconstruction for debilitating lower extremity swelling

More than 10 million cases of venous thromboembolisms are reported on an annual basis and are major contributors to morbidity and mortality. Studies have found that ≤90% of pulmonary embolisms originate from the abdominal and lower extremity veins. The mainstay of venous thromboembolism treatment has been, and still continues to be, anticoagulation. However, for patients for whom anticoagulation is contraindicated or has failed, physicians have turned to surgical innovations such as inferior vena cava (IVC) filters to create partial interruption of the IVC. Before the invention of IVC filters, the Adams-DeWeese clip was developed to create caval interruption, which allowed for venous return while preventing pulmonary emboli from distal veins. We report a case of endovascular release of a long-term Adams-DeWeese clip, which had caused IVC occlusion and debilitating bilateral lower extremity swelling.

Acute right extremity deep vein thrombosis and left-sided inferior vena cava thrombosis treated by percutaneous mechanical thrombectomy (PMT) combined with catheter directed thrombolysis (CDT): A case report

INTRODUCTION

Left-sided inferior vena cava (IVC) is an uncommon condition with a prevalence rate of 0.2% to 0.5%. Most of them remain asymptomatic and are discovered incidentally. The patient condition in this case is critical, and conventional procedures are not applicable. The surgical approach being considered is innovative, but it carries significant risks and uncertain therapeutic efficacy.

PATIENT CONCERNS

A 42-year-old male presented with acute right lower extremity pain with swelling for 2 days.

DIAGNOSIS

The patient was subsequently diagnosed with acute right lower extremity deep vein thrombosis, inferior vena cava thrombosis, and a left-sided IVC.

INTERVENTIONS

Based on the treatment guidelines for lower extremity deep venous thrombosis.

OUTCOMES

We successfully cured him with percutaneous mechanic thrombectomy (PMT) combined with catheter directed thrombolysis (CDT).

CONCLUSION AND SIGNIFICANCE

The relatively low incidence of left-sided IVC does not diminish the significance of its identification. PMT combined with CDT is a safe way to treat acute thrombosis. It provides a new approach for similar patients in the future.

Inferior vena cava thrombosis extension into the right atrium: An unusual case report of renal cell carcinoma

Inferior vena cava filling defects are common findings on computed tomography and magnetic resonance imaging, and accurate determination of pseudo, benign, or malignant thrombus is essential for clinical management. Inferior vena cava thrombosis involvement extending into the right atrium is a rare presentation of renal cell carcinoma. The degree of inferior vena cava and right atrium involvement is critical in determining management and prognosis of patients. Inferior vena cava thrombosis surgical thrombectomy is often a risky procedure due to the intraoperative determination of inferior vena cava thrombosis involvement. Accurate recognition of inferior vena cava thrombosis with right atrial involvement is critical in determining appropriate treatment options and preoperative level of involvement for surgical intervention. This case features a unique presentation of inferior vena cava thrombosis in renal cell carcinoma with right atrial involvement.

Risk factors and a predictive model for nonfilter-associated inferior vena cava thrombosis in patients with lower extremity deep vein thrombosis

Objective

Nonfilter-associated inferior vena cava thrombosis (IVCT) is an under-recognized but severe state of venous thromboembolism. The aims of this study were to investigate risk factors and develop a prediction model based on clinical data and imaging findings to evaluate the probability of IVCT in patients with lower extremity deep vein thrombosis (LEDVT).

Methods

A single-center retrospective cohort study was conducted. We analyzed the clinical data and multimodal imaging findings of consecutive patients with confirmed LEDVT between February 2016 and January 2022. The demographics, presentation of LEDVT, laboratory examination, thrombus characteristics, comorbidities and risk factors for LEDVT, and imaging findings were analyzed using an independent t-test, Chi-square test, Fisher's exact test, and regression analysis to determine the univariable and multivariable associations and to establish a predictive model to assess the probability of IVCT.

Results

A total of 267 eligible patients were included, of whom 40 were in the IVCT group and 227 were in the non-IVCT group. The incidence of nonfilter-associated IVCT was 15.0% (40/267). Age < 63.5 years [odds ratio (OR) 2.54; 95% confidence interval (CI), 1.10-5.85, p = 0.029], male sex (OR 2.82; 95% CI, 1.19-6.72, p = 0.019), proximal DVT (OR 8.21; 95% CI, 1.01-66.76, p = 0.049), bilateral DVT (OR 7.30; 95% CI, 3.28-16.21, p < 0.001), and D-dimer >4.72 μg/ml (OR 4.64; 95% CI, 1.80-11.72, p = 0.001) were risk factors for IVCT's occurrence. Then, we established a prediction model based on these risk factors. The diagnostic efficiency [area under the curve (AUC) of receiver operating characteristic (ROC) curve was 0.858] for predicting IVCT was superior to that of isolated risk factors, including age < 63.5 years (AUC of ROC curve was 0.624) or D-dimer >4.72 μg/ml (AUC of ROC curve was 0.656).

Conclusion

Age < 63.5 years, male sex, proximal LEDVT, bilateral LEDVT and D-dimer >4.72 μg/ml were risk factors. The diagnostic efficiency of the predictive model for predicting IVCT was superior to that of a single risk factor alone. It may be used for predicting the probability of nonfilter-associated IVCT in patients with LEDVT.

The association between iliac vein compression degree and characteristics of first diagnosed left lower extremity deep vein thrombosis

Objective

This study aimed to investigate the association between the left common iliac vein (CIV) compression degree and characteristics of first diagnosed left lower extremity deep vein thrombosis (DVT).

Patients and methods

This was a single-center retrospective observational study. Between January 2015 and June 2022, first diagnosed left lower extremity DVT patients with enhanced computed tomography of lower extremities were included. Patient demographics, comorbidities, risk factors, DVT characteristics, and CIV compression degree were collected and analyzed. Logistic regressions were performed to evaluate the odds ratio (OR) with a 95% confidence interval (CI) of iliofemoral or mixed DVT vs. compression percentage. The association between compression percentage and iliofemoral or mixed DVT was evaluated on a continuous scale with restricted cubic splines (RCS). The association between compression percentage and thrombus burden was evaluated using the Spearman test.

Results

A total of 196 (mean age, 61.8 ± 16.1 years; 86 males) patients were included. The median CIV compression percentage in iliofemoral or mixed DVT patients was significantly greater than in non-iliofemoral or non-mixed DVT, respectively (64.4 vs. 46.6%, p < 0.001; 67.8 vs. 54.8%, p = 0.004). CIV compression >50% was associated with significantly increased morbidity of iliofemoral DVT (adjusted OR, 2.96; 95% CI, 1.58-5.52; p = 0.001) or mixed DVT (adjusted OR, 2.39; 95% CI, 1.19-4.81; p = 0.014). RCS showed that a greater compression percentage was associated with a continuously increased OR of iliofemoral DVT (overall p = 0.003, non-linear p = 0.577) or mixed DVT (overall p = 0.020, non-linear p = 0.771). CIV compression percentage had a positive correlation with thrombus burden (rs = 0.284, p < 0.001).

Conclusion

A greater left CIV compression percentage may be associated with increasing likelihood of more proximal location and severe clot extent in first diagnosed left lower extremity DVT.

Silent Pulmonary Embolism in Deep Vein Thrombosis: Relationship and Risk Factors

PURPOSE

This study aimed to evaluate risk factors for silent pulmonary embolism (PE) in symptomatic deep vein thrombosis (DVT) and investigate the relationship between DVT and silent PE.

METHODS

This was a single-centre, retrospective cohort study. Between 5 January 2015 and 31 December 2021, consecutive patients with symptomatic DVT received CT pulmonary angiography and CT venography were analyzed. Patient demographics, comorbidities, risk factors, and image findings were analyzed. The group differences were compared using a Chi-square test, Fisher's exact test, independent t test, or Mann-Whitney U test. Multivariant regression was used to determine predictive factors for silent PE.

RESULTS

A total of 355 patients (mean age, 60.5 ± 16.6 years) were included. The incidence of silent PE was 43.1%. The main or lobar pulmonary arteries were affected in 53.6% of patients, which is more often found in iliofemoral DVTs (56.6% vs 26.7%, p = .027). The multivariant analysis showed male patients (p = .042; OR 1.59; 95% CI, 1.02-2.50), inferior vena cava involvement (p = .043; OR 1.81; 95% CI, 1.02-3.20) and D-dimer value > 3.82 μg/ml (p < .001; OR 2.32; 95% CI, 1.43-3.77) were risk factors for silent PE. Unilateral DVT patients with ipsilateral iliac vein compression had a lower incidence of silent PE (28.8% vs 52.9%, p < .001).

CONCLUSION

Iliofemoral DVT was associated with a more proximal PE. The male patients, inferior vena cava involvement, and D-dimer > 3.82 μg/ml were risk factors for silent PE. Ipsilateral iliac vein compression reduced the incidence of silent PE.

Severe compression of left iliac vein is a protective factor for the risk of inferior vena cava thrombosis

OBJECTIVE

The purpose of this study is to evaluate the association between left iliac vein (LIV) compression and inferior vena cava thrombosis (IVCT) in patients with LIV involvement of deep vein thrombosis (DVT).

METHODS

A total of 263 consecutive DVT patients were retrospectively reviewed and divided into group IVCT and non-IVCT. The influences of LIV smallest diameter and percentage compression on the risk of IVCT were investigated using logistic regression analysis.

RESULTS

The mean age of IVCT patients was significantly younger than that of non-IVCT patients (55.5±1.8 vs. 62.7±1.1, p=0.001). The percentage of provoked DVT in IVCT patients was higher than that in non-IVCT patients (67.1% vs 48.2%, p=0.01). The smallest diameter of LIV in ICVT patients was larger than that in non-IVCT patients (4.1±0.3 vs. 2.5±0.2, p<0.001). Mean percentage compression of LIV in IVCT patients was significantly lower than that in non-IVCT patients (63.5±2.2 vs. 74.3±1.3; P<0.001). Age was associated with decreased odds of ICVT (OR: 0.965, 95% CI: 0.965-0.985, P=0.001). Provoked DVT was associated with increased odds of ICVT (OR:2.011, 95% CI: 1.070-3.782, P=0.03). LIV compression was associated with decreased odds of ICVT for each 1mm decrease in smallest diameter of the LIV (OR, 0.717; 95% CI, 0.627-0.820; P <0.001), and for each 10% increase in percentage compression of the LIV (OR, 0.715; 95% CI, 0.612-0.835; P <0.001).

CONCLUSION

Among LIV involvement of DVT patients, non-IVCT patients had more severe LIV compression than IVCT patients. Severe LIV compression may be a protective factor for the risk of IVCT.

Treatment of Atypical Clots

The term unusual site thrombosis refers to the occurrence of venous thromboembolism outside of the lower limbs and the pulmonary arteries. Unusual site thrombosis can virtually affect any venous segment, with the most common and/or clinically relevant sites including the upper limbs veins, the retinal veins, the splanchnic veins and the cerebral veins. Clinical features are obviously heterogeneous, while many predisposing factors are common, though with different prevalence among the various disorders. Antithrombotic therapy is prescribed to most patients, but the type, intensity, and duration of treatment vary both within and among patient groups. Increasing evidence is supporting the use of the direct oral anticoagulants in patients with upper limb deep vein thrombosis, cerebral vein thrombosis, and with splanchnic vein thrombosis. This article will review available evidence on the treatment of venous thrombosis occurring in unusual sites.

Management strategies and clinical outcomes in patients with inferior vena cava thrombosis: Data from GARFIELD-VTE

BACKGROUND

Inferior vena cava (IVC) thrombosis is a rare form of venous thromboembolism (VTE). The optimal treatment strategies and outcomes are unclear in patients with this presentation.

OBJECTIVE

We aimed to compare baseline characteristics, treatment patterns and 24-month outcomes in IVC thrombosis patients (n = 100) with lower extremity deep vein thrombosis (LEDVT) patients (n = 7629).

METHODS

GARFIELD-VTE is a prospective, observational registry of 10 868 patients with objectively diagnosed VTE from 415 sites in 28 countries.

RESULTS

IVC thrombosis patients were younger (51.9 vs. 59.8 years), more frequently had active cancer (26.0% vs. 8.9%) or history of cancer (21.0% vs. 12.2%), and less frequently had recent trauma or surgery than LEDVT patients. IVC thrombosis was more frequently treated with parenteral anticoagulants alone (35.1% vs. 15.9%), whereas patients with LEDVT more commonly received vitamin K antagonists (32.0% vs. 25.8%) or direct oral anticoagulants (49.0% vs. 35.1%). Thrombolysis (11.0% vs. 3.6%) and surgical/mechanical interventions (4.0% vs. 1.4%) were more frequent in IVC thrombosis. At 24-months, the rate per 100 person-years (95% confidence interval) of all-cause mortality was higher in patients with IVC thrombosis than LEDVT (13.28 [8.57-20.58] vs. 4.91 [4.55-5.3]); the incidence of cancer-associated mortality was comparable as was the incidence of VTE recurrence (4.11 [1.85-9.15] vs. 4.18 [3.84-4.55]). Major bleeding was slightly higher in IVC thrombosis (2.03 [0.66-6.31] vs. 1.66 [1.45-1.89]).

CONCLUSION

In summary, IVC thrombosis patients have higher all-cause mortality rates than those with LEDVT, a finding only partly attributable to malignancy.

Venous Thromboembolism for the Practicing Cardiologist

Venous thromboembolism (VTE), encompassing pulmonary embolism (PE) and deep vein thrombosis (DVT), is encountered commonly. Acute PE may present as a high-risk cardiovascular emergency, and acute DVT can cause acute and chronic vascular complications. The goal of this review is to ensure that cardiologists are comfortable managing VTE-including risk stratification, anticoagulation therapy, and familiarity with primary reperfusion therapy. Clinical assessment and determination of degree of right ventricular dysfunction are critical in initial risk stratification of PE and determination of parenteral versus oral anticoagulation therapy. Direct oral anticoagulants have emerged as preferred first-line oral anticoagulation strategy in VTE scenarios.

Review article inferior vena cava thrombosis: a case series of patients observed in Taiwan and literature review

Inferior vena cava thrombosis (IVCT) is rare and can be under-recognized. However, the associated complications and mortality may be severe. We report the first case series of IVCT observed in Taiwan with a brief literature review. Eight Taiwanese patients with IVCT between May 2012 and December 2019 were enrolled in this study. Deep venous thrombosis (DVT, 8/8) and pulmonary embolism (5/8) were reported. Various risk factors were identified, including an unretrieved inferior vena cava (IVC) filter, pregnancy, surgery, presence of lupus of anticoagulants, essential thrombocythemia, antithrombin deficiency, and hemoglobin H disease. Of note, four of our patients experienced complete IVC thrombosis with bilateral lower extremity swelling (due to DVT) and abdominal wall superficial venous dilatation, while four other patients presented with partial IVCT and unilateral DVT. The etiology, clinical characteristics, presentations, diagnosis, and treatment of IVCT were reviewed.

Case report of a 'snake thrombus' in the right heart: a rare finding on echocardiography

Background 

A right heart thrombus originating from an inferior vena cava thrombosis (IVCT) is a rare entity. In accordance with venous thromboembolism (VTE), IVCT can be categorized as primary or secondary. Secondary ICVT can be the result of a predisposing hypercoagulable state and/or from external compression on the inferior vena cava (IVC) such as in case of malignancies. Renal cell carcinoma (RCC), amongst others, has been described in the context of secondary IVCT.

Case summary 

An 80-year-old man was presented in our emergency department with complaints of dyspnoea and oedema. Echocardiography revealed a large snake-like thrombus in the IVC extending into the right atrium. Subsequent computed tomography resulted in a diagnosis of an RCC. The patient was considered to be in too poor clinical condition for surgical removal. In the next days, his condition deteriorated, after which palliative care was initiated and the patient deceased at day 12 of admission.

Conclusion 

A right heart thrombus is a rare finding during echocardiography. This case demonstrates an incidental finding of a ‘snake thrombus’ in the IVC and right heart secondary to RCC. This case illustrates the importance and additional value of echocardiography in the setting of suspected right-sided heart failure.

Inferior vena cava-syndrome

Inferior vena cava syndrome (IVCS) is caused by agenesis, compression, invasion, or thrombosis of the IVC, or may be associated with Budd-Chiari syndrome. Its incidence and prevalence are unknown. Benign IVCS is separated from malignant IVCS. Both cover a wide clinical spectrum reaching from asymptomatic to highly symptomatic cases correlated to the underlying cause, the acuity, the extent of the venous obstruction, and the recruitment and development of venous collateral circuits. Imaging is necessary to determine the underlying cause of IVCS and to guide clinical decisions. Interventional therapy has changed the therapeutic approach in symptomatic patients. This article provides an overview over IVCS and focuses on interventional therapeutic methods and results.

Inferior vena cava syndrome in neonates: An evidence-based systematic review of the literature

Neonatal inferior vena cava syndrome (IVCS), though uncommon, is associated with significant morbidity and mortality. Information on risk factors, diagnosis, treatment, and outcomes is limited. This review comprised 61 neonates across 33 reports. Thrombosis occurred in 98% and 42% involved a central venous catheter. Diagnosis was mainly established by ultrasound in 82%. Therapeutically, heparin was employed in 36% and thrombolysis in 18% of the cases. The overall mortality was 23%. An algorithm of clinical signs, investigation, and management is presented. Well-designed prospective studies are needed to establish a concrete investigational approach to neonatal IVCS and institute safe, evidence-based treatment.

Extensive Inferior Vena Cava Thrombosis in a Liver Transplant Patient: A Case Report

Thrombosis of the inferior vena cava is a clinical condition with very diverse presentations, ranging from asymptomatic patients to others with severe edema in the legs and lower torso. We report the case of a 27-year-old female patient, previously diagnosed with autoimmune hepatitis, with asymptomatic extensive thrombosis of the inferior vena cava. The thrombus extended from the renal veins up to the emergence of the hepatic veins, causing post-sinusoidal portal hypertension (Budd-Chiari syndrome). The patient underwent an orthotopic cadaveric liver transplant with removal of the retrohepatic vena cava and thrombectomy of blood clots from the infrahepatic vena cava. She initially recovered well from surgery, but on the 8 postoperative day she had a significant increase in hepatic injury markers and was diagnosed with rethrombosis of the inferior vena cava and hepatic veins. A surgical thrombectomy was performed, with an intraoperative finding of chronic thrombus in both renal veins, previously undiagnosed. The thrombectomy was successful, but the patient's hepatic function continued to worsen and a second liver transplant was performed. After the second transplant she underwent several imaging exams that showed no signs of rethrombosis. She was kept on postoperative anticoagulation indefinitely, first with intravenous heparin then with rivaroxaban. An extensive investigation failed to identify any causes of thrombophilia associated with this vast thrombosis. She is currently alive and with good graft function 1 year and 4 months after the second transplant.

Central Venous Catheter-Related Deep Vein Thrombosis in the Pediatric Cardiac Intensive Care Unit

BACKGROUND

Central venous catheter (CVC) use is common in the management of critically ill children, especially those with congenital heart disease. CVCs are known to augment the risk of deep vein thrombosis (DVT), but data on CVC-associated DVTs in the pediatric cardiac intensive care unit (CICU) are limited. In this study, we aim to identify the incidence of and risk factors for CVC-related DVT in this high-risk population, as its complications are highly morbid.

MATERIALS AND METHODS

The PC4 database and a radiologic imaging database were retrospectively reviewed for the demographics and outcomes of patients admitted to the Texas Children's Hospital CICU requiring CVC placement, as well as the incidence of DVT and its complications.

RESULTS

Between January 2017 and December 2017, 1215 central lines were placed over 851 admissions. DVT was diagnosed in 8% of admissions with a CVC, 29% of which demonstrated thrombus in the inferior vena cava. The risk factors significantly associated with DVT included the presence of >1 line, higher total line hours, longer intubation times, and extended CICU stay. A diagnosis of low cardiac output syndrome, sepsis, central line-associated bloodstream infection, and cardiac catheterization were also significant risk factors. Interestingly, cardiac surgery with cardiopulmonary bypass appeared to be protective of clot development. DVT was a highly significant risk factor for mortality in these patients.

CONCLUSIONS

CVC-related DVTs in critically ill children with congenital heart disease are associated with higher risks of morbidity and mortality, highlighting the need for well-designed studies to determine the best preventative and treatment strategies and to establish guidelines for appropriate monitoring and follow-up of these patients.

Presentation and Management of Inferior Vena Cava Thrombosis

BACKGROUND

Inferior vena cava thrombosis (IVCT), although rare, has a potential for significant morbidity and mortality. IVCT is often a result of IVC filter thrombosis, but it can also occur de novo. Although anticoagulation remains the standard of care, endovascular techniques to restore IVC patency have become key adjunctive therapies in recent years. This study examines a single-center experience with diagnosis and management of IVCT.

METHODS

A retrospective Institutional Review Board-approved review of a single-center institutional database was screened to identify IVCT thrombosis using International Classification of Diseases code 453.2 over a 3-year period. Etiology of IVCT was separated into 2 groups: those with IVC thrombosis in the setting of prior IVC filter place and those in whom IVCT occurred de novo. Patient demographics, presenting characteristics, and management of IVCT were examined. Treatment options included expectant management with anticoagulation versus catheter-directed thrombolysis (CDT), mechanical thrombectomy, stenting, or a combination. For those who underwent intervention, technical success, defined as restoration of IVC patency, was assessed.

RESULTS

Forty-one unique patients were identified with radiographically confirmed diagnosis of ICVT (mean age 61, range 25-91; 21 female, 51.2%). Eighteen (43.9%) patients presented with thrombosed IVC filter. Risk factors for venous thromboembolism included tobacco usage, current or prior smoking (n = 17, 41.5%), history of prior deep vein thrombosis (n = 25, 61.0%), malignancy (n = 17, 41.5%), use of hormonal supplements (n = 3, 7.3%), known thrombophilia (n = 4, 9.8%), and obesity (body mass index: mean 29, range 18.8-58.53). Eleven patients (26.8%) presented with pulmonary embolism (PE), and of those 63.6% had IVC filter thrombosis (n = 7). Risk of PE was not significantly different between those patients presenting with a thrombosed IVC filter compared to those with de novo IVCT (38.9% vs. 17.4%, P = 0.12) Management of IVCT included anticoagulation alone (n = 27, 65.9%), CDT (n = 5, 12.2%), mechanical thrombolysis (n = 10, 24.4%), and adjunctive IVC stent (n = 3, 7.3%). Among the 14 (34.1%) patients who had intervention for IVCT, patency was restored in 12 patients (85.7%).

CONCLUSIONS

IVCT is a rare event and is associated with known risk factors for venous thromboembolism. PE can occur in roughly 25% of patients presenting with IVCT. Presence of a filter does not appear to confer an advantage in preventing PE when IVCT occurs. Although majority of IVCT is managed with anticoagulation alone, endovascular interventions, including lysis and stenting, can safely restore patency in most properly selected patients.