A 33 year-old woman with no significant past medical history presented with vaginal bleeding and left leg swelling. Work up revealed an acute left-sided ilio-femoral deep vein thrombosis (DVT) extending into the infra-renal inferior vena cava (IVC) and a massive uterine fibroid causing extrinsic IVC compression with occlusion to the level of the renal veins. Her suprarenal IVC was patent but measured 34 mm.
Which of the following is the best management for this patient's acute DVT and IVC compression?
Show Answer
The correct answer is: D. IVC filter insertion and hysterectomy.
A hysterectomy was necessary given the presence of a large symptomatic fibroid causing IVC compression and acute DVT. However, the gynecology service raised concerns about potential cardiovascular collapse during the operation resulting from thrombus migration into the lungs after acute relief of extrinsic IVC compression. Therefore, the major issue became optimal management of the patient's acute DVT given the increased risk of pulmonary embolism following hysterectomy. Percutaneous suction thrombectomy (AngioVac) from SVC access was discussed as a possible intervention,1 but this procedure requires systemic anticoagulation that would have precluded hysterectomy (Choice E). Surgical thrombectomy was also considered, but vascular surgery deemed her a high-risk candidate for this given that the IVC would likely need to be cross-clamped, which would necessitate cardiopulmonary bypass during thrombectomy and hysterectomy (Choice A). As previously mentioned, systemic anticoagulation would have precluded hysterectomy so low molecular weight heparin (Choice B) and rivaroxaban (Choice C) would not be appropriate in this case. Temporary caval interruption with an IVC filter was ideal in this scenario and is the correct answer (Choice D). However, the only commercially-available option in this patient with an IVC diameter of 34 mm was a non-retrievable bird nest filter.2 Placement of a permanent supra renal IVC filter in an otherwise healthy young female with no other risk factors for hypercoagulability was not ideal.
Therefore, after a multidisciplinary discussion involving vascular medicine, cardiology, cardiothoracic surgery, vascular surgery and gynecology, it was decided to seek compassionate use approval for placing an Angel Catheter IVC filter device in the patent proximal supra-renal IVC segment followed by hysterectomy and cardiopulomary support on standby during the hysterectomy in the hybrid operating room.
An Angel Catheter is a novel IVC filter device attached to a triple lumen central venous catheter.3 It can be placed into the IVC regardless of diameter and is also easily removed. Once the approval for compassionate use was obtained, an Angel Catheter was first placed via the right femoral vein and full expansion was confirmed on fluoroscopy. Hysterectomy was then performed with no significant cardiopulmonary instability during the surgery. Following surgery, the Angel Catheter was maintained and utilized for central venous access during the immediate post-operative course. The filter was left in place for 72 hours and then successfully removed. The final venogram confirmed a widely patent IVC. Images below show a schematic of this catheter, successful placement in the IVC, and tumor size upon surgical resection. On follow up, patient continues to do well and has not had any further thrombotic events.
References
Todoran TM, Sobieszczyk PS, Levy MS, et al. Percutaneous extraction of right atrial mass using Angiovac aspiration system. J Vasc Interv Radiol 2011;22:1345-7.
Roehm JO. The bird's nest filter: a new percutaneous transcatheter inferior vena cava filter. J Vasc Surg 1984;1:498-501.
Cadavid CA, Gil B, Restrepo A, et al. Pilot study evaluating the safety of a combined central venous catheter and inferior vena cava filter in critically ill patients at high risk of pulmonary embolism. J Vasc Interv Radiol 2013;24:581-5.
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