Endovascular Management of Acute Symptomatic Inferior Vena Cava Thombosis: Efficacy and Outcomes
Charles C Sticco, Jonathan A Schor, Kuldeep Singh, Quinghua Pu, Jonathan S Deitch
Staten Island University Hospital, Staten Island, NY
INTRODUCTION: The management of acute caval thrombosis (ACT) has evolved to catheter-based therapies the results of which remain uncertain. We report our 7 year experience treating acute inferior vena cava (IVC) thrombosis using endovascular methods.
METHODS: Demographic, clinical, procedural and outcome data was prospectively collected for symptomatic patients presenting with IVC thrombosis between the years 2004-2011. Multimodality treatment using catheter directed thrombolysis (CDT) with tissue plasminogen activator (t-PA), pharmacomechanical catheter-directed thromboylysis (PCDT), venoplasty and venous stenting was used.
RESULTS: 17 patients (59% male) underwent treatment for acute (< 2 weeks) symptomatic inferior vena cava thrombosis. Presenting symptoms were limb swelling in 16 patients (94%), pain in 15 patients (88%), motor dysfunction in 9 patients (53%) and sensory loss in 6 patients (35%). Phlegmasia cerulean dolens was present in 7 patients. A history of malignancy was identified in six. Five patients had a prior history of DVT and were being treating with warfarin with subtherapeutic international normalized ratios (INR). Fourteen of the patients had an inferior vena cava filter at presentation (Trapease 8, G2X 3, Option 2, Eclipse 1). Two patients had a documented hypercoaguable state. Twelve patients underwent venous angioplasty. Four patients (24%) underwent venous stenting of the IVC or iliofemoral position. Mean tissue plasminogen activator (t-PA) intraoperative dose was 21.5 mg. Mean t-PA infusion dose was 10.3mg. 53% of patients required two interventions and none required more than three interventions. Significant (>50% luminal gain) angiographic resolution of venous thrombus was achieved in 88% of patients. Symptomatic improvement was observed in 94% of patients. Two patients who presented with phlegmasia died following intervention. Three patients (18%) had clinically symptomatic pulmonary embolism. One patient underwent an above knee amputation secondary to venous gangrene. Other complications included local hematoma (18%) and hematuria (71%), all of which resolved spontaneously. There were no observed episodes of major bleeding complications. There were no remote bleeding complications. 11 (65%) patients were monitored with venous duplex and clinical exam. Median follow up was 12 months (range, 2- 21 months). 8 (72%) remained patent on duplex. Symptomatic improvement was noted in 82% with complete resolution of symptoms in 64%. Late complications including pain, swelling and venous ulceration were noted in 36%.
CONCLUSIONS: Endovascular treatment of ACT, regardless of etiology, is a safe and effective with good short term clinical results even in patients who rethrombosed. An aggressive endovascular approach to treatment of acute symptomatic ACT is warranted even in the presence of a thrombosed caval filter. The presence of phlegmasia portends a poor prognosis.
Back to Annual Meeting Program