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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3645_Библиотеки_им_академика_М_И_Перельмана
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▶ An inferior venocavagram is performed to identify intraluminal thrombus, the size of the cava,
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duplication anomalies, and the level of the renal veins as demonstrated by the inow defect representing
non-contrast-enhanced blood return from the renal veins into the column of the opacied vena cava (Fig.
70.3, black arrows).
▶ e inferior vena caval lter is placed in an infrarenal location (Fig. 70.4). e black arrows demonstrate the
renal inow on the postdeployment cavagram.
Teaching Points
▶ Carbon dioxide can be used as a contrast agent in the setting of iodinated contrast allergies or renal
failure.
▶ Currently accepted indications for IVC Filter placement in patients with documented venous
thromboembolism (VTE) include patients with the following:
■ Contraindication to anticoagulation or inability to maintain adequate anticoagulation
■ Documented progression or recurrence of VTE while on anticoagulation
■ Complications from anticoagulation
■ Massive pulmonary embolism requiring thrombolysis or surgical thrombectomy
▶ With increased used of retrievable lters, indications for use continue to expand which can include the
following:
■ Prophylaxis in patients at risk for VTE who may be bedbound for a prolonged period due to trauma or
surgery
■ Patients with large clot burdens such as iliocaval deep vein thrombosis or thrombus in the inferior vena
cava
▶ e current line of lters can be placed in inferior vena cavae measuring up to 28mm.
▶ If a megacava is identied, a Bird’s Nest permanent lter can be placed in cava measuring between 28 and
40mm. Bilateral iliac lters should be placed in cavae measuring greater than 40mm.
▶ IVC lters should be placed just below the renal inows.
Management
▶ With the increased use of retrievable lters, patients should be educated about early retrieval of these lters
once risk of VTE returns to normal.
▶ Internal jugular approach is preferred when possible for ease of catheterizing the le iliac vein to exclude
duplication anomaly, the ability to capture and move unexpected thrombosis caudally to allow for infrarenal
lter position, and for patient comfort in recovering in a seated rather than supine position.
Further Reading
Harvey JJ, Hopkins J, McCaerty IJ, etal. Inferior vena caval lters:what radiologists need to know. Clin Radiol. 2013;
68(7):721–732.
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History
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▶ Intractable Abdominal Pain Status Post Inferior Vena Cava Filter Placement
Figure 71.1
Case 71
Figure 71.2
Figure 71.3
Figure 71.4
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Case 71 Inferior Vena Cava Filter Removal
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Figure 71.5
Figure 71.6
Figure 71.7
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Figure 71.8
Findings
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▶ Coronal computed tomography (CT) reconstruction shows an inferior vena cava (IVC) lter in the infrarenal
IVC (Fig.71.5). e IVC is tortous, and relative to the axis of the vessel, the lter is mildly tilted. e medial
leg of the lter appears to be protruding through the wall of the vessel (arrow).
▶ A tip-deecting wire (Fig. 71.6, arrow) is seen under the hook at the neck of the lter. is was used to free the
lter from its position against the wall of the cava, making the hook accessible for capture. Aer a loop snare
failed to snare the hook, an alligator forceps was used (71.6 arrow and 71.7). Once the forceps grasped the
hook, the sheath was advanced over the lter which was removed without further diculty (Fig. 71.8).
Teaching Points
▶ Truly temporary lters must be removed and are rarely, if ever, used; almost all lters currently being placed
are retrievable lters approved for permanent implantation, for example, the Gunther Tulip ©, Option ©, and
Trapese ©.
▶ e incidence of deep vein thrombosis is increased by the presence of a lter, and the risk increases over time.
Removal of IVC lters, when appropriate, is performed to reduce the sequela of venous incompetence and
caval thrombosis.
▶ Early removal increases likelihood of success. Within 3months, over 90% can be successfully removed,
decreasing to under half at 1year.
▶ Filters can be dicult to remove if the hook is embedded in the wall or becomes unformed during the
attempt. In such cases, a tip-deecting wire or balloon displacement can be used to reposition the hook into
the lumen of the IVC. Alternatively, a “sling” technique can be used in which a reverse-curve catheter is
advanced distal to the lter and a wire advanced out of the catheter (extending cranial to the lter) can be
snared, allowing the lter to be pulled into the guiding sheath and removed.
▶ IVC perforation is dened as any part, usually a leg, of the lter extending >3mm beyond the wall of the IVC.
Perforation can result in pain or injury to adjacent structures.
▶ ere are currently no prospective trials comparing ecacy and complications of dierent lter designs.
Management
▶ Prior to removing a lter, a cavogram should be performed to assess for trapped thrombus. When present, clot
that occupies >25% of the volume of the lter precludes removal in most cases.
▶ e most common causes of failed retrieval is endothelization of the legs in the wall of the cava.
Further Reading
Iliescu B, Haskal ZJ. Adanced techniques for removal of retrievable inferior vena cava lters. Cardiovasc Intervent Radiol. 2012;
35(4):741–750.
PREPIC (Prevention du Risque d’Embolie Pulmonaire par Interrruption Cave) Study Group. Eight year follow up of patients
with permanent vena cava lters in the prevention of pulmonary embolism:the PREPIC randomized study. Circulation
2005; 112:416–422.
211
Case 72
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History
▶ A60-Year-Old Female with Chronic Indwelling Permanent Inferior Vena Cava Filter Placed 6 Years Prior
Presents with Several-Month History of Chronic Bilateral Leg Swelling with 1 Week of Acute Worsening
Based on ndings seen on Figures72.1–72.5, is there a potential treatment for this patient?
Figure 72.1
Figure 72.2
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Figure 72.3
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Figure 72.4
Figure 72.5
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Case 72 Inferior Vena Cava Stent
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Acute on chronic thrombosis of the venous system below a permanent inferior vena cava (IVC) lter
extending to the above-knee popliteal veins bilaterally. is patient could potentially undergo bilateral
venous lysis.
Figure 72.3
Figure 72.6
214
Figure 72.7
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Figure 72.8
Figure 72.9
Figure 72.10
215
Figure 72.11
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Figure 72.12
Figure 72.13
Findings
▶ Contrast-enhanced computed tomography (CT) (Figs. 72.6, 72.3, and 72.7) demonstrates complete occlusion
with extensive thrombus extending from the infrarenal IVC lter (Fig. 72.6 arrow) to the popliteal veins
bilaterally (Fig.72.7, arrows).
▶ Selective venograms from the right lower extremity (Figs. 72.8 and 72.9) demonstrate lling defects within the
femoral vein (arrows, Fig. 72.8) representing acute clot, with irregularity of the right common iliac vein (white
arrows, Fig. 72.9) representing chronic changes extending to a permanent IVC lter (black arrow, Fig. 72.9).
▶ Bilateral lysis catheters (white arrows, Fig. 72.10) extending from just above the IVC lter (black arrow,
Fig. 72.10) to the popliteal veins were le with a 24-hour alteplase infusion at a total rate of 1.0 mg/hr.
216
▶ Aer 24 hours of alteplase infusion, venogram (Fig. 72.11) shows improved ow through the lter (black
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arrow).
▶ Decision was made to stent across the IVC lter (black arrow, Fig. 72.12) with re-creation of the iliac vein
conuence (white arrows, Fig. 72.12).
▶ Aer lysis and stent placement, a venogram (Fig. 72.13) depicts a widely patent right common iliac vein and IVC.
Teaching Points
▶ Unlike iliofemoral deep vein thrombosis (see Case 73), there are no established indications for recanalization
of a chronically occluded IVC.
▶ Prior to intervention, physical examination and imaging are critical to evaluate the extent of clot burden and
to identify involvement of hepatic or renal vein inows, which may aect stent landing sites.
▶ Chronically imbedded lters can be stented open with a high-radial-force, self-expanding stent such as a
Wallstent ©.
▶ Self-expanding stents are used because of their ability to re-expand when an external force is removed.
Balloon expandable stents are prone to crush when confronted with external forces.
Management
▶ Stenting is performed with ACT 250–300 seconds.
▶ Aer IVC recanalization and stent placement, anticoagulation is suggested for 2–3months.
▶ Follow up with patient at 3, 6, and 12months and annually aer procedure with ultrasound. Repeat
venogram is performed in the setting of increased symptoms or if the ultrasound identies areas of
abnormality.
Further Reading
Bjarnason H. Tips and tricks for stenting the inferior vena cava. Semin Vasc Surg. 2013; 26:29–34.
Neglen P, Oglesbee M, Olivier J, etal. Stenting of chronically obstructed inferior vena cava lters. J Vasc Surg.
2011;54:153–161.
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