Authors

• Ivar Vacula
  Angiological outpatient clinic, Trnava
• Juraj Maďarič
  Angiological clinic of the Faculty of medicine, Comenius University, National Institute for Cardiovascular diseases, Bratislava
• Ján Tomka
  Clinic of Vascular Surgery, Slovak Medical University, National Institute of Cardiovascular Diseases, Bratislava, Slovakia
• Michal Hulman
  Clinic of Heart Surgery of the Faculty of medicine, Comenius University, National Institute of Cardiovascular Diseases, Bratislava, Slovakia

Introduction

In patients with thrombosis of the inferior vena cava (VCI), two basic therapeutic strategies are preferred. Percutaneous pharmacomechanical thrombectomy/catheter thrombolysis and oral anticoagulants (with consideration of vena cava filter placement) as for conservative pathway ⁽¹⁾. Surgical thrombectomy is often used only in patients with renal cell carcinoma invading VCI ⁽²⁾. In other patients, open surgery is chosen only exceptionally ⁽³⁾.

Case report

30-years old woman already treated for thrombosis of vena cava inferior (VCI) with oral anticoagulants for six months, was sent to our angiological lab. Without the heaviness in both calves, she had no severe complaints. Her mother died 51 years old due to fatal pulmonary embolism (paraneoplastic – lung carcinoma). Our patient’s uncle (father‘s brother) was treated for bilateral consecutive upper limb thrombosis (subclavian vein).

On physical examination, she was thin (BMI 19,7), normotensive, without oedema of legs or other pathological findings on organ systems. Ultrasound examination proved thrombus beginning in the left internal iliac vein (VII) with the liberated large corpus, floating in the whole VCI (Figure 1). Immediately, our National Institute for Cardiovascular Diseases (NICD) in Bratislava was consulted. CT angiography was performed with intention to consider placement of retrievable filter (Figure 2). As the CT and the transthoracic echocardiography (Figure 3) confirmed the head of the thrombus reached the right atrium, filter was no longer an option. Our patient was admitted to Clinic of Heart Surgery of NICD and was prepared for operation. Two teams worked simultaneously. The device for extracorporeal circulation was needed. Heart surgeon performed thoracotomy and he was prepared to catch the thrombus in case of embolism, while vascular surgeon did the complete thrombectomy through extraperitoneal lumbotomy. The whole thrombus of 31cm length was successfully removed with no signs of embolism (Figure 4). The patient recovered completely. Primary thrombophilia – heterozygous mutation of the FII G20210A was confirmed. We decided for indefinite – life-long anticoagulation (warfarin – VKA). Time in therapeutic range reached 100 %.

2 years later, the repetitive floating thrombus in the VCI was confirmed despite of effective anticoagulation. CT angiogram proved the thrombosis of both internal iliac veins. Thrombotized varicose veins were seen in paravaginal plexi on the left side. The operative thrombectomy of both iliac veins and a phlebotomy of VCI was performed. The left internal iliac vein was ligated. Anticoagulation therapy with the target INR 2,5-3,0 is still maintained. No further episode of venous thromboembolism was seen, no oncological disease was found.

Discussion

It seems reasonable to estimate the risk of pulmonary embolism in patients with thrombosis of VCI considering presence or absence of floating part of the thrombus. The risk of pulmonary embolism in a patient with firmly adhered mural thrombus is relatively low (15 %). In contrary, in the presence of floating thrombus, potentially fatal pulmonary embolism is very high (50 %) and can appear despite the effective anticoagulation in as much as 27 % of these patients ⁽⁴⁾. The psychological aspect of sending almost asymptomatic patient for a surgical procedure was very important for us and we paid additional effort to discuss all risks and benefits with our patient. Our first aim was to protect the patient before sudden death from massive pulmonary embolism.

The effective oral anticoagulation provides a very reliable secondary prevention of VTE. Unfortunately, this treatment failed in our patient.

From the later history of our case, we can suppose that the operative ligation of the left internal iliac vein was probably the decisive step to prevent next episodes of the thrombosis.

Conclusions

Operative thrombectomy performed by experienced vascular surgeon is still sometimes the only therapeutic possibility in the treatment of vena cava inferior thrombosis.

Literature

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4. Radomski JS, Jarrell BE, Carabasi RA, Yang SL, Koolpe H. Risk of pulmonary embolus with inferior vena cava thrombosis. Am Surg. 1987 Feb;53(2):97-101.