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Fig. 1. Initial venogram demonstrates complete thrombosis of the IVC to the level of the IVC filter.
Fig 3. Persistent thrombus remains around the IVC filter after use of the Angiojet device. |
Fig. 2. Angiojet thrombectomy device at the level of the IVC filter.
Fig 4. Amplatz thrombectomy device at the level of the IVC filter. | |
Case Reference No. CC-0498-06 The patient is a 44-year-old man who sustained a pelvic fracture in a motor vehicle accident. An IVC filter was placed by the vascular surgery service for prophylaxis. Several weeks later, the patient developed severe bilateral lower extremity swelling and pain. A venogram demonstrated acute thrombus involving both legs extending from the popliteal veins through the iliac veins and IVC to the level of the filter (Fig. 1). From bilateral popliteal vein approaches, catheter-directed thrombolysis was begun with 150,000 U/hour of urokinase. A follow-up venogram the next day demonstrated persistent clot burden around the IVC filter and no antegrade spontaneous flow in the IVC. An Angiojet mechanical thrombectomy device was used throughout the IVC, including through the filter (Fig. 2), with no significant change despite maximal effort (Fig. 3). Then an 80-cm-long Amplatz thrombectomy device was used through the IVC filter, from both the right and left leg approaches (Fig. 4). This resulted in immediate spontaneous antegrade flow through the filter via two channels created by the Amplatz device (Fig. 5). Thrombolysis was continued overnight and followed by placement of a stent across a left iliac vein stenosis, with an excellent final result (Fig. 6). The patient remains asymptomatic and had no DVT on ultrasound examination at 9-month follow-up. |
Fig 5. Two channels are noted through the filter thrombus after use of the Amplatz device.
Fig 6. Final venogram shows significant improvement after an additional day of thrombolysis and stent placement in the left common iliac vein. | |
Questions: 1) Is mechanical thrombectomy indicated for DVT treatment? 2) Which thrombectomy device is best in large vessels such as the iliac veins or IVC? 3) What are the indications, if any, for prophylactic IVC filters? Related cases: Case 1097_08 --External iliac vein occlusion: treatment with endovascular stents MM#96-32 Caval thrombosis and thrombolysis after filter placement | ||
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