eMedicine Specialties > General Surgery > Abdomen

Inferior Vena Caval Thrombosis: Treatment

Author: Luis G Fernandez, MD, FACS, FASAS, FCCP, FCCM, FICS, Assistant Clinical Professor of Surgery and Family Practice, University of Texas Health Science Center; Chairman, Division of Trauma Surgery and Surgical Critical Care, Chief of Critical Care Units, Trinity Mother Francis Health System
Coauthor(s): Douglas M Geehan, MD, Associate Professor, Department of Surgery, University of Missouri at Kansas City
Contributor Information and Disclosures

Updated: Dec 29, 2008

Treatment

Medical Therapy

Treatment options for inferior vena caval thrombosis (IVCT) have evolved as understanding of the pathophysiological mechanisms has increased. Both surgical and medical options are available. The goals of therapy center on managing the primary impact of the deep vein thrombosis (DVT) and the impact of embolization. Medical professionals are encouraged to investigate the most recent research to keep apprised of the latest information relating to the various risks and benefits of treatment modalities. Medical management can include anticoagulation therapy and thrombolytic agents.

Anticoagulation

Heparin or warfarin may be used to prevent propagation of thrombus. One group has reported no embolic events with this therapy, even with so-called free-floating IVCT. However, propagation may still occur. Therapy is usually converted to oral anticoagulation with warfarin, but the time course of warfarin therapy is somewhat empiric.

Thrombolytic agents

Most thrombolytic agents have been reported in the treatment of IVCT. The relative merits of thrombolytic therapy must be weighed against the risks of hemorrhagic complications.

Urokinase, tissue-type plasminogen activator (tPA), and streptokinase have all been used. Typically, delivery is catheter-directed with or without a pulse spray. Patients require concurrent heparin therapy; however, tPA protocols do not use concurrent heparin because of the risk of bleeding complications. Up to a 25% risk of pulmonary embolism during therapy has been reported. Some reports advocate using filters above the thrombolysis site; some do not. This therapy may play the greatest role as part of combination therapy with endovascular interventions.

Surgical Therapy

In the broadest sense, surgical therapy encompasses caval interruption and thrombectomy. Currently, both of these modalities are being used less frequently.

Caval interruption

  • Ligation
    • The proper level must be chosen.
    • Ligation effects a permanent, complete occlusion of the inferior vena cava (IVC).
    • The risk of recurrent pulmonary embolism is not zero.
  • Filters
    • Filters are relatively noninvasive.
    • Filters allow central flow.
    • Thrombosis may occur at the insertion site or at the site of the filter itself.
    • Numerous proprietary configurations are available.
    • Technology is constantly changing.
    • Data from older studies may not extrapolate to current devices.
    • Filters may be placed at several different anatomic levels as indicated by the clinical situation.

Thrombectomy

  • Thrombectomy is often carried out for therapy of phlegmasia.
  • Rethrombosis rates are significant.
  • The procedure is typically performed in conjunction with a distal arteriovenous fistula to maintain high flow.
  • The operative mortality rate is reportedly 2%; the morbidity rate is 30%.
  • Thrombectomy often fails to completely remove the thrombus.
  • The procedure may be required for cases of septic thrombus.

Endovascular interventions

  • These techniques are particularly helpful to treat patients with IVCT that has arisen from iatrogenic causes. The numerous clinical scenarios that lend themselves to this approach can include (1) long-term venous access, (2) hemodialysis access, and (3) surgery on the IVC, including hepatic transplantation.
  • Several interventional modalities are available to treat IVCT. The optimal result can often be obtained by using a combination of these options, as follows: (1) percutaneous balloon angioplasty, (2) Wall stents, and (3) Z stents.
  • The number and type of expandable stents are changing as product development continues. The various stents have limitations both in vessel diameter and length of available stent. Consulting with vascular surgeons, radiologists, and available literature to identify the locally available devices is encouraged and recommended.

Follow-up

For excellent patient education resources, visit eMedicine's Circulatory Problems Center. Also, see eMedicine's patient education article Blood Clot in the Legs.

More on Inferior Vena Caval Thrombosis

Overview: Inferior Vena Caval Thrombosis
Workup: Inferior Vena Caval Thrombosis
Treatment: Inferior Vena Caval Thrombosis
Follow-up: Inferior Vena Caval Thrombosis
Multimedia: Inferior Vena Caval Thrombosis
References
[ CLOSE WINDOW ]

References

  1. Iqbal J, Nagaraju E. Congenital absence of inferior vena cava and thrombosis: a case report. J Med Case Reports. Feb 12 2008;2:46. [Medline].

  2. Anderson RC, Adams P Jr, Burke B. Anomalous inferior vena cava with azygos continuation (infrahepatic interruption of the inferior vena cava). Report of 15 new cases. J Pediatr. Sep 1961;59:370-83. [Medline].

  3. Bass JE, Redwine MD, Kramer LA, et al. Spectrum of congenital anomalies of the inferior vena cava: cross-sectional imaging findings. Radiographics. May-Jun 2000;20(3):639-52. [Medline].

  4. Ramanathan T, Hughes TM, Richardson AJ. Perinatal inferior vena cava thrombosis and absence of the infrarenal inferior vena cava. J Vasc Surg. May 2001;33(5):1097-9. [Medline].

  5. Van Veen J, Hampton KK, Makris M. Kilt syndrome?. Br J Haematol. Sep 2002;118(4):1199-200. [Medline].

  6. Gayer G, Zissin R, Strauss S, et al. IVC anomalies and right renal aplasia detected on CT: a possible link?. Abdom Imaging. May-Jun 2003;28(3):395-9. [Medline].

  7. Dougherty MJ, Calligaro KD, DeLaurentis DA. Congenitally absent inferior vena cava presenting in adulthood with venous stasis and ulceration: a surgically treated case. J Vasc Surg. Jan 1996;23(1):141-6. [Medline].

  8. White RH. The epidemiology of venous thromboembolism. Circulation. Jun 17 2003;107(23 Suppl 1):I4-8. [Medline].

  9. Ruggeri M, Tosetto A, Castaman G, et al. Congenital absence of the inferior vena cava: a rare risk factor for idiopathic deep-vein thrombosis. Lancet. Feb 10 2001;357(9254):441. [Medline].

  10. Chee YL, Culligan DJ, Watson HG. Inferior vena cava malformation as a risk factor for deep venous thrombosis in the young. Br J Haematol. Sep 2001;114(4):878-80. [Medline].

  11. Koc Z, Oguzkurt L. Interruption or congenital stenosis of the inferior vena cava: prevalence, imaging, and clinical findings. Eur J Radiol. May 2007;62(2):257-66. [Medline].

  12. Ueda J, Hara K, Kobayashi Y, et al. Anomaly of the inferior vena cava observed by CT. Comput Radiol. May-Jun 1983;7(3):145-54. [Medline].

  13. Gayer G, Luboshitz J, Hertz M, et al. Congenital anomalies of the inferior vena cava revealed on CT in patients with deep vein thrombosis. AJR Am J Roentgenol. Mar 2003;180(3):729-32. [Medline].

  14. Cho BC, Choi HJ, Kang SM, et al. Congenital absence of inferior vena cava as a rare cause of pulmonary thromboembolism. Yonsei Med J. Oct 31 2004;45(5):947-51. [Medline].

  15. D'Aloia A, Faggiano P, Fiorina C, et al. Absence of inferior vena cava as a rare cause of deep venous thrombosis complicated by liver and lung embolism. Int J Cardiol. Apr 2003;88(2-3):327-9. [Medline].

  16. Takehara N, Hasebe N, Enomoto S, et al. Multiple and recurrent systemic thrombotic events associated with congenital anomaly of inferior vena cava. J Thromb Thrombolysis. Apr 2005;19(2):101-3. [Medline].

  17. Anderson FA Jr, Wheeler HB, Goldberg RJ, et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med. May 1991;151(5):933-8. [Medline].

  18. Angle JF, Matsumoto AH, Al Shammari M, et al. Transcatheter regional urokinase therapy in the management of inferior vena cava thrombosis. J Vasc Interv Radiol. Nov-Dec 1998;9(6):917-25. [Medline].

  19. Aswad MA, Sandager GP, Pais SO, et al. Early duplex scan evaluation of four vena caval interruption devices. J Vasc Surg. Nov 1996;24(5):809-18. [Medline].

  20. Banjo AO. Comparative study of the distribution of venous valves in the lower extremities of black Africans and Caucasians: pathogenetic correlates of prevalence of primary varicose veins in the two races. Anat Rec. Apr 1987;217(4):407-12. [Medline].

  21. Campbell DN, Liechty RD, Rutherford RB. Traumatic thrombosis of the inferior vena cava. J Trauma. May 1981;21(5):413-5. [Medline].

  22. Carter CJ. The natural history and epidemiology of venous thrombosis. Prog Cardiovasc Dis. May-Jun 1994;36(6):423-38. [Medline].

  23. Chang TC, Zaleski GX, Lin BH, et al. Treatment of inferior vena cava obstruction in hemodialysis patients using Wallstents: early and intermediate results. AJR Am J Roentgenol. Jul 1998;171(1):125-8. [Medline].

  24. Farber SP, O'Donnell TF Jr, Deterling RA, et al. The clinical implications of acute thrombosis of the inferior vena cava. Surg Gynecol Obstet. Feb 1984;158(2):141-4. [Medline].

  25. Figueroa AJ, Stein JP, Lieskovsky G, et al. Adrenal cortical carcinoma associated with venous tumour thrombus extension. Br J Urol. Sep 1997;80(3):397-400. [Medline].

  26. Fleiner-Hoffmann AF, Pfammatter T, Leu AJ, et al. Alveolar echinococcosis of the liver: sequelae of chronic inferior vena cava obstructions in the hepatic segment. Arch Intern Med. Dec 7-21 1998;158(22):2503-8. [Medline].

  27. Flynn P, Zammit-Maempel I. Case report: computed tomography demonstration of inferior vena caval thrombosis and incorporation into an abdominal aortic aneurysm. Clin Radiol. Apr 1998;53(4):306-7. [Medline].

  28. Fox RH, Turner MJ, Gardner AM. Pseudothrombosis of the infra-renal IVC during helical CT--what causes this pitfall?. Clin Radiol. Oct 1996;51(10):741. [Medline].

  29. Girard P, Hauuy MP, Musset D, et al. Acute inferior vena cava thrombosis. Early results of heparin therapy. Chest. Feb 1989;95(2):284-91. [Medline].

  30. Gotoh A, Gohji K, Fujisawa M, et al. Renal angiomyolipoma associated with inferior vena caval tumour thrombus. Br J Urol. May 1998;81(5):773-4. [Medline].

  31. Gouge SF, Paulson WD, Moore J Jr. Inferior vena cava thrombosis due to an indwelling hemodialysis catheter. Am J Kidney Dis. Jun 1988;11(6):515-8. [Medline].

  32. Hartman DS, Hayes WS, Choyke PL, et al. From the archives of the AFIP. Leiomyosarcoma of the retroperitoneum and inferior vena cava: radiologic-pathologic correlation. Radiographics. Nov 1992;12(6):1203-20. [Medline].

  33. Hausler M, Duque D, Merz U, et al. The clinical outcome after inferior vena cava thrombosis in early infancy. Eur J Pediatr. May 1999;158(5):416-20. [Medline].

  34. Jackson BT, Thomas ML. Post-thrombotic inferior vena caval obstruction. A review of 24 patients. Br Med J. Jan 3 1970;1(687):18-22. [Medline].

  35. Jones AL, Ojar D, Redhead D, et al. Case report: Use of an IVC filter in the management of IVC thrombosis occurring as a complication of acute pancreatitis. Clin Radiol. Jun 1998;53(6):462-4. [Medline].

  36. Kouroukis C, Leclerc JR. Pulmonary embolism with duplicated inferior vena cava. Chest. Apr 1996;109(4):1111-3. [Medline].

  37. Krafte-Jacobs B, Sivit CJ, Mejia R, et al. Catheter-related thrombosis in critically ill children: comparison of catheters with and without heparin bonding. J Pediatr. Jan 1995;126(1):50-4. [Medline].

  38. Kwok CK, Horowitz MD, Livingstone AS, et al. Mature testicular teratoma with vena caval invasion presenting as pulmonary embolism. J Urol. Jan 1993;149(1):129-31. [Medline].

  39. Lam KK, Lui CC. Successful treatment of acute inferior vena cava and unilateral renal vein thrombosis by local infusion of recombinant tissue plasminogen activator. Am J Kidney Dis. Dec 1998;32(6):1075-9. [Medline].

  40. Lerut J, Gordon RD, Iwatsuki S, et al. Surgical complications in human orthotopic liver transplantation. Acta Chir Belg. May-Jun 1987;87(3):193-204. [Medline].

  41. Mathew CV, Shanabo A, Zyka I, et al. Retroperitoneal fibrosis with large-vessel obstruction. An uncommon vascular disorder. Acta Chir Scand. 1985;151(5):475-80. [Medline].

  42. McWilliams RG, Chalmers AG. Pseudothrombosis of the infra-renal inferior vena cava during helical CT. Clin Radiol. Nov 1995;50(11):751-5. [Medline].

  43. Mulvihill SJ, Fonkalsrud EW. Complications of superior versus inferior vena cava occlusion in infants receiving central total parenteral nutrition. J Pediatr Surg. Dec 1984;19(6):752-7. [Medline].

  44. Nagy KK, Duarte B. Post-traumatic inferior vena caval thrombosis: case report. J Trauma. Feb 1990;30(2):218-21. [Medline].

  45. Nesbitt JC, Soltero ER, Dinney CP, et al. Surgical management of renal cell carcinoma with inferior vena cava tumor thrombus. Ann Thorac Surg. Jun 1997;63(6):1592-600. [Medline].

  46. O'Brien WM, Lynch JH. Thrombosis of the inferior vena cava by seminoma. J Urol. Feb 1987;137(2):303-5. [Medline].

  47. O'Sullivan DA, Torres VE, Heit JA, Liggett S, King BF. Compression of the inferior vena cava by right renal cysts: an unusual cause of IVC and/or iliofemoral thrombosis with pulmonary embolism in autosomal dominant polycystic kidney disease. Clin Nephrol. May 1998;49(5):332-4. [Medline].

  48. Palmer MA. Inferior vena cava occlusion secondary to aortic aneurysm. J Cardiovasc Surg (Torino). May-Jun 1990;31(3):372-4. [Medline].

  49. Paolillo V, Sicuro M, Nejrotti A, et al. Pulmonary embolism due to compression of the inferior vena cava by a hepatic hemangioma. Tex Heart Inst J. 1993;20(1):66-8. [Medline].

  50. Park JH, Chung JW, Han JK, et al. Interventional management of benign obstruction of the hepatic inferior vena cava. J Vasc Interv Radiol. May-Jun 1994;5(3):403-9. [Medline].

  51. Park JH, Lee JB, Han MC, et al. Sonographic evaluation of inferior vena caval obstruction: correlative study with vena cavography. AJR Am J Roentgenol. Oct 1985;145(4):757-62. [Medline].

  52. Peck KE, Bonoan JT, Cunha BA. Postlaparoscopic traumatic inferior vena caval thrombosis. Heart Lung. Jul-Aug 1998;27(4):279-82. [Medline].

  53. Peillon C, Manouvrier JL, Testart J. Inferior vena cava thrombosis secondary to chronic pancreatitis with pseudocyst. Am J Gastroenterol. Dec 1991;86(12):1854-6. [Medline].

  54. Perhoniemi V, Salmenkivi K, Vorne M. Venous haemodynamics in the legs after ligation of the inferior vena cava. Acta Chir Scand. Jan 1986;152:23-7. [Medline].

  55. Petersen BD, Uchida BT. Long-term results of treatment of benign central venous obstructions unrelated to dialysis with expandable Z stents. J Vasc Interv Radiol. Jun 1999;10(6):757-66. [Medline].

  56. Schreiber D. Deep Venous Thrombosis and Thrombophlebitis. eMedicine Journal [serial online]. Available at http://www.emedicine.com/emerg/topic122.htm. Accessed 2008.

  57. Shefler A, Gillis J, Lam A, et al. Inferior vena cava thrombosis as a complication of femoral vein catheterisation. Arch Dis Child. Apr 1995;72(4):343-5. [Medline].

  58. Simpson AH, Kilby JO. Inferior vena cava thrombosis following a cycle ride. J R Soc Med. Dec 1988;81(12):738-9. [Medline].

  59. Smith L, Hamill J, Metcalf R, et al. Caval thrombectomy for severe staphylococcal osteomyelitis. J Pediatr Surg. Jan 1997;32(1):112-4. [Medline].

  60. Soler R, Rodriguez E, Lopez MF, et al. MR imaging in inferior vena cava thrombosis. Eur J Radiol. Jan 1995;19(2):101-7. [Medline].

  61. Storti S, Pagano L, Marra R, et al. Urokinase and AT-III concentrate treatment in inferior vena cava thrombosis associated with nephrotic syndrome. Blood Coagul Fibrinolysis. Dec 1990;1(6):743-5. [Medline].

  62. Stringer MD, Michell M, McIrvine AJ. Inferior vena caval thrombosis complicating acute pancreatitis. Case report. Acta Chir Scand. Feb 1988;154(2):161-3. [Medline].

  63. Takayama H, Kinouchi T, Meguro N, et al. Renal vein thrombosis misdiagnosed as a renal cell carcinoma with a tumor thrombus in the inferior vena cava. Int J Urol. Jan 1998;5(1):94-5. [Medline].

  64. Takeuchi M, Maruyama K, Nakamura M, et al. Posttraumatic inferior vena caval thrombosis: case report and review of the literature. J Trauma. Sep 1995;39(3):605-8. [Medline].

  65. Tien YC, Yang CW, Ng KK, et al. Thrombosis of the inferior vena cava in a pregnant woman with nephrotic syndrome--diagnostic and therapeutic dilemma. Nephrol Dial Transplant. Jan 1999;14(1):210-3. [Medline].

  66. Toumbouras M, Spanos P, Konstantaras C, et al. Inferior vena cava thrombosis due to migration of retained functionless pacemaker electrode. Chest. Dec 1982;82(6):785-6. [Medline].

  67. Valla D, Benhamou JP. Obstruction of the hepatic veins or suprahepatic inferior vena cava. Dig Dis. Mar-Apr 1996;14(2):99-118. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

inferior vena caval thrombosis, IVC thrombosis, IVCT, deep venous thrombosis, DVT, thrombophlebitis, renal cell carcinoma, renal vein thrombosis, RVT, hepatic venous thrombosis, HVT, Virchow triad, Virchow's triad, Budd-Chiari syndrome

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Luis G Fernandez, MD, FACS, FASAS, FCCP, FCCM, FICS, Assistant Clinical Professor of Surgery and Family Practice, University of Texas Health Science Center; Chairman, Division of Trauma Surgery and Surgical Critical Care, Chief of Critical Care Units, Trinity Mother Francis Health System
Luis G Fernandez, MD, FACS, FASAS, FCCP, FCCM, FICS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Legal Medicine, American College of Surgeons, American Society of Abdominal Surgeons, American Society of General Surgeons, American Society of General Surgeons, American Society of Law Medicine and Ethics, American Trauma Society, Association for Surgical Education, Association of Military Surgeons of the US, Chicago Medical Society, Illinois State Medical Society, International College of Surgeons, New York Academy of Sciences, Pan American Trauma Society, Society of Critical Care Medicine, Society of Laparoendoscopic Surgeons, Southeastern Surgical Congress, Texas Medical Association, and Undersea and Hyperbaric Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Douglas M Geehan, MD, Associate Professor, Department of Surgery, University of Missouri at Kansas City
Douglas M Geehan, MD is a member of the following medical societies: American College of Surgeons, American Institute of Ultrasound in Medicine, American Medical Association, Association for Academic Surgery, Phi Beta Kappa, Society of American Gastrointestinal and Endoscopic Surgeons, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael A Grosso, MD, Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital
Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.