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Inferior Vena Caval Thrombosis Treatment & Management

  • Author: Luis G Fernandez, MD, FACS, FASAS, FCCP, FCCM, FICS, KHS; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Dec 01, 2015
 

Approach Considerations

Once the diagnosis has been confirmed, the clinician must choose an appropriate treatment regimen for inferior vena caval thrombosis (IVCT) on the basis of the underlying pathophysiology. Both surgical and medical options are available. 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.

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

There is very little evidence available on the surgical correction or the treatment of a complete absence of the inferior vena cava (IVC). A case report, in which there was a complete absence of the IVC but patent iliac veins and nonhealing pretibial ulceration, described successful treatment with a prosthetic graft from the iliac vein to the intrathoracic azygos vein.[22] Authors of another case report concluded that, based on their review of the available literature, surgical options in this patient population are limited.[33]

Go to Deep Venous Thrombosis for more complete information on this topic.

The goals of therapy center on managing the primary impact of the deep vein thrombosis (DVT) and the impact of embolization. Medical management can include anticoagulation therapy and thrombolytic agents (see Medication).

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Anticoagulation and Thrombolytic Agents

Heparin or warfarin may be used to prevent the propagation of thrombi. One group 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.

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 (PE) during therapy has been reported. Some reports advocate using filters above the thrombolysis site[34] ; some do not. This therapy may play the greatest role as part of combination therapy with endovascular interventions.

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Caval Interruption

When using ligation for caval interruption, the proper level must be chosen. Ligation effects a permanent, complete occlusion of the IVC, but the risk of recurrent PE is not zero.

Filters are relatively noninvasive, allow central flow, and may be placed at several different anatomic levels as indicated by the clinical situation. However, thrombosis may occur at the insertion site or at the site of the filter itself. There are numerous proprietary configurations of filters available, and the technology is constantly changing; therefore, data from older studies may not extrapolate to current devices.

Go to Inferior Vena Cava Filters for more complete information on this topic.

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Thrombectomy and Endovascular Intervention

Thrombectomy is often carried out for therapy of phlegmasia, but rethrombosis rates are significant and thrombectomy often does not completely remove the thrombus. The procedure is typically performed in conjunction with a distal arteriovenous fistula to maintain high flow, and it may be required for cases of septic thrombus. The operative mortality is reportedly 2%; the morbidity is 30%.

Endovascular interventions

Endovascular techniques are particularly helpful to treat patients with IVCT that has arisen from iatrogenic causes (see Etiology). 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 the following options:

  • Percutaneous balloon angioplasty
  • Wallstents
  • 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.

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Contributor Information and Disclosures
Author

Luis G Fernandez, MD, FACS, FASAS, FCCP, FCCM, FICS, KHS Assistant Clinical Professor of Surgery and Family Practice, University of Texas Health Science Center; Adjunct Clinical Professor of Medicine and Nursing, University of Texas, Arlington; Chairman, Division of Trauma Surgery and Surgical Critical Care, Chief of Trauma Surgical Critical Care Unit, Trinity Mother Francis Health System; Brigadier General, Texas Medical Rangers, TXSG/MB

Luis G Fernandez, MD, FACS, FASAS, FCCP, FCCM, FICS, KHS 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 Law, Medicine & 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, Society of Critical Care Medicine, Society of Laparoendoscopic Surgeons, Southeastern Surgical Congress, Texas Medical Association, Undersea and Hyperbaric Medical Society, American Society of General Surgeons, American Society of General Surgeons, Pan American Trauma Society

Disclosure: Received honoraria from KCI for speaking and teaching; Partner received honoraria from PACIRA for speaking and teaching. for: Received honoraria from PACIRA for speaking and teaching.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, 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, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Acknowledgements

Douglas M Geehan, MD Associate Professor, Department of Surgery, University of Missouri-Kansas City School of Medicine

Disclosure: Nothing to disclose.

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.

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Virchow triad/venous thromboembolism (VTE) risk factors.
Photo showing dilated superficial abdominal veins (upper quadrant), with bruising and thrombosed large abdominal veins (lower quadrant).
Abdominal CT scan shows absent inferior vena cava with thrombosis of very prominent collateral veins in the abdominal wall, corresponding to right side of abdomen as seen in earlier photo.
Veins of abdomen and thorax. Unless stated otherwise, lithograph plate is from Gray's Anatomy (online edition of the 20th US edition of Gray's Anatomy of the Human Body, originally published in 1918).
 
 
 
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