Author + information
- Received May 30, 2017
- Revision received June 10, 2017
- Accepted June 20, 2017
- Published online September 27, 2017.
- Michael N. Young, MD∗ (, )
- Mazen Albaghdadi, MD, MS,
- Rasha Al-Bawardy, MD,
- Jorge Borges, MD, MPH, PhD and
- Kenneth Rosenfield, MD, MHCDS
- ↵∗Address for correspondence:
Dr. Michael N. Young, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, GRB8-852E, Boston, Massachusetts 02114.
A 55-year-old man presented with profound unilateral right leg swelling. Approximately 1 month before, he had suffered a pulmonary embolism complicated by bleeding on anticoagulation, prompting placement of a retrievable inferior vena cava (IVC) filter. On this admission, ultrasound evaluation revealed extensive bilateral deep venous thromboses (Figure 1). On examination, the patient exhibited diminished sensation and absent pedal pulses of the right foot consistent with phlegmasia. Following an emergent multidisciplinary evaluation by vascular surgery and medicine, we proceeded with IVC filter removal and catheter-based thrombectomy.
First, we placed 26-F and 15-F sheaths in the right and left internal jugular veins, respectively, through which we initiated a venovenous bypass circuit. Venography confirmed complete IVC filter thrombosis (Online Video 1) extending inferiorly into the bilateral iliofemoral venous systems. We performed vacuum-assisted thrombectomy (Online Video 2) above the filter using an AngioVac Cannula (AngioDynamics, Latham, New York). The filter was subsequently extracted using a 4-F 10-mm gooseneck snare in tandem with a 5-F AL1 catheter (Figure 2).
Vacuum filtration was then performed from the IVC to the right iliofemoral venous system. Adjunctive techniques to debulk thrombus included: 1) clot maceration (Online Video 3) using a rotational CleanerXT wire (Argon Medical Devices, Inc., Plano, Texas); 2) balloon venoplasty with 10- and 12-mm catheters; and 3) mechanical embolectomy via active balloon catheter pullback under proximal suction by the AngioVac device (Figure 3). We repeated vacuum filtration in the left iliofemoral system. Completion venography (Online Video 4) demonstrated excellent angiographic results (Figure 4). Following clot extraction (Figure 5), the swelling of the right leg resolved (Figure 6), pedal pulses and sensation of the foot normalized, and the patient was successfully discharged to a rehabilitation facility.
In this case of lower extremity phlegmasia due to thrombotic IVC filter occlusion, we show that vacuum-assisted thrombectomy in tandem with a venovenous bypass circuit is feasible and effective. Extracorporeal bypass allows for externalization and filtration of thrombus through the AngioVac device. Meanwhile, the reinfusion cannula minimizes central blood loss and permits continued vacuum-assisted filtration (1,2).
For supplemental videos and their legends, please see the online version of this article.
Dr. Rosenfield has served on the scientific advisory board of and as a consultant for Angiodynamics, Abbott Vascular, Amgen, Cardinal Health, Inspire MD, Silk Road Medical, Surmodics, Thrombolex, Volcano-Philips, and University of Maryland; has received institutional research grant support from Angiodynamics, Atrium-Getinage, Lutonix-BARD, National Institutes of Health, and Inari Medical; has served on the board of directors for VIVA; has served as the president of the Society for Cardiovascular Angiography and Interventions; and has served as the president of the National PERT Consortium. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 30, 2017.
- Revision received June 10, 2017.
- Accepted June 20, 2017.
- 2017 American College of Cardiology Foundation