Presentation and Management of IVC Thrombosis
Katherine Teter, MD, Caron Rockman, MD, Juanita Erb, RN, Ezra Shrem, BA, Mikel Sadek, MD, Rebecca Sussman, BA, Jeffrey Berger, MD, Thomas S. Maldonado, MD.
New York University Langone Medical Center, New York, NY, USA.
Objectives: Inferior vena cava thrombosis (IVCT), although rare, has a potential for significant morbidity and mortality. IVCT is often a result of IVC filter thrombosis, but it can also occur de novo. While anti-coagulation remains standard of care, endovascular techniques to restore IVC patency have become key adjunctive therapies in recent years. This study examines a single center experience with diagnosis and management of IVCT.
Methods: A retrospective IRB-approved review of a single center institutional database was screened to identify IVCT thrombosis using ICD code 453.2 over a three-year period. Etiology of IVCT was separated into two groups: those with IVC thrombosis in the setting of prior IVC filter place and those in whom IVCT occurred de novo. Patient demographics, presenting characteristics, and management of IVCT were examined. Treatment options included expectant management with anticoagulation versus catheter-directed thrombolysis, mechanical thrombectomy, stenting or a combination. For those who underwent intervention technical success, defined as restoration of IVC patency, was assessed.
Results: 41 unique patients were identified with radiographically-confirmed diagnosis of ICVT (mean age 61, 25-91; 21 female, 51.2%). 18 (43.9%) patients presented with thrombosed IVC filter. Risk factors for venous thromboembolism included tobacco usage, current or prior (smoking n=17, 41.5%), history of prior DVT (n=25, 61.0%), malignancy (n=17, 41.5%), use of hormonal supplements (n=3, 7.3%), known thrombophilia (n=4, 9.8%), and obesity (BMI mean 29, 18.8-58.53). 11 patients (26.8%) presented with PE, and of those, 63.6% had IVC filter thrombosis (n=7). Risk of PE was not significantly different between those patients presenting with a thrombosed IVC filter compared to those with denovo IVCT (38.9% vs 17.4%, p=0.12) Management of IVCT included: anticoagulation alone (n=27, 65.9%), catheter-directed thrombolysis (n=5, 12.2%), mechanical thrombolysis (n=10, 24.4%), adjunctive IVC stent (n=3, 7.3%). Among the 14 (34.1%) patients who had intervention for IVCT, patency was restored in 12 patients (85.7%).
Conclusions: IVCT is a rare event and is associated with known risk factors for venous thromboembolism. Pulmonary embolism can occur in roughly 25% of patients presenting with IVCT. Presence of a filter does not appear to confer an advantage in preventing PE when IVCT occurs. Although majority of IVCT are managed with anticoagulation alone, endovascular interventions, including lysis and stenting, can safely restore patency in most properly selected patients.
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