•Ahmed

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Introduction: Deep vein thrombosis (DVT) is a severe medical condition characterized by the formation of blood clots within deep veins, primarily affecting the lower extremities. Patients with risk factors such as obesity, hypertension (HTN), and a history of DVT or pulmonary embolism (PE) are predisposed to developing DVT. Inferior vena cava (IVC) filters are commonly used as a preventive measure in individuals at high risk of embolic events. We present a case of a morbidly obese patient with multiple risk factors who developed extensive DVT, necessitating thrombectomy and IVC filter removal.

Case Presentation: A 59-year-old morbidly obese woman with a history of HTN, type 2 diabetes mellitus (T2DM), and prior DVT and PE presented with right medial collateral ligament (MCL) sprain following a fall. Further evaluation revealed DVT in her right popliteal and left iliofemoral veins, leading to the initiation of anticoagulation therapy. Subsequent imaging revealed extensive thrombus involving the IVC and other major veins, with haziness around the existing IVC filter, necessitating thrombectomy and IVC filter retrieval.

Endovascular Technique: Thrombectomy and IVC filter removal were performed in two procedures, utilizing a combination of devices, including AngioVac for thrombectomy and specialized catheters for IVC filter retrieval. Follow-up imaging confirmed successful outcomes, with restored venous flow and improved clinical symptoms.

Results: Post-intervention imaging demonstrated patent venous flow, resolving thrombus, and no perioperative complications. At the 3-week follow-up, the patient showed improved lower extremity symptoms and no edema.

Discussion: This case underscores the challenges in managing extensive DVT with IVC filter complications in patients with multiple comorbidities. Successful thrombectomy and IVC filter retrieval using AngioVac highlight the importance of employing various techniques and devices to optimize outcomes. The study also emphasizes the significance of considering the complex interplay of risk factors in DVT management.

Conclusion: Thrombectomy and IVC filter removal were successfully performed in a high-risk patient with extensive DVT and IVC filter complications. This case report emphasizes the importance of a multidisciplinary approach in managing complex DVT cases. Further research is needed to explore optimal strategies for the management of DVT in high-risk patients, considering their comorbidities and potential complications associated with IVC filters.

Relevant history:

Upon complaining of LLE swelling, ultrasonography confirmed DVT of her right popliteal and left iliofemoral veins and she was subsequently started on Eliquis. The patient re-presented to the ED the next day after experiencing hematochezia following an enema with no reported prior history of GI bleeding. Computed tomography venography (CT) studies revealed extensive occlusive thrombus involving the IVC, bilateral iliac, popliteal, posterior tibial, and peroneal veins. Additionally, non-occlusive thrombus were identified in the femoral veins and left external iliac veins. The patient had an IVC filter placed approximately 15 years ago which showed increased haziness around the IVC below the caval filter and extending bilaterally to the pelvic veins which demonstrated new thrombus when compared to similar exams performed six months ago.

Relevant test results:

Post intervention venogram showed patent IVC, popliteal, femoral, external iliac, and common iliac veins bilaterally. Good flow was observed through the bilateral lower extremity venous system to the central vein. No perioperative complications were observed. The patient was discharged on Eliquis for long-term management of her DVT. At the 3-week follow-up visit, the patient displayed no lower extremity pitting edema and had improved range of motion and sensation of her bilateral lower extremities with minimal tenderness.

Teaching points:

Thrombectomy of the IVC thrombus peripheral to the IVC filter was performed using a 7 French Fogarty via the right femoral access. C20 Angiovac with ECMO tubing were inserted into the right common femoral vein for outflow and the right IJV for inflow. Angiovac suction of the remaining IVC thrombus was performed and IVUS confirmed clearance with mild residual thrombus in the IVC filter. To retrieve the IVC filter, right IJV access using 6 French sheath was exchanged to 20 French sheath Dryseal. A Bard filter retrieval kit with floppy Glidewire was used to snare the IVC filter, but was unable to reach around the filter. However, using a UF catheter, the floppy Glidewire was advanced and the IVC filter was retrieved inside the dry seal sheath. Completion venogram showed no signs of residual thrombus or contrast extravasation, indicating procedural success.

This case highlights the challenges faced in managing extensive DVT with IVC filter complications in a patient with multiple comorbidities that led to lower extremity swelling and GI bleeding in the setting of venous outflow obstruction. The successful retrieval of the IVC filter using UF catheter with a floppy Glidewire as well as Angiovac suction for thrombectomy underscore the importance of employing various techniques and devices to optimize outcomes.