Endovascular Recanalization and Reconstruction of the Inferior Vena Cava After Filter-Induced Thrombosis

Purpose: The inferior vena cava (IVC) filter was introduced in the 1960s, and long-term filter-related complications are common, with 2% to 10% of patients having IVC thrombosis. Patients with IVC thrombosis have lower extremity edema and pain, which can lead to incapacitating edema at rest, claudication, and ulcers. Anticoagulation treats acute symptoms and decreases the risk of pulmonary embolism; thrombus progression can lead to severe postphlebitic symptoms. Endovascular treatment is effective in reestablishing flow to the IVC. This presentation reviews a case of IVC thrombosis secondary to filter placement and discusses the techniques and challenges of performing endovascular recanalization while considering safety and efficacy.

Materials and Methods: A pregnant woman with deep vein thrombosis (DVT) of the calf, despite anticoagulation treatment, had clot propagation requiring heparin and IVC filter placement. Over 10 years, there were three unsuccessful IVC filter removals performed. Despite anticoagulation, she had multiple DVTs and constant debilitating pain. After years of misdiagnosis for the cause of her pain, she presented to our clinic, and a computed tomography venogram demonstrated IVC thrombosis at the filter extending through her common femoral veins. For treatment, venous access was gained via the right internal jugular and bilateral greater saphenous veins. A guidewire was carefully advanced through both iliacs into the IVC using a braided special crossing catheter (NaviCross). The internal jugular wire was exchanged for a snare. The lower extremity guidewires were snared and pulled through the internal jugular sheath to gain through-and-through access. Serial dilations of the IVC and bilateral iliofemoral veins were performed. Repeat venogram showed reestablished flow through the IVC. The IVC and bilateral iliacs were stented.

Results: Successful reconstruction of the IVC and bilateral iliofemoral vessels was performed in this case.

Conclusions: Endovascular treatment is effective for reestablishing IVC flow after thrombosis. Studies show primary patency of 80% at 19 months and comparable major bleeding rate to those in DVT thrombolysis studies. A procedural difficulty may occur passing wires through chronically occluded segments; multiple access sites yield better wire manipulation. Take caution with venoplasty; there is a rupture risk in the filter segment of the IVC. Evidently, endovascular recanalization of the occluded filter–bearing IVC is feasible and safe for reestablishing flow.