Teaching Case

Fresh iliofemoral thrombosis in a patient due to abdominal surgery

The patient presented with a large low abdominal cystic tumor originating probably from the ovaries, mild ascites causing compression of the pelvic veins. Additionally, swelling of the left leg was present that was caused by a fresh thrombosis of the femoral vein ascending into the external iliac vein on the left side. The right pelvic and leg veins were patent. Surgery for the abdominal tumor was planned and it was decided to perform placement of a vena cava filter prior to surgery in order to avoid pulmonary embolism by the present thrombus which might occur due to perioperative manipulations.

After antegrade puncture of the right common femoral vein, cavography and selective phlebography of both renal veins were performed to visualize the venous topography for exact filter placement and to check absence of thrombus in the inferior vena cava (Fig. 1). Thereafter, a self-expanding tulip filter (Cook Inc., Bjaeverskov DK) was placed via the transfemoral route (Fig. 2). The filter was placed with its proximal end exactly at the level of the venous confluens of the renal veins in order to allow collateral perfusion of the filter head in case caval thrombosis due to emboli or genuine thrombosis would occur. The type of filter chosen is a self-expanding self-centering filter from elgiloy which is MR-compatible. The filter has a hook on its proximal end that allows retrieval of the filter by a transjugular route within 14 days after placement. In the very case, however, it was planned to leave the filter because of the age of the patient and to avoid an additional trauma by a second intervention. Full iv heparinization was recommended until the date of surgery. Cava filter placement is one of the oldest percutaneous interventions. However, the indications for filter placement are very various from one medical community to another. Clear indications include recurrent pulmonary Embolism (PE) despite adequate anticoagulation, imminent or recurrent PE and contraindication to anticoagulation and imminent PE in high risk patients with right heart malfunction. Fresh thrombosis in patients that require abdominal or limb surgery of the same side is an indication for temporary filter placement. In that very case, removal of the filter, however, was abandoned to avoid major drawbacks by a second intervention. Prophylatic filter placement in patients with thigh or iliac thrombosis is under discussion, because there are some papers indicating that filters may prevent PE in only a minority of those patients but are burdened by a higher rate of long-term sequelae such as caval obstruction.