F. Iqbal ( Bangor General Hospital, Bangor, North Wales, United Kingdom. )
D.R. Prichard ( Bangor General Hospital, Bangor, North Wales, United Kingdom. )
P.D. Birch ( Bangor General Hospital, Bangor, North Wales, United Kingdom. )
Thromboembolic phenomena are common in the elderly population and their consequences can be life threatening. Although anticoagulants are the mainstay of therapy, there are conditions in which their use is contraindicated. Alternative therapeutic options involve the use of more invasive techniques to prevent major thromboembolic incidents. We describe a case in which a modified Greenfield titanitim filter was inserted into the inferior venacava to prevent recurrent pulmonary emboli from iliofemoral venous thrombosis. Anticoagulants were contraindicated due to the presence of a haemorrhagic gastritis.
A 75 year old male was admitted with a one day history of swelling of his right calf and thigh. The past medical history documented atrial fibrillation and a cerebrovascular accident from which he had made a full recovery. He had also undergone a Billroth type II gastrectomy for chronic duodenal ulceration. Multiple gastroscopies had consistently demonstrated a haemorrhagic gastritis presumed to be due to biliary refiux secondary to this surgery. One month prior to his present admission he had sudden onset of breathlessness without chest pain and a pulmonary embolism was suspected. This was confirmed on a ventilation/perfusion lung scan. He was started on calcium heparin while in hospital vigilantly, but long term anticoagulation was not acceptable. On admission his general condition was good. Pulse was 80 per minute, irregularly irregular and the B.P. was 110/70. Hiss JVP was not raised and the heart sounds were normal. Examination of the respiratory, abdominal and central nervous systems was unremarkable. The right leg was swollen, tender and warm. A clinical diagnosis of right iliofemoral venous thrombosis was made and confirmed by venogram (Figure 1)
and colour Doppler ultrasonography. Full long-term anticoagulation was felt once again to be contraindicated in view of the known haemorrhagic gastritis, therefore, a modified Greenfield vena caval filter (Figure 2)
was successfully inserted via a left femoral vein approach. There were no subsequent complications and the patient remained well at two months following insertion. The position of the filter was checked and clots were ruled out in the filter by an ultrasonogram (Figure 3).
Venous thromboembolism is a potentially fatal disease and its incidence has not changed over the last 30 years1. The proportion of the aged population over 65 years has almost doubled. It is relatively common for patients in this age group presenting with thromboembolism to have a co-existing pathology which precludes anticoagulation, e.g., bleeding diathesis, bleeding peptic ulcers, cerebral aneurysms, severe hypertension, severe liver disease, recent eye or neurosurgery, hypersensitivity, confusion and frequent falls. Consideration must therefore, be given to alternative treatment strategies. The diagnosis is often difficult as clinical signs are unreliable2. High resolution real-time ultrasonography supplemented by colour Doppler imaging is increasingly accepted as a highly accurate, non-invasive technique to establish the diagnosis3. Surgical interruption or ligation of the JVC has resulted in significant morbidity and mortality. The use of intra caval balloons and other devices is associated with a high incidence of IVC thrombosis: Vena cavalifiters were introduced in an attempt to overcome these problems, yet still provide effective trapping of emboli. Of these Kimray-Greenfield filter has gained the widest acceptance4. This was originally of large calibre (24 French) and required surgical replacement by a venous cut down. The modified filter allows percutaneous placement by a 12 French introducer system via either the femoral or jugular vein. In our patient the right iliofemoral vein was blocked due to thrombosis, therefore, left femoral vein was chosen. With a 12 French introducer system the sheath is introduced up to a point below the renal veins, then it is withdrawn to fully uncover the capsule. Longitudinal axis of the filter should be in the vertical axis of WC. Once the filter is ejected, the sheath is withdrawn. Compression of the puncture site for 10 minutes is required. The complications of percutaneous placement of an WC filter include air embolism, clot formation around the introducer system and filter and filter misplacement. The limbs of the filter may also penetrate the wall of the vena cava resulting in retroperitoneal bleeding or perforation into adjacent structure, e.g., bowel, ureter and aorta. Delayed complications include occlusion of the WC which occurs in about 5-6% of patients, filter-migration to right atrium or pulmonary artery and infection5,6. None of these complications was encountered in our patient although the limbs of the filter were noted to have opened asymmetrically. This seems to be a relatively common occurrence with this design of filter but does not appear to have compromised its effectiveness in this patient.
We are grateful to Dr. P.N. Ohri, Associate Specialist, Dr. L. Roche, S.H.O. for their help and Mrs. M. Dyson for typing the manuscript.
1. Lindbald, B., sternby, N.H., Bergquist, 0. Incidence of venous thromboembolism verified by necropsy over 30 years. Br.Med.J., 1991;302:709-11.
2. Goldhaber, S.Z., Hennekens, C.H., Evans, D.A. et a!. Factors associated with correct antemortem diagnosis of major pulmonary embolism. Am.J.Med., 1982;73:822-26.
3. Reis, S.E., Poisk, J.F., Hirsch, DR. et a!. Frequency of deep venous thrombosis in asymptomaticpatientswithcoronsry srteLybypsss grafts.Am.Heart.J., 1991;122:478-82.
4. Tadarworthy, SM., Zoniga, W.C, Salomonowitz, E. et al. Kimray-Greenfield vena cava filter: percutaneous introduction!. Radiology, 1984;151:525-26.
5. Prince, M., Novelline, LA., Athanasoulis, CA. eta!. Dismeterof the inferiorvena cava snd its implications forthe use of vena cava! filter L Radiology, 1983;149:687-89.
6. Roehm, J.O.E., Gianturco, C, Barth, M.H. et aL Percutaneous transcatheter filter for the inferior vena cava: a new device for the treatment of patients with pulmonary embolism. Radiology, 1984;150:255-57.