Management of Cavoatrial Deep Venous Thrombosis: Incorporating New Strategies

Abstract

Cavoatrial deep venous thrombosis (DVT) is diagnosed with increasing prevalence. It can be managed medically with anticoagulation or with directed interventions aimed to efficiently reduce the thrombus burden within the target venous segment. The type of management chosen depends greatly on the etiology and chronicity of the thrombosis, existing patient comorbidities, and the patient's tolerance to anticoagulants and thrombolytic agents. In addition to traditional percutaneous catheter-based pharmacomechanical thrombolysis, other catheter-based suction thrombectomy techniques have emerged in recent years. Each therapeutic modality requires operator expertise and a coordinated care paradigm to facilitate successful outcomes. Open surgical thrombectomy is alternatively reserved for specific patient conditions, including intolerance of anticoagulation, failed catheter-based interventions, or acute emergencies.

Keywords: deep venous thrombosis; thrombectomy; thrombolysis.

Fig. 1

Cavoatrial deep venous thromboses (DVTs) resulting from indwelling or implantable devices. (a) Iliocaval DVT (solid arrow) extending from an infrarenal OptEase filter (dashed arrow). (b) Free-floating right atrial thrombus (solid arrow) extending from an indwelling catheter (dashed arrow).

Fig. 2

Characterization of iliocaval deep venous thrombosis (DVT). A 56-year-old woman with prior history of left common iliac vein DVT and stenting, presented with unilateral right lower extremity edema. Right common iliac vein DVT was confirmed with venography (a) and intravascular ultrasound (b and c).

Fig. 3

Catheter-directed thrombolysis for treatment of iliocaval deep venous thrombosis (DVT). A 39-year-old woman with history of factor V Leiden with previously placed inferior vena cava filter reported to the ER with bilateral lower extremity swelling. (a) CT chest with contrast demonstrates a right pulmonary artery embolus. The patient was referred for a venogram and potential thrombolysis. (b) Contrast venogram performed via the left common iliac vein demonstrates acute appearing thrombus in the inferior vena cava. Catheter-directed thrombolysis was performed, and follow-up venogram (c) demonstrated thrombus resolution in the right iliocaval segment.

Fig. 4

AngioVac suction thrombectomy under protection of inferior vena cava (IVC) (black arrows) filter. A 52-year-old man with history of renal cell carcinoma was incidentally found to have a large volume iliocaval deep venous thrombosis (a and b). (c) An IVC filter was placed in the suprarenal (white arrow) IVC and the AngioVac suction thrombectomy catheter was advanced across the filter through a 26F sheath. The suprarenal IVC (black arrow) filter was removed at the completion of the procedure. (d) Extent of intraluminal thrombus removed.

Fig. 5

Adjunct pharmaco-mechanical thrombolysis in the setting of AngioVac suction thrombectomy. A 31-year-old woman who cannot tolerate therapeutic anticoagulation received an infrarenal inferior vena cava (IVC) filter placement due to recent pulmonary embolism. The patient (white arrow) subsequently developed thrombosis of her IVC filter. (a) A suprarenal vena cava filter (white arrow) was placed in preparation for AngioVac suction thrombectomy of caval thrombosis at the site of her prior IVC filter placement. (b) Adjunct pharmaco-mechanical thrombolysis (white arrow) was performed in the setting of AngioVac suction (black arrow) at the level of the filter thrombosis. (c) Completion venography demonstrates complete recanalization and infrarenal IVC filter removal. At the completion of the procedure, the temporary suprarenal IVC filter was also removed (not shown).