Simultaneous proximal embolic protection and inferior vena cava mechanical thrombectomy using the FlowTriever system

Abstract

Interventional radiologists have the unique ability to apply their imaging knowledge, wide scope of technical skills, and use of innovative technologies to comprehensively address the percutaneous management of the thromboembolic disease processes. This report illustrates successful management of a thrombosed IVC, while protecting against possible pulmonary embolism. Here, we present a 49-year-old female with stage IIIB ovarian cancer who presented with severe bilateral lower extremity edema and anasarca in setting of occlusive thrombus of IVC. The thrombus was the result of compressionfrom a large hepatic hematoma which gradually developed after radical hysterectomy. A new mechanical thrombectomy device approved for use in pulmonary embolism, Inari FlowTriever catheter, was used off-label to remove the clot. The self-expanding mesh discs in the Inari FlowTriever catheter were utilized to protect against pulmonary embolism while percutaneously draining the hepatic hematoma and alleviating the IVC compression. The IVC was largely patent at the end of the procedure, and the patient experienced complete resolution of her symptoms. This case report demonstrates the successful and safe off-label use of a new mechanical thrombectomy device approved for pulmonary embolism thrombectomy in the IVC and illustrates a novel application of the nitinol mesh discs in the device as proximal embolic protection.

Figure 1. a, b

Abdominopelvic CT image (a) reveals severe obstructive mass effect from the patient’s large hepatic hematoma on the suprarenal IVC. The venogram (b) shows occlusion of the IVC.

Figure 2. a, b

Fluoroscopy image (a) shows deployment of the FlowTriever catheter discs (red arrows) proximal to thrombus as proximal embolic protection. Black arrow illustrates the drainage catheter placed in hepatic hematoma. The schematic figure (b) shows the FlowTriever catheter discs in fully opened configuration. The FlowTriever catheter comes in four sizes of a trio of self-expanding nitinol mesh discs near the tip of the catheter, which are used for mechanical clot capture and retrieval through the Triever20.

Figure 3

Final venogram demonstrates largely patent IVC with small burden of residual chronic clot in the distal IVC.