Venovenous bypass using continuous renal replacement therapy and endovascular inferior vena cava reconstruction to treat bilateral massive iliocaval deep venous thrombosis

Abstract

Many inferior vena cava (IVC) anomalies remain asymptomatic because of collateral circulation, but thrombosis of these channels can cause acute deep venous thrombosis with serious sequelae. For those with threatened limbs, anticoagulation is the mainstay of treatment, with endovascular pharmacomechanical thrombolysis replacing open surgical thrombectomy. Described is a severe case of massive iliocaval deep venous thrombosis with bilateral lower extremity Rutherford IIb acute limb ischemia in a patient with congenital IVC atresia. After initial thrombolysis, endovascular IVC reconstruction was accomplished to decompress the lower extremities. The patient ultimately required a right through-knee amputation but remains ambulatory with a prosthetic.

Revascularization of acute inferior vena cava thrombosis and atresia in an adolescent

“…We previously reported the use of femoralejugular continuous renal replacement therapy as a method of venovenous bypass for emergent offloading of elevated lower extremity venous pressure. 9 The mid-term durability of IVC recanalization and stenting appears reasonable, with 4-year primary and secondary patency of 52% to 78% and >90%, respectively. 17,18 Recent venous stents seek to maximize the interstice size and flexibility, although previous stent designs still offer a wider variety, including sizes #24 mm.…”

“…Motor dysfunction from venous hypertension is concerning, and higher venous pressures can lead to compartment syndrome. 9 Regardless of the etiology, the incidence of IVC atresia and adverse events has likely remained underestimated owing to the lack of standardized methods for detecting IVC occlusion. Open treatment of proximal venous thrombosis is difficult.…”

Multimodal imaging assessment for feasibility of endovascular reconstruction in cases of inferior vena cava atresia

“…1,2 It can be asymptomatic due to collateral flow and discovered incidentally in approximately 25%-33% of cases. 1,3 However, patients may present with a myriad of symptoms such as painful engorgement of superficial collateral veins, lower extremity swelling, venous thrombosis (VT) at a young age, non-healing venous ulcers, and rarely renal dysfunction. Premature development of lower extremity VT is the most common initial presentation of this condition.…”

“…5 Given that management is primarily focused on the treatment of complications, many patients will require endovascular pharmacomechanical thrombectomy or catheter-directed thrombolysis. 3 Unfortunately, treatment of thrombosis alone is not a feasible monotherapy in patients who continue to have symptomatic occlusions or non-healing venous ulcers. 2 Open reconstruction for similar pathology in femoral and iliocaval occlusions is associated with low patency rates and early morbidity and angioplasty lacks efficacy and durability.…”

“…IVC atresia is a rare condition with a prevalence of 0.0005%–1% of the population 1,2 . It can be asymptomatic due to collateral flow and discovered incidentally in approximately 25%–33% of cases 1,3 . However, patients may present with a myriad of symptoms such as painful engorgement of superficial collateral veins, lower extremity swelling, venous thrombosis (VT) at a young age, non‐healing venous ulcers, and rarely renal dysfunction.…”