B52-11 Hemodynamic Assessment of Shock in Inferior Vena Caval Thrombosis

Introduction Acute inferior vena cava thrombosis (IVCT) is a well-documented complication of IVC filter placement with risk of significant morbidity and mortality. We present a case of acute IVCT presenting as undifferentiated shock despite pulmonary artery catheterization (PAC) availability. Case An 81-year-old male with history of heart failure presented for syncope. Evaluation revealed bilateral pulmonary emboli and deep vein thrombosis (DVT). Echocardiogram showed reduced left ventricular ejection fraction (LVEF) from baseline (25% from 45%) and right ventricular dysfunction. The patient was deemed a poor anticoagulation candidate, thus IVC filter was placed. Nuclear stress test showed mild ischemia in the left anterior descending artery territory, with plan for outpatient evaluation. The hospital course was complicated by shock with cold lower extremities. Milrinone was initiated for suspected cardiogenic shock given his reduced LVEF. PAC revealed low filling pressures (central venous pressure 1 mmHg, wedge pressure 4 mmHg), but hemodynamics and urine output failed to improve with fluid administration. The patient developed lower abdominal pain and decreased low extremity pulses. CT demonstrated acute IVCT (image 1). The patient was taken for emergent thrombectomy, with intubation complicated by cardiac arrest. Thrombolytics were administered. Despite return of spontaneous circulation, he continued to decline and expired. Discussion IVCT is found in approximately 2.6%-4.0% of patients with lower extremity DVT1. Acute IVCT is an uncommon complication of IVC filter placement, however actual occurrence may be underreported due to inconsistent detection and a rise in the number of untretrieved IVC filters in the US, a key risk factor. Incidence varies by filter type. Few case reports of filter-associated IVCT with obstructive shock have been reported in the literature. Diagnosis can be established by doppler ultrasonography or CT venogram, and low filling pressures on PAC may be suggestive in the appropriate context. Management includes anticoagulation and endovascular intervention, though limited information on efficacy and safety in filter-associated IVCT is available2. Prompt recognition and intervention are imperative to minimize poor outcomes as occurred here. Additionally, awareness of risk for hemodynamic compromise with preload reduction, as occurs with intubation, is advised. 1. Alkhouli M, Morad M, Narins CR, Raza F, Bashir R. Inferior Vena Cava Thrombosis. JACC Cardiovasc Interv. 2016;9(7):629-643. doi:10.1016/j.jcin.2015.12.268 2. Andreoli JM, Thornburg BG, Hickey RM. Inferior Vena Cava Filter-Related Thrombus/Deep Vein Thrombosis: Data and Management. Semin Interv Radiol. 2016;33(2):101-104. doi:10.1055/s-0036-1581087 This abstract is funded by: None