Preoperative vena caval interruption for venous thrombosis associated with ovarian malignancy

A 70-year-old, postmenopausal, nulliparous women presented with loss of weight and appetite for 2 months, abdominal distension for 15 days and swelling of the right lower limb for 10 days. Total abdominal hysterectomy had been done 20 years ago for a fibromyoma uterus. On examination she was of thin build, afebrile and normotensive. There was no lymphadenopathy. The right lower limb was swollen, warm and painful. The left lower limb was normal. The abdomen was distended with fluid. A 20 cm × 15 cm mass was felt in the hypogastrium arising out of the pelvis. The same mass was felt per vaginam. Ultrasound and CT scan revealed, two large masses of mixed echogenicity (10 cm × 11 cm and 11 cm × 12 cm) in the lower abdomen. The abdomen had free fluid and the ovaries were not visualized. CA-125 was 1040 units. Compression ultrasound of the lower limbs revealed right femoral vein thrombus, but the left femoral vein was normal. A diagnosis of an ovarian tumor with venous thrombosis was made. The patient received a heparin infusion for 48 hr, after which low molecular weight heparin was started. On day 6, the left lower limb also developed signs of thrombosis. A Doppler ultrasound showed bilateral femoro popliteal vein thrombosis (right more than left) with partial recanalization. The thrombus had progressed despite adequate anticoagulation. The anticoagulants also posed a risk of bleeding during surgery; so vena caval interruption was considered to prevent pulmonary embolism in the absence of complete resolution of the clot. As the thrombus involved both of the iliofemoral venous systems, it was decided to put the inferior vena cava (IVC) filter through the jugular route. Under local anesthesia, the internal jugular vein was cannulated using the Saldinger technique. A 6F-valved sheath was introduced into the internal jugular vein. Through this sheath, a 5F pigtail catheter was introduced and its tip was placed in the IVC just above the renal veins. A renogram was performed to opacify the IVC and both the renal veins. The inferior vena cava measured 28 mm. The pigtail catheter was exchanged over a 0.35" guide wire. The 6F sheath was removed and a 6F IVC filter delivery system was introduced and its tip was placed below the right renal vein. A trapeare filter, a self-expanding nitinol material, was attached to the proximal end of the delivery system in an unexpanded state. The sheath containing the filter was screwed securely to the proximal end of the delivery system. Using a long pusher, the filter was pushed through the delivery system and positioned in the intra renal position. Once the position of the filter was confirmed, the delivery sheath was gradually withdrawn thereby releasing the filter. On release, the self-expanding nitinol material filter attained its diamond shape. The upper tip of the filter was just at the level of the right renal vein. A repeat venogram confirmed the site of the filter in relation to the renal veins and normal flow through it. The 6F delivery system was removed and local compression was applied at the puncture site for 15 min for hemostasis. No complication was encountered during the procedure. On exploratory laparotomy, the ovarian tumor was staged as IC (FIGO staging) and optimal debulking was done. The postoperative period was uneventful. Anticoagulation was continued for 36 months. The signs of a deep venous thrombosis resolved gradually after laparotomy. On histology the tumor was a papillary serous cystadenocarcinoma. The patient is presently on chemotherapy and the thrombus has resolved completely. The relationship between malignancy and venous thrombembolism has been convincingly demonstrated. Neoplastic cells activate the clotting system directly by generating thrombin or indirectly by stimulating mononuclear cells to elaborate procoagulants. Cancer cells can injure endothelial cells thereby intensifying hypercoagulability (1). Thus, cancer patients have an ongoing thrombotic stimulus due to underlying cancer and its associated treatments and are also at increased risk from anticoagulant-related bleeding (2). In this patient, the thrombus had not resolved despite adequate anticoagulation. Delaying surgical intervention for the ovarian tumor to await thrombus resolution was not a viable alternative. Not only does the presence of a tumor act as an ongoing stimulus for the thrombus, but also delay in removal of the tumor would lead to dissemination of malignancy. The risk of a pulmonary embolism from an untreated proximal deep vein thrombosis is approximately 50% and the case fatality rate from an untreated pulmonary embolism is about 8% (3). The anticoagulants needed to prevent a pulmonary embolism posed a risk of bleeding during surgery. A population-based study found that among patients receiving anticoagulation the presence of malignancy was significantly associated with major hemorrhage (4). To prevent a pulmonary embolism the option of vena caval interruption was considered in this patient. The death rate from recurrent pulmonary embolism following vena caval interruption is reported to be low. Some authors have even advocated inferior vena caval filters as a primary therapy instead of anticoagulants in patients with malignancy with a deep venous thrombosis or a pulmonary embolism (5, 6). Normally filters are introduced through the femoral route. Most of the filters available until now have been bulky and 11F compatible. The newer generation Trapeare (Cordis) International, Miami, FL, USA filter is made of nitinol and is 6F compatible. This makes the procedure extremely simple and because of the nitinol material, the same filter can be used in a wide range of IVC sizes. We used the jugular route for IVC filter implantation because the iliofemoral system was thrombosed in our patient. Thus, vena caval filter placement is an acceptable alternative for patients with progressive thrombosis despite adequate anticoagulation and in those at increased risk of having bleeding complications due to anticoagulants.