CASE REPORT
Filt e r pla ce m e n t in du plica t e d in fe r ior ve n a ca va : ca se r e por t a n d r e vie w
of t h e lit e r a t u r e
Ra fa e l D e m a r chi M a lgorI; M a r cone Lim a Sobr e ir aI I; Pr iscila N une s Boa ve nt ur aI I; Re gina M our aI I I; W inst on Bon e t t i YoshidaI V
IFellow, Vascular Surgery Service, Depart m ent of Surgery and Ort hopedics, Universidade Est adual Paulist a ( UNESP) , Bot ucat u, SP, Brazil.
I IConsult ant , Vascular Surgery Service, Depart m ent of Surgery and Ort hopedics, UNESP, Bot ucat u, SP, Brazil.
I I IPhD. Associat e professor, Vascular Surgery, Depart m ent of Surgery and Ort hopedics, UNESP,
Bot ucat u, SP, Brazil.
I VPhD. Professor, Vascular Surgery, Depart m ent of Surgery and Ort hopedics, UNESP, Bot ucat u, SP, Brazil.
Correspondence
J Vasc Bras. 2008; 7( 2) : 167- 170.
ABSTRACT
Double inferior vena cava is a rare anat om ic variat ion w it h prevalence ranging bet ween 0.2- 3.0% . I n cases of duplicat ion, inferior vena cava filt er placem ent opt ions include placing it in bot h vena cava, coil- em bolizat ion of t he int ervenous segm ent plus placing a filt er in t he right inferior vena cava, or suprarenal filt er placem ent . We report a case of deep venous t hrom bosis aft er unilat eral prim ary t ot al hip replacem ent , present ing wit h cont raindicat ions for ant icoagulant t herapy, in which cavography showed inferior vena cava duplicat ion. I nferior vena cava filt er placem ent was
perform ed in t he supra- renal port ion and was proved t o be an adequat e and safe procedure.
Ke yw or ds: Vena cava inferior, vena cava filt ers, abnorm alit ies
RESUM O
Veia cava inferior dupla é um a variação anat ôm ica rara cuj a prevalência é de 0,2- 3% . O im plant e de filt ro de veia cava, quando indicado em casos com duplicidade da veia cava inferior, pode ser realizado de diferent es form as: em am bas as veias cavas; em um a delas, em bolizando a
Pa la vr a s- cha ve : Veia cava inferior, filt ros de veia cava, anorm alidades
I n t r odu ct ion
Duplicat ed inferior vena cava ( I VC) is a rare m alform at ion, wit h prevalence bet ween 0.2- 3% .1 - 3
Knowing t his anat om ical variat ion is im port ant in cases of surgical repairs in t he I VC and it s t ribut aries.4 , 5
Diagnosis of duplicat ed I VC in m ost cases is perform ed by findings of com plem ent ary
exam inat ions, since t he signs or sym pt om s are rare during t he pat ient 's life. Filt er placem ent in duplicat ed I VC can be perform ed using radioscopic cont rol, which is t he m et hod of choice. Som e aut hors have also described filt er placem ent using ult rasound cont rol when t here is a duplicat ed vena cava.6 - 8
There are few report s of filt er placem ent in t he vena cava in t his sit uat ion. We report a case of vena cava filt er placem ent in suprarenal posit ion in a pat ient w it h duplicat ed I VC.
Ca se de scr ipt ion
A 74- year- old fem ale pat ient , hypert ensive, obese ( body m ass index = 34.92) was subm it t ed t o right t ot al hip art hroplast y. Drug prophylaxis ( 5,000 UI unfract ioned heparin every 8 hours
subcut aneously) for venous t hrom boem bolism was prescribed, st art ing 12 hours aft er t he surgery. On t he 30t h post operat ive day, due t o a coagulat ion disorder t hat occurred during hom e
Venous duplex scan of t he lower lim bs showed im ages of deep venous t hrom bosis in t he fem oral, poplit eal, post erior t ibial and fibular veins in t he right lower lim b, w it h absence of deep venous t hrom bosis in t he left lower lim b. Laborat ory t est s were norm al, as well as chest x- ray,
Aft er int errupt ing prophylaxis wit h heparin due t o bleeding and having a scheduled surgery for surgical wound debridem ent , t he pat ient was considered as high risk for em bolism and, t herefore, received an indicat ion of I VC filt er placem ent .
Aft er left com m on fem oral vein punct ure and insert ion of a 6- Fr sheat h, venography showed
duplicat ed I VC since t he beginning of t he iliac vein confluence, also w it h presence of int eriliac vein, unt il t he right renal vein ent rance level (Figure 1).
Considering t he proper space in t he suprarenal vena cava, choice was for vena cava filt er placem ent ( VenaTech LP - B, Brown, Nashville, USA) in t his posit ion, passing t he filt er from t he previously approached left fem oral vein and t hrough t he left vena cava (Figure 2).
The pat ient progressed unevent fully in t he im m ediat e post operat ive period and showed no signs of pulm onary t hrom boem bolism aft er t he debridem ent surgery in t he right hip j oint . Because of hip prost hesis infect ion, t he pat ient rem ained 60 days hospit alized and was discharged wit h no event s concerning t he procedure of I VC filt er placem ent during hospit al st ay.
D iscu ssion
Prevalence of duplicat ed vena cava is low, and it s associat ion wit h venous t hrom bosis and filt er indicat ion is even m ore unusual.1 1 Only six cases of duplicat ed vena cava filt er placem ent have
been described so far. I ndicat ions of filt er placem ent in I VC in t hese cases were: 1) cont raindicat ion of ant icoagulat ion, t hree cases ( bleeding and recent neurosurgery) ;1 1 2)
Filt ers used for placem ent were Kim ray Greenfiled ( Medi- Tech/ Bost on Scient ific, Wat ert oen, USA) , Sim on Nit inol ( C.R. Bard, Murray Hill, USA) , Vena Tech LP ( B/ Brown, Bet hlehem , USA) . I n t hree cases, t he filt ers were im plant ed in bot h cava branches; in one case, parallel t o left branch em bolizat ion; and in t wo cases, in suprarenal posit ion.
Am ong t he opt ions of placem ent sit e,1 2 - 1 4 perhaps t he chosen posit ion in t his case is t he m ost int erest ing as it avoids addit ional procedures, such as em bolizat ion of one of t he vena cavae or it s int erconnect ion. I n addit ion, only one filt er is used, represent ing an expressive reduct ion in cost s, since endovascular m at erials are im port ed and, t herefore, very expensive in Brazil.
Filt er release in suprarenal vena cava is safe and has already been est ablished in special sit uat ions. Greenfield et al. have suggest ed filt er placem ent in t he I VC using suprarenal posit ion when t here are t hrom bi ext ending above t he level of renal veins or inside t hem , in pregnant pat ient s or in wom en of fert ile age.1 4 Suprarenal placem ent has also been described in cases of sm all- caliber
vena cava.1 5
The need of ant icoagulat ion aft er filt er placem ent is not consensual. Decousus et al.,1 6 in a
random ized st udy, showed t hat pat ient s who underwent filt er placem ent and were ant icoagulat ed had higher recurrence rat es of pulm onary t hrom boem bolism in t he long t erm com pared wit h t hose who were only ant icoagulat ed. Therefore, it is possible t hat pat ient s who underwent filt er
placem ent and were not ant icoagulat ed m ay have even higher recurrence rat es. On t he ot her hand, a recent consensus report does not recom m end use of ant icoagulant s in t he long t erm for t hese pat ient s. Our pat ient was not ant icoagulat ed aft er filt er placem ent .1 7
The pat ient rem ains asym pt om at ic aft er 6 m ont hs, and has no problem s inherent t o t he procedure ( Figures 3 and 4) . Such evolut ion suggest s t hat suprarenal vena cava filt er placem ent can be a safe and effect ive opt ion when t here is duplicat ed vena cava.
Re fe r e n ce s
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17. British Committee for Standards in Haematology Writing Group, Baglin TP, Brush J, Streiff M. Guidelines on use of vena cava filters. Br J Haematol. 2006;134:590-5.
Cor r e sponde nce :
Rafael Demarchi Malgor
200 First Street SW � GONDA 4th South
Division of Vascular and Endovascular Surgery, Mayo Clinic 55905 – Rochester, MN – USA
Email: [email protected]
No conflicts of interest declared concerning the publication of this case report.
