Critical Care: Fellow Case Report Poster - Critical Care II |

Use of a Percutaneous, Large-Bore Cannula to Reduce Venous Clot Burden and Treat Phlegmasia Cerulea Dolens FREE TO VIEW

Kavita Pal, MD; Ziv Haskal, MD; Andrew Mihalek, MD
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University of Virginia, Charlottesville, VA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):242A. doi:10.1016/j.chest.2016.08.255
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SESSION TITLE: Fellow Case Report Poster - Critical Care II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Phlegmasia cerulea dolens is a form of severe venous thromboembolism (VTE) that can result in a vascular emergency. It is caused by significant thrombosis leading to occlusion, or near occlusion, of the venous drainage system of the limb, characterized by the triad of swelling, pain, and cyanosis (1). It often requires anticoagulation and in some cases thrombolysis (surgical or catheter directed (CDT)). We describe the use of a large bore cannula with mechanical vacuum (AngioVac™ - AngioDynamics, Latham, NY) to debulk an extensive lower extremity thrombus.

CASE PRESENTATION: A 61year old male with a recent history of a motor vehicle accident complicated by subarachnoid hemorrhage and femoral deep vein thrombosis, treated with an inferior vena cava (IVC) filter was transferred to our hospital after noted to have cool, swollen, bilateral lower extremities. An ultrasound showed extensive thrombi starting at the distal portion of the IVC, extending to the left and right external iliac veins, common femoral veins, down to the popliteal veins. Mechanical aspiration thrombectomy with the AngioVac™ device was performed. Repeat venograms demonstrated marked interval reduction of clot burden (Figure 1). A one month follow up showed improvement of his exam and repeat ultrasound showed patent external iliac veins bilaterally.

DISCUSSION: Anticoagulation alone is unable to acutely resolve the short term complications of VTE. CDT is a percutaneous procedure which dissolves clots by directly administering thrombolytics. CDT could be dangerous in patients with contraindications to thrombolytics due to the bleeding risk. The AngioVac™ aspiration is a unique tool that offers a non-operative alternative for mechanically removing large amounts of obstructing thrombus from central veins. A clinical outcome study showed successful evacuation of the offending mass in 73% of cases with the use of the AngioVac™ with 87% of the patients surviving the hospitalization (2).

CONCLUSIONS: In patients with absolute contraindications for thrombolysis, the Angiovac™ provides a method strictly consisting of mechanical thrombectomy. Although further studies need to be done, the use of the AngioVac™ could potentially offer an advantage over existing CDT by reducing bleeding events and achieving improved patient outcomes.

Reference #1: Mahomed A, Williams D. Phlegmasia caerulea dolens and venous gangrene. Br J Surg;83(8):1160-1

Reference #2: Donaldson et al., Thrombectomy using suction filtration and veno-venous bypass. Catheter. Cardiovasc Interv. 2015 Aug;86(2):E81-7

DISCLOSURE: The following authors have nothing to disclose: Kavita Pal, Ziv Haskal, Andrew Mihalek

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