PUSH-PULL TECHNIQUE FOR MECHANICAL VACUUM-ASSISTED INFERIOR VENA CAVA AND BILATERAL ILIAC THROMBECTOMY Eric J. Lehr, Glenn Barnhart, Samuel J. Youssef, Mai T. Pham. Swedish Heart and Vascular Institute, Seattle, WA, USA.
RESULTS
BACKGROUND Management of the thrombosed inferior vena cava (IVC) often involves anticoagulation and thrombolysis. A large-bore thrombectomy cannula has previously been described for mechanical aspiration in conjunction with veno-veno extracorporeal bypass (VVECB), but can be challenging to steer. We describe using bilateral femoral venous balloon catheters to direct the aspiration cannula from the IVC sequentially into each iliac and proximal femoral vein.
Right
Left
Postoperative
METHODS
Preoperative
A 58-year-old gentleman with nonresectable glioblastoma multiforme presented with worsening bilateral lower extremity edema. Duplex ultrasound showed the completely occluded IVC with thrombosis extending bilaterally into the ilio-femoral veins and was confirmed by computed-tomographic venogram. Lytic therapy was contraindicated because of previous intracranial bleeding after anticoagulation for a pulmonary embolism.
Figure 2: Compared to the preoperative venograms, completion femoral venograms demonstrate recanalized bilateral iliac veins and IVC.
Figure 1: Preoperative Computed Tomography of Chest, Abdomen and Pelvis Under general anesthesia, bilateral internal jugular veins (IJ) were accessed. Following heparinization, an 18F return cannula was positioned in the left IJ and a 26F sheath was placed in the right IJ. The aspiration cannula was directed through the right IJ sheath and VVECB was established. Thrombus was extracted from the IVC. The cannula was advanced past an IVC filter but could not be directed beyond the proximal iliac veins. While pausing VVECB, access to the right and left common femoral veins was obtained. A 12mmx20mm balloon catheter was directed over a hydrophilic guidewire through the right femoral vein and into the aspiration cannula. With the balloon inflated, the aspiration cannula was pushed from the right IJ and pulled with the balloon catheter into the from through the IVC, through the IVC filter and into the proximal right femoral vein. VVECB was reestablished and iliac thrombectomy was performed with multiple passes. The technique was repeated on the left side. Sheaths were removed and hemostasis obtained.
CONCLUSIONS • A “push-pull” technique with right IJ aspiration cannulation and femoral venous balloon catheter intubation of the aspiration cannula can effectively guide a large-bore thrombectomy aspiration cannula into the femoral veins for percutaneous mechanical thrombectomy of thrombosed IVC and iliac veins.