A trip down memory lane: The ultimate inferior vena cava filter

An 86 year-old-woman presented to the emergency room with progressive bilateral leg swelling and tenderness over one week. The patient was a poor historian, and no prior medical records were available for review. A lower extremity venous Doppler demonstrated bilateral deep vein thrombosis. The patient was deemed a significant fall risk, contraindicating anticoagulation. A routine abdominal radiograph obtained to exclude bowel obstruction failed to demonstrate prior caval interruption, and the patient was admitted for inferior vena cava (IVC) filter placement. The patient was consented, prepped and brought into the interventional radiology suite. During patient positioning, the patient was noted to have significant abdominal venous collateralization. A pre-procedure magnified fluoroscopic radiograph demonstrated a vague, liner, horizontal structure overlying the mid abdomen. A decision was made to perform computed tomography imaging, which demonstrated an infrarenal Adams-DeWeese IVC clip, the ultimate IVC filter (Figures 1 and 2). OPEN IN VIEWER

OPEN IN VIEWER

Figure 2.

Sagittal, non-contrast CT image demonstrating an infrarenal Adams-DeWesse clip with distal narrowing of the IVC.

Closing off the IVC to prevent pulmonary embolism was first suggested by Trousseau in 1868. ¹ Prior to the late 1950s, caval interruption was performed in patients with contraindications to anticoagulation primarily via suture ligation. ¹ Although effective in preventing pulmonary embolism, ligation was associated with post-procedural cardiogenic shock and chronic venous insufficiency resulting in postphlebitic syndrome in 20–45% of patients. ² To address these shortcomings, a number of external clips were subsequently developed which divided and compressed the IVC into a thin, flat vessel with or without further subdivisions. ¹ The clip offered protection from pulmonary embolism without significantly altering caval pressure and flow mechanics. ² The Adams-DeWeese clip divided the IVC into small 3-mm channels which were sufficient to capture most lethal pulmonary emboli. ² A suture was placed on the outer grooves near the open end to securely hold to clip after placement. ² The major large collaterals (ovarian and spermatic veins) were concurrently ligated during placement. ¹ The long-term IVC patency rate was approximately 70%. ¹ These external clips paved the way for modern, intraluminal IVC filters. Although rarely encountered in current practice, it is important to be familiar with historical methods of caval interruption and their potential complications.