This column summarizes patient cases posted to SIR Connect (SIR’s popular online member community), the responses from other SIR members and how that feedback helped the original poster. To see how SIR’s online community can help you, visit SIR Connect at connect.sirweb.org.
By Paul Eikens, MD, and Sudhen B. Desai, MD Spring 2017
I am will be starting a LE/IVC lysis case this week that I would appreciate some advice on:
54 y/o with h/o meth use and anxiety but o/w healthy presented with right leg swelling and thigh pain. No phlegmasia.
No left sided symptoms. No known prior DVT history. U/S showed right CFV and right ileac DVT and I was asked to lyse. Given that right LE dvt is somewhat unusual we got an Abd/Pelvic CT which demonstrated a nearly occlusive calcified intraluminal IVC mass between the renal veins and intrahepatic IVC with acute appearing clot below extending into bilateral common ileac veins. Renal veins are patent. There are retroperitoneal collaterals.
I have never encountered calcified IVC thrombus, which is what I am presuming this is since there is no soft tissue mass. My questions are:
1. Can I safely presume that this is not malignant? Should I attempt at some point to biopsy it to be sure?
2. Given that there is probably some small risk this could be malignant, is it safe to lyse the acute clot?
3. How do I address the calcified clot once the acute clot is lysed? I presume I will need to stent, but the adjacent renal and hepatic veins make this difficult and I have some concerns about stent migration to the heart.
4. I presume even with a stent I will still have a compromised lumen. If so does she require lifetime anticoagulation?
—Paul Eikins, MD
I am an interventional/diagnostic radiologist. I completed a radiology residency and interventional radiology fellowship (1996) at the University of Utah. I have been in private practice in Missoula, Montana, since 2001.
One of the challenges of practicing in a geographically isolated area is the need to provide tertiary-level care without the volume of cases that might be seen in a more population-dense practice. A large portion of what I do is diagnostic radiology and realistically, interventional radiology occupies less than 50 percent of my practice. In spite of our non-full-time IR practice, my interventional partners and I take pride in the breadth and quality of service we provide. There are times, however, when a forum like SIR Connect is invaluable, allowing us to solicit the advice of our peers and the world’s experts, and transfer their experiences and knowledge to our patients.
I submitted to the SIR Connect forum an example of complex deep venous thrombosis. We treat lower-extremity DVT frequently, but I had never encountered calcified IVC thrombus. The SIR Connect forum provided almost real-time advice during the 3-day course of this patient’s care and also facilitated actual real-time intraprocedural advice from Elizabeth B. Spencer, MD, FSIR, who kindly provided her phone number. Everyone’s thoughts and advice were appreciated.
The case turned out well. A longer duration of pharmacologic thrombolysis might have resulted in a more satisfying degree of clot lysis, but our current protocol, which includes following fibrinogen, precluded that. After pharmacomechanical thrombolysis, a suprarenal IVC stent and bilateral iliac stents we had restored patency and brisk flow to the previous occluded IVC and iliac veins. The patient had significant improvement in her lower extremity pain and edema.
Without having access to SIR Connect, I believe we still would have found a way to treat this patient with a good outcome. My partners and I would have relied on familiar techniques, literature searches and discussion of the treatment plan. I wonder, however, if my confidence level with the decisionmaking would have been as high had SIR Connect not been available to serve as a reference.
The discussion on the forum, which continued beyond the completion of this case, went on several tangents that I am still digesting and integrating into my practice. The discussion concerning fibrinogen stands out. Prior to this discussion, I had been unaware of any suspected correlation between using any of the mechanical thrombolytic devices and fibrinogen drop. I was also surprised to hear that following fibrinogen levels during thrombolysis was not without controversy. At this point in our practice, we continue to follow fibrinogen levels, but the discussion has opened my eyes to issues that I was unaware of and certainly not easily discerned from the available literature outside the forum.
One observation that I drew from SIR Connect was that an impressive number of posts on the forum provide literature references, including posts referring me to cases in the literature very similar to mine. Despite this, the forum is unavoidably often reliant on anecdotal and unpublished evidence. Clearly a large volume of our collective knowledge exists outside of academia and unfortunately outside of the available peer-reviewed literature. The forum provided me access to that fund of experiential knowledge and I hope the frequent unresolved questions that arise will drive future published research.
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