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Off-label use of a vena caval filter in the SVC in an adolescent with upper deep vein thrombosis

Published online by Cambridge University Press:  14 December 2022

João DiasOpen the ORCID record for João Dias[Opens in a new window],
Joana Marinho,
Patrícia Vaz Silva,
Sofia Simões,
Sónia Silva and
António Pires
João Dias*
Affiliation:
Centro Hospitalar e Universitário de Coimbra EPE, Serviço de Cardiologia Pediátrica, Portugal
Joana Marinho
Affiliation:
Centro Hospitalar e Universitário de Coimbra EPE, Serviço de Cardiologia Pediátrica, Portugal
Patrícia Vaz Silva
Affiliation:
Centro Hospitalar e Universitário de Coimbra EPE, Serviço de Cardiologia Pediátrica, Portugal
Sofia Simões
Affiliation:
Centro Hospitalar e Universitário de Coimbra EPE, Serviço de Oncologia Pediátrica, Portugal
Sónia Silva
Affiliation:
Centro Hospitalar e Universitário de Coimbra EPE, Serviço de Oncologia Pediátrica, Portugal
António Pires
Affiliation:
Centro Hospitalar e Universitário de Coimbra EPE, Serviço de Cardiologia Pediátrica, PortugalUniversidade de Coimbra, Faculdade de Medicina, Coimbra, Portugal
*
Author for correspondence: Dr. J. O. Dias, Serviço DE Cardiologia Pediátrica, Hospital Pediátrico de Coimbra, Avenida, R. Dr. Afonso Romão, Coimbra, 3000-602, Portugal. Tel: +351239488700. E-mail: joaodias@chuc.min-saude.pt
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Abstract

Vena caval filters remain as a useful tool in patients with deep vein thrombosis and contraindications to anticoagulation. Although they are rarely used in paediatric patients, they have been shown to be safe and effective when used in the inferior vena cava.

In this case report, we describe the off-label use of a retrievable vena caval filter in the superior vena cava in an adolescent with acute lymphoblastic leukaemia with extensive thrombosis of the right upper neck veins as a means to reduce the risk of pulmonary embolism.

Information

Type
Brief Report
Information
Cardiology in the Young , Volume 33 , Issue 8 , August 2023, pp. 1440 - 1441
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Copyright
© The Author(s), 2022. Published by Cambridge University Press

Vena caval filters are vascular devices used for the prophylaxis of deep vein thrombosis in patients with absolute contraindications to anticoagulation therapy. They have been used in the adult population since the late 60s, Reference Mobin-Uddin, Utley and Bryant1 usually deployed in the inferior vena cava in adult patients.

More recently, the placement of filters in the superior vena cava has been shown to be effective and safe, using the filters originally designed for the inferior vena cava. Reference Usoh, Hingorani and Ascher2

In paediatric patients, several small single centre reports Reference Kukreja, Gollamudi, Patel, Johnson and Racadio3–Reference Reed, Teitelbaum, Stanley, Mazer, Tonkin and Rollins5 showed that the use of filters in the inferior vena cava is feasible and effective, although concerns were raised regarding the potential risk for complications, such as vena cava perforation. Reference Rottenstreich, Revel-Vilk, Bloom and Kalish4

Case Report

A 15-year-old boy with a Philadelphia chromosome-positive acute lymphoblastic leukaemia (Ph+ ALL) was diagnosed with a central catheter-related deep vein thrombosis of the right subclavian and jugular veins. Concomitantly, he developed invasive pulmonary aspergillosis after first induction of chemotherapy, refractory to antifungal treatment due to a presumed catheter-related infection. As he had episodes of diffuse alveolar pulmonary haemorrhage, anticoagulation therapy was contraindicated.

Consequently, central venous catheter removal was deemed urgent. However, as the risk of pulmonary embolism during the procedure was considered high, deployment of a vena caval filter in the superior vena cava was planned prior to central venous catheter removal. This management plan was in accordance with institutional ethical guidelines, namely a multidisciplinary approach and a thorough discussion with both the parents and the patient.

On angiography, the superior vena cava was 50 mm in length and had a diameter of 22 mm. A Cordis OPTEASE™ filter was successfully deployed in superior vena cava via the right femoral vein with the hook pointing caudally (fig 1).

Figure 1.

Deployed cordis OPTEASE™ inferior vena cava filter in the superior vena cava. Filter hook was positioned caudally for posterior removal through the femoral vein.

The central venous catheter was then removed without incidents and its position confirmed angiographically (fig 2). Over the following days, the patient rapidly improved from his systemic infection.

Figure 2.

Deployed cordis OPTEASE™ inferior vena cava filter in the superior vena cava (SVC). Angiogram in the SVC excluded SVC perforation.

After excluding the presence of significant thrombi within the device, the filter was successfully retrieved after 19 days using a 15-mm ONE Snare™ via a 12Fr sheath.

Conclusions

In paediatric patients, the placement of retrievable filters in the superior vena cava using inferior vena cava filters is technically feasible and safe in carefully selected patients with upper deep vein thrombosis.

This procedure should be reserved for those patients with confirmed catheter-related upper deep vein thrombosis that require its urgent removal, whose use of anticoagulation or anti-aggregation therapy is contraindicated.

To the best of our knowledge, this procedure has not previously been reported in a child.

Financial support

This research received no specific grant from any funding agency, commercial, or not-for-profit sectors

Conflicts of interest

None.

References

Mobin-Uddin, K, Utley, JR, Bryant, LR. The inferior vena cava umbrella filter. Prog Cardiovasc Dis 1975; 17: 391–399.CrossRefGoogle ScholarPubMed
Usoh, F, Hingorani, A, Ascher, E, et al. Long-term follow-up for superior vena cava filter placement. Ann Vasc Surg 2009; 23: 350–354.CrossRefGoogle ScholarPubMed
Kukreja, KU, Gollamudi, J, Patel, MN, Johnson, ND, Racadio, JM. Inferior vena cava filters in children: our experience and suggested guidelines. J Pediatr Hematol Oncol 2011; 33: 334–338.CrossRefGoogle ScholarPubMed
Rottenstreich, A, Revel-Vilk, S, Bloom, AI, Kalish, Y. Inferior vena cava (IVC) filters in children: a 10-year single center experience. Pediatr Blood Cancer 2015; 62: 1974–1978.CrossRefGoogle ScholarPubMed
Reed, RA, Teitelbaum, GP, Stanley, P, Mazer, MJ, Tonkin, IL, Rollins, NK. The use of inferior vena cava filters in pediatric patients for pulmonary embolus prophylaxis. Cardiovasc Intervent Radiol 1996; 19: 401–405.CrossRefGoogle ScholarPubMed
Figure 0

Figure 1.Deployed cordis OPTEASE™ inferior vena cava filter in the superior vena cava. Filter hook was positioned caudally for posterior removal through the femoral vein.

Figure 1

Figure 2.Deployed cordis OPTEASE™ inferior vena cava filter in the superior vena cava (SVC). Angiogram in the SVC excluded SVC perforation.