with Vena Caval Umbrella

Transcription

1 Prevention of Pulmonary Embolus with Vena Caval Umbrella Results in 150 Patients Thomas 0. Orvald, M.D., George M. Callard, M.D., and James R. Jude, M.D. ABSTRACT A simple technique for effectively interrupting the inferior vena cava in patients with pulmonary emboli was introduced in The effectiveness of this method was evaluated in 150 patients having vena caval umbrella insertion following diagnosis of pulmonary embolism. These patients have been followed from two months to three years. The untoward sequelae and complications of insertion have been few. There have been 3 instances of documented pulmonary emboli occurring after insertion of the vena caval umbrella. Postoperative vena cavograms were obtained in 16 patients, and the patency was determined. The incidence of significant postoperative sequelae was directly related to the presence of preexisting venous disease. Only 1 death was directly attributed to vena caval umbrella insertion. Mortality figures reflect the fact that many of the patients were critically ill. The mortality in most cases was due to the underlying disease and not directly related to caval interruption itself. P ulmonary embolism continues to cause an estimated 50,000 in-hospital deaths annually in the United States. Mindful of the potentially lethal nature of the disease, physicians have responded with a number of therapeutic approaches. Basically these have utilized two techniquesmedication to alter the coagulation mechanism and surgical interruption of venous pathways. Although controversy exists about the proper sequence and timing of its use, placing a ligature between the clot and the heart, as advocated by Ochsner [lo], is generally conceded to be the most effective means of aborting further pulmonary emboli. In 1967 a technique was introduced by Mobin-Uddin and colleagues [7] in which a prosthetic device is inserted through the internal jugular vein and positioned in the inferior vena cava. This, in effect, places an obstruction between the most frequent origin of pulmonary emboli and the heart. The virtue of the technique appears to be twofold: it is a minor procedure performed rapidly under local anesthesia; and, because of its design, it From the Department of Surgery, Section of Thoracic and Cardiovascular University of Miami School of Medicine, Miami, Fla. Accepted for publication July 10, Address reprint requests to Dr. Orvald, 6465 S. Yale, Suite 804, Tulsa, Okla Surgery, 196 THE ANNALS OF THORACIC SURGERY

2 Prevention of Pulmonary Embolus with Vena Caual Umbrella affords immediate protection against large emboli without completely interrupting the vena cava. Clinical Material and Methods Our experience with use of the vena caval umbrella following the diagnosis of pulmonary embolism forms the basis of this report. The effectiveness of the method as a simple means of preventing further, potentially lethal emboli was evaluated in 150 patients. Follow-up has been from two months to three years. There were 48 women and 102 men. Their average age was 55.5 years. The indications for caval interruption were: (1) recurrent episodes of pulmonary embolism in the face of adequate anticoagulation therapy; (2) a single major episode of pulmonary embolism; (3) contraindications to anticoagulant therapy; and (4) recurrent phlebitis with iliofemoral vein thrombosis. Operation was performed after one or more episodes of pulmonary embolism had occurred and in several patients in whom caval interruption was considered necessary to avoid threatened embolism. The majority of candidates were referred from the medical services with either evidence of myocardial disease or thrombophlebitis. Clinical impressions of pulmonary embolism were confirmed by means of pulmonary arteriography in 93 patients and lung scan in 27. The remaining group was diagnosed on purely clinical grounds. The significant predisposing factors and their relationship to ultimate mortality are presented in Table 1. A technique of insertion has been outlined in detail previously [6]. Briefly, the patient is taken to the operating room, where he is placed on a fluoroscopy table and the right side of his neck is prepared and draped. Using local anesthesia, the internal jugular vein is isolated and the capsule with the umbrella in place is inserted intraluminally. Under fluoroscopic control using the image intensifier, the umbrella is positioned within the inferior vena cava immediately below the renal veins. The umbrella is ejected TABLE 1. PREDISPOSING FACTORS AND THEIR RELATIONSHIP TO ULTIMATE MORTALITY IN 150 PATIENTS WITH THE DIAGNOSIS OF PULMONARY EMBOLISM Factor No. of Patients Deaths Venous disease (thrombophlebitis, varicose veins) Heart disease (CHF, MI, cor pulmonale) Postoperative Trauma Pelvic disease Malignancy Bedridden Unknown "Percentage of total deaths. CHF = congestive heart failure; MI = myocardial infarction (20.6%)a (46%) 25 7 (11%) 5 2 (3.2%) 3 1 (1.6%) 3 3 (4.7%) 6 2 (3.2%) 10 6 (9.5%) VOL. 15, NO. 2, FEBRUARY,

3 OKVALD ET AL. arid secured, the applicator is removed, and the small incision is closed. The entire procedure lasts an average of 30 minutes. If the patient had overt evidence of thrombophlebitis and no contraindications to the use of anticoagulants, intravenous aqueous heparin is given postoperatively. Roentgenography of the inferior vena cava was performed postoperatively in 19 patients. Ten of the vena cavas were open, and 9 were closed. M o?'tal i t y Only 1 patient died as a result of the procedure. This was a young patient who had septic pelvic thrombophlebitis following an abortion. She was seriously ill, and 24 hours following insertion became hypotensive and subsequently died. At postmortem examination a significant amount of blood was found in the retroperitoneal area adjacent to the position of the umbrella. It was believed that the umbrella had perforated the vena cava and that this contributed to her death. Sixty-three patients died in the immediate postoperative period and during the next six months following insertion of the umbrella. Postmortem examinations were obtained in 23 patients. Six deaths were proved to be secondary to pulmonary embolism, which was thought to have occurred following insertion in 2 patients. In the 4 patients who died and in whom significant pulmonary emboli were found at postmortem examination, the location and configuration of the emboli closely corresponded to that seen in the preoperative pulmonary arteriograms. Therefore it was believed that embolism had occurred prior to insertion of the umbrella. Fifty-seven of the deaths were secondary to other illnesses. The majority of the patients who died had significant heart disease as manifested by congestive heart failure or had had myocardial infarctions. The high mortality seen in patients with cardiac disease is similar to that in other series presented by Crane [3] and Nabseth and Moran [9]. Complications of Inseytion and Long-Teym Sequelae Complications directly related to the insertion of the umbrella are listed in Table 2. The most significant of these was a documented perforation of the vena cava, as discussed before under Mortality. There was 1 patient with pneumothorax and 2 cases of malpositioning in which the umbrella was TABLE 2. COMPLICATIONS OF VENA CAVAL UMBRELLA INSERTION IN 150 PATIENTS Complication No. of Patients Perforation 3 Malposi tion 2 Pneumothorax 1 Neck hematoma THE ANNALS OF THORACIC SURGERY

4 Preuention of Pulmonary Embolus with Vena Caual Umbrella TABLE 3. LATE SEQUELAE OF VENA CAVAL UMBRELLA INSERTION IN 150 PATIENTS Sequela No. of Patients Swelling Phlebitis 33 (37.80/,)a 16 (18.4y0) Pain, fatigue Ulcer 5 (5.7%) 2 (2.3%) 'Percentage of surviving patients. placed in the right iliac vein. A second umbrella was subsequently inserted in the proper position in 1 of these patients. The other malpositioned umbrella was allowed to remain in place, and although no further embolism occurred, was removed because of persistent pain. The significant sequelae are listed in Table 3. The late sequelae found in the 87 patients surviving more than six months were all related to venous stasis. Many of these survivors developed transitory edema immediately after operation, but this disappeared following elevation and compression of the legs. The majority of patients with serious venous stasis problems had a history of preexisting venous disease. In the long-term survivors (two years) there was slight edema in 35 patients. Incidence of Recurrent Emboli There were 3 documented recurrences of pulmonary emboli, an incidence of Zyo. Two of these were fatal, and at postmortem examination fresh emboli were demonstrated, as discussed before under Mortality. In 1 patient, clinical findings were suggestive of recurrent emboli and pulmonary angiography was confirmatory. This patient was placed on anticoagulant therapy, and no further episodes occurred. The effectiveness of the vena caval umbrella method of preventing TABLE 4. SURGICAL METHODS OF TREATING PULMONARY EMBOLI- COMPARATIVE EXPERIENCE" No. with No. with Method & No. of Recurrent Recurrent Author Patients Embolism Fatal Embolism Femoral vein ligation Crane [3] Mozes et al. [S] Inferior vena cava ligation Blalock et al. [2] Crane [3] Mozes et al. [8] Nabseth & Moran [9] Orvald et al. [present report] 'After Nabseth and Moran [9] (10%) 13 (5%) (26.4%) 10 (8.2%) VOL. 15, NO. 2, FEBRUARY,

5 ORVALD ET AL. TABLE 5. OPERATIVE MORTALITY WITH INFERIOR VENA CAVA INTERRUPTION PROCEDURES Source of Data Mortality (yo) Mozes et al. [8] 5.4 Donaldson et al. r Nabseth & Moran Orvald et al. [present report] < 1.0 pulmonary embolism can be compared to that in other large series of venous ligation techniques (Table 4). Femoral vein ligation provides inadequate protection against emboli. Vena caval ligation confers excellent protection but carries a significant mortality from the operative procedure itself, especially when performed on seriously ill patients. The comparative operative mortality figures from several large inferior vena caval ligation series is presented in Table 5. Comment The most alarming figure in our series is the fearsome overall mortality rate of 42y0. It is important, however, to evaluate these figures in the light of our take all comers attitude. A significant number of the patients having vena caval umbrellas inserted were in moribund condition at the time of the operation. Most of these had severe congestive heart failure secondary to coronary artery disease, valvular disease, or cor pulmonale. In spite of this, only 2 patients died as a result of proved recurrent pulmonary emboli, and only 1 died as a direct result of the operation. It is well recognized that the in-hospital mortality after ligation of the inferior vena cava in patients with congestive heart failure is high. Nabseth and Moran [9] reported a mortality rate of 41%, Crane [3] had a 21% mortality, and 20% of the patients of Mozes and associates [S] died. In evaluating the various methods of treatment, it is important to consider not only the effectiveness of prevention of further emboli but also the mortality rate of the operative procedure. These figures must in turn be compared with the expected incidence and mortality of recurrent pulmonary emboli in untreated patients. Barker and his colleagues [l], in a postoperative review of 1,665 patients having had a nonfatal pulmonary embolus and no specific treatment, reported a 31ojb likelihood of recurrent embolism and an lsyo chance of recurrent fatal embolus. The mortality rate for each episode of embolism of a magnitude sufficient to produce symptoms is reported by Dexter [4] to be between 20 and 38y0. In view of the above statistics, it would appear that our operative mortality of <l.oyo, recurrent embolism rate of 2yo, and low morbidity rate provide convincing evidence of the worthwhile results obtained with use of the vena caval umbrella in preventing pulmonary embolism. 200 THE ANNALS OF THORACIC SURGERY

6 References Prevention of Pulmonary Embolus with Vena Caval Umbrella Barker, N. W., Nygaard, K. K., Walters, W., and Priestley, J. 7'. A statistical study of postoperative venous thrombosis and pulmonary embolism: Time of occurrence during operative period. Proc. Stag Meet. Mayo Clin. 16: 17, Blalock, J. B., Meyer, K., and Dukes, W. F. Treatment of thromboembolic disease by ligation of the inferior vena cava. R.Z. Med. J. 42:441, Crane, C. Femoral vs. caval interruption for venous thromboembolism. N. Engl. J. Med. 270:819, Dexter, L. Pulmonary Embolism and Acute Cor Pulmonale. In I. W. Hurst and R. Logue (Eds.), 'The Heart (2d ed.). New York: McGraw-Hill, P Donaldson, G. A., Linton, K. R., and Kodkey, G. V. Twenty year survey of thromboembolism at Massachusetts General Hospital, N. Engl. J. Med. 265:208, Mobin-Uddin, K., McLean, R., Bolooki, H., and Jude, J. R. Caval interruption for prevention of pulmonary embolism. Arch. Surg. 99:711, Mobin-Uddin, K., Smith, P. E., Martinez, L. D., Lombardo, C. R., and Jude, J. R. A vena caval filter for the prevention of pulmonary embolus. Surg. Forum 18:209, Mozes, M., Adar, R., Bogokowsky, H., and Agmon, M. Vein ligation in treatment of pulmonary embolism. Surgery 55521, Nabseth, D. C., and Moran, J. M. Reassessment of the role of inferior-venacava ligation in venous thromboembolism. N. Engl. J. Med. 273:1250, Ochsner, A. Indications for and results of inferior vena caval ligation for thromboembolic disease. Postgrad. Med. 27: 193, VOL. 15, NO. 2, FEBRUARY,