Thirty-year Experience with Surgical Interruption of the Inferior Vena Cava for Prevention of Pulmonary Embolism

Abstract

Case records of 237 patients treated by inferior vena cava (IVC) ligation (154), suture plication (27) or clip application (56) were reviewed. Indications for surgery included failure of anticoagulation or femoral vein ligation to control embolism and threat of potentially massive, septic or paradoxical emboli. Overall hospital mortality was 15% and recent operative mortality was 2%. The incidence of early postoperative leg swelling was 36% and late venous sequellae occurred in 50% of the follow-up group of 140 cases followed an average of 44.3 months. Morbidity secondary to IVC interruption was decreased by use of the prosthetic lip, but clip application was still associated with early leg swelling in 21% and late mild swelling in 24%. The incidence of proven or suspected recurrent emboli was 7.6% with no significant variation by type of IVC procedure, and recurrent emboli were fatal in 2.5%. Refinement of indications, operative methods and perioperative care for IVC interruption procedures over the years has substantially improved the surgical approach to prevention of life-threatening pulmonary embolism.

Strain Gauge Plethysmographic Studies after Clipping of the Inferior Vena Cava

“…With a patency rate of 88.8%, no case of recurrent embolism, of peripheral origin, and a minimal late morbidity rate, our data compare favorably with the published results of complete IVC iterruption. 6,9,10 In the present study, MVO is the same in clipped patients as in the control group. MVO is also normal in Case 8 where the IVC could not be demonstrated by either abdominal sonography or isotopic venography.…”

Prophylaxis of Pulmonary Embolism with Partial Interruption of the Inferior Vena Cava: Indications and Results

“…After the implantation of the extraluminal clip or the intraluminal filter, no patient showed a pathologic dilatation of the superficial abdominal veins, but we did find moderate and significant dilatation of the superficial abdominal veins in 12 patients after implanting the intraluminal umbrella.8 A small to moderate swelling tendency of both lower extremities was found in 10% of the patients after a caval clip placement and in 60 % after intraluminal umbrella implantation . 9 The phlebographic and hemodynamic results are more impressive. In 116 patients we made a phlebographic study of the inferior vena cava one to fourteen years after the partial interruption : 71 of them had an extraluminal clip 26 an intraluminal filter, and 19 an intraluminal umbrella.…”

Inferior Vena Cava Interruption: How and When?

“…Surgical ligation of the IVC is associated with such rates of morbidity (serious venous sequelae in up to 65% of cases) and mortality (up to 19%, although this rate probably reflects the underlying clinical status more than the surgical procedure itself) (4,5) that it has now been abandoned.…”

“…They were an improvement on caval ligation or caval plication (5), but their insertion still required general or epidural anesthesia and a laparotomy, with all the specific potential complications of those procedures. It is therefore unlikely that a prospective comparison between clips and filters, as was proposed by Goldhaber et al in 1984 (11), will ever be performed.…”

“…In fact, for many decades, caval ligation was the only "treatment" of deep-vein thrombosis (DVT), at least until the efficacy of anticoagulant treatment in preventing recurrent pulmonary embolism (PE) was clearly demonstrated in 1960 (2). At the same time, the morbidity and the mortality rates of caval ligation (3)(4)(5) drove the development of newer and supposedly safer tools. Plication, then clips, and finally caval umbrellas or filters became available.…”