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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 57-62

A case series of inferior vena cava filter implantation in three COVID-19 patients with deep venous thrombosis


1 Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
2 Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China

Date of Submission05-Mar-2021
Date of Decision24-Mar-2021
Date of Acceptance28-Mar-2021
Date of Web Publication28-Jun-2021

Correspondence Address:
Dr. Weici Wang
Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan - 430022
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/VIT.VIT_45_20

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  Abstract 


The coronavirus disease 2019 (COVID-19) can cause venous thromboembolism, including deep venous thrombosis (DVT) and pulmonary embolism (PE), but there has been little research on the implantation of an inferior vena cava filter (IVCF) to prevent lethal PE complications. The purpose of this study is to determine the feasibility and effectiveness of IVCF implantation in DVT-COVID-19 patients through the aid of X-ray and bedside color ultrasound (US) techniques. We present three COVID-19 cases that were simultaneously confirmed as acute DVT. The first DVT-COVID-19 patient suffered from unexpected hemiplegia in the right limb. Due to the possibility of a cerebral hemorrhage, we performed X-ray-guided IVCF insertion to prevent PE occurrence. The second patient was diagnosed as having right limb gangrene. Due to the severe infection, we performed one bedside US-guided IVCF implantation before his acute right thigh amputation on the same day. The third patient complained of a feeling of paralysis in his left lower extremity. The X-ray radiograph determined thoracic and lumbar vertebra fractures. We also performed one bedside US-guided IVCF implantation before his vertebra internal fixation surgery. After the standard treatments, the first and third patients were discharged, while the second patient died due to an unexpected acute cardiovascular disease event in the intensive care unit. US-guided IVCF implantation is an effective method that can be considered as a precautionary strategy for preventing lethal PE occurrence, especially for critical DVT-COVID-19 patients who are not suitable to be transferred to a routine X-ray operation room.

Keywords: Bedside ultrasound, case series, COVID-19, deep venous thrombosis, inferior vena cava filter


How to cite this article:
Cai C, Guo Y, You Y, Cai F, Xie M, Li Y, Wang W. A case series of inferior vena cava filter implantation in three COVID-19 patients with deep venous thrombosis. Vasc Invest Ther 2021;4:57-62

How to cite this URL:
Cai C, Guo Y, You Y, Cai F, Xie M, Li Y, Wang W. A case series of inferior vena cava filter implantation in three COVID-19 patients with deep venous thrombosis. Vasc Invest Ther [serial online] 2021 [cited 2022 Oct 6];4:57-62. Available from: https://www.vitonline.org/text.asp?2021/4/2/57/319597




  Introduction Top


Since December 8, 2019, an epidemic of coronavirus disease 2019 (COVID-19) has spread rapidly. There are more than 90,353,576 COVID-19 patients worldwide, with 1,936,410 deaths having been reported to date.[1] Deep venous thrombosis (DVT) has been reported to be as high as 31% in intensive care unit (ICU) patients with COVID-19 infections.[2] Moreover, fatal pulmonary embolization (PE) has been reported to be as high as 20.6% in severe ICU COVID-19 patients.[3] Inferior vena cava filter (IVCF) implantation is the recommended precautionary strategy for fatal PE among DVT patients.[4] Nowadays, IVCF implantation is generally performed under X-ray or color ultrasound (US) guidance including either transabdominal US or intravascular ultrasonography.[4] US-guided IVCF implantation at the bedside is however more convenient and carries a lower risk of infection.[5] There is currently no guidance with respect to the preferred method of implantation during the current COVID-19 pandemic.


  Case Reports Top


Case 1

A 61-year-old woman patient (PADUA index: 4, Caprini index: 5) experienced 7 days of respiratory distress. She was confirmed COVID-19 positive thanks to a real-time reverse transcription polymerase chain reaction test. After admission, high flow nasal cannula (HFNC) and supportive care were performed immediately. At day 4, she complained of fatigue of the right lower limb. Due to the low oxygen saturation, a cranial computerized tomography (CT) scan was not performed immediately. At day 6, a bedside chest X-ray was performed, as shown in [Figure 1]a. At day 8, there was obvious edema of the right lower extremity. Consequently, the patient was scheduled for color US detection to screen for DVT. The scan confirmed that there was fresh thrombosis in the right femoral vein. She was anticoagulated with enoxaparin sodium (4000U, q12 h). At day 10, the patient became drowsy and had evidence of the right limb hemiplegia. A cerebral hemorrhage may have been the reason for these symptoms, a leading cause of morbidity in COVID-19 patients.[6] Anticoagulation was consequently withheld indefinitely and recommended implantation of an IVCF to prevent fatal PE occurrence. A CT scan of the chest at day 10 had showed typical COVID-19 features in the lungs [Figure 1]b. She was transported to the digital subtraction angiograph (DSA) operation room for IVCF implantation. After a successful Seldinger puncture of the left femoral vein, a permanent VenaTech® LP IVC filter (B. Braun, Melsungen, Germany) was placed just distal to the right renal vein, as shown in [Figure 1]c and d. A repeat chest X-ray on day 13 [Figure 1]e had showed signs of improvement compared with day 6. She was followed up regularly with her blood work [Table 1]. CT scan of the chest on day 23 showed signs of improvement compared to day 10 [Figure 1]f.
Table 1: Continuous laboratory assays of patient 1

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Figure 1: Radiographic information and IVC filter implantation of patient 1. (a) At day 6, X-ray radiography showed a blurred texture of bilateral lungs. (b) At day 10, representative COVID-19 lesions could be seen in bilateral lungs. (c and d) IVC filter implantation was successfully performed with the aid of DSA guiding. The IVC was patent. (e) At day 13, there were fewer inflammatory lesions compared to day 6 (a). (f) At day 23, the follow-up CT scan showed fewer inflammatory lesions compared to the day 10 CT image (b)

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She was eventually asymptomatic and discharged at day 28. This patient was the first case to receive DSA-guided IVCF implantation in our COVID-19 therapy Centre. The DSA operation room and equipment was meticulously disinfected to safeguard the health of patients making use of the service in the future.

Case 2

A 70-year-old male patient (PADUA index: 5, Caprini index: 7) was confirmed as having COVID-19 disease. After 25 days of chronic ischemia, there was dry gangrene of his right thigh [Figure 2]a. On admission to hospital, color US detection determined that he was suffering from a right iliac artery embolism and venous thrombosis. A series of other poorly prognostic symptoms, such as left toe ischemia [Figure 2]b and left lower extremity inter-muscular venous thrombosis were also found. Initial laboratory tests are shown in [Table 2]. Because revascularization surgery to salvage the right lower limb was not feasible, he was scheduled for the right thigh amputation surgery following IVCF implantation [Figure 2]c and [Figure 2]e.
Table 2: Continuous laboratory assays of patient 2

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Figure 2: Bedside US-guided IVC filter implantation of patient 2 on the isolation ward. (a and b) Severe ischemia signs were observed in the right thigh and left toes. (c) There was no blood flow in the right iliac artery and vein. (d) The tip of the IVC filter sheath was adjusted to be 1 cm below the right renal vein. (e) One retrievable inferior vena cava filter was implanted. (f) At day 3, after emergent right thigh amputation surgery, X-ray radiography showed obvious inflammatory lesions in bilateral lungs. There was no shift of the inserted IVC filter. (g) At day 9, in the intensive care unit, bedside X-ray radiography presented exacerbation in bilateral lungs. Black arrow indicates the inferior vena cava filter

Click here to view


At day 2, this patient was scheduled for implantation of a retrievable Cook Celect IVCF (William Cook, Europe) for preventing acute pulmonary embolism (PE) before the amputation surgery. The intervention was performed with bedside US on the isolation ward. First, we confirmed patency of the inferior vena cava, left iliac vein, and femoral vein. This assured that percutaneous US-guided IVCF implantation is feasible [Figure 2]c. After local anesthesia and successful Seldinger puncture of the left femoral vein, the filter sheath was visually inserted into the left femoral vein through one 6Fguide sheath. Next, we injected 10 mL diluted SonoVue US contrast agent (Bracco, Milan, Italy) through the filter sheath to adjust the catheter tip location. The tip of the filter sheath was anchored 1 cm below the right renal vein [Figure 2]d. The filter was delivered into the catheter and deployed according to the manufacturer's recommendations [Figure 2]e. IVCF was deployed successfully.

Postoperatively, he was transferred to the isolated ICU. Severe bilateral pneumonia was confirmed on a bedside chest X-ray on day 3 [Figure 2]f.

The IVCF position remained unchanged [Figure 2]f and [Figure 2]g. At day 9, he suffered an acute cardiac event with elevated hsTNI (10025.40 ng/L). He was treated medically for acute coronary syndrome. At day 10, the creatine kinase-myocardial band (262.70 ng/mL) and hsTNI (>50000.00 ng/L) levels kept increasing despite aggressive medical therapy. The patient eventually passed away on day 11 [Table 2].

Case 3

A 40-year-old man (PADUA index: 4, Caprini index: 8) showed typical COVID-19 radiographic manifestations in [Figure 3]a and [Figure 3]b. On admission, he was complaining of partial paralysis and an uncomfortable feeling of his left lower limb at day 4. A bedside X-ray showed compressed fractures in the 12th thoracic vertebrae (T12) and the 1st lumbar (L1) vertebrae [Figure 3]c and [Figure 3]d. Furthermore, bedside US scanning showed fresh venous thrombosis in the left iliac vein.
Figure 3: Radiographic information and bedside IVC filter implantation of patient 3. (a and b) At day 3, a CT scan showed representative COVID-19 lesions in transverse and coronal windows, respectively. (c and d) X-ray radiography presented the compressed fractures in the 12th thoracic vertebrae (T12) and the 1st lumbar (L1) vertebrae. (e) There was no blood flow in the left iliac vein. (f and g) After adjusting the tip of the IVC filter sheath, one retrievable inferior vena cava filter was implanted 1 cm below the right renal vein. (h and i) At day 9, X-ray radiography showed successful internal fixation surgery. There was no shift of the inserted IVC filter. (j and k) At day 18, there were obviously fewer inflammatory lesions in transverse and coronal windows compared to day 4 (c and d), respectively. Black arrow indicates the inferior vena cava filter

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At the time of consultation, the patient experienced continuous lower limb paralysis. It was decided to proceed with internal fixation surgery of both T12 and L1 fractures. Iliac vein thrombosis however increased the risk of PE during orthopedic surgery.[7] A preoperative IVCF could substantially decrease this risk. Initial laboratory tests are shown in [Table 3].
Table 3: Continuous laboratory assays of patient 3

Click here to view


At day 5, he was scheduled for preoperative implantation of a retrievable Cook Celect IVCF (William Cook, Europe) [Figure 3]e and [Figure 3]g following the similar procedures reported for patient two. At day 6, he underwent orthopedic surgery and was transferred to his isolation postoperatively. At day 9, an X-ray confirmed that his IVC filter had not shifted [Figure 3]h and [Figure 3]i. At day 18, another CT scan was performed which showed complete normalization of lung parenchyma [Figure 3]j and [Figure 3]k. He recovered well from COVID-19 and was subsequently discharged.


  Discussion Top


Venous thromboembolism, comprising DVT and PE, is a common and serious complication predominantly occurring in hospitalized patients. The treatment of DVT and PE is nonspecific. Anticoagulant and thrombolytic therapies are essential strategies as reported elsewhere.[8] However, for hemorrhagic or preoperative patients who are suffering from DVT simultaneously, IVC filter insertion could be an effective intervention for preventing lethal PE.

Our report describes three severe COVID-19 patients also presenting with DVT disease. All of them had reached IVCF implantation intervention criteria to prevent acute PE. There was however no recommendation on the best IVCF implantation strategy in the latest COVID-19 practices guidelines. ICVF implantation is normally performed under DSA guidance, as presented in case 1. Severe COVID-19 patients however often present with hypoxemia, requiring continuous HFNC and ECG monitoring. These unstable features would not allow transfer of these patients to the DSA room. Transferring patients from isolation wards would also increase the likelihood of cross-infection in the hospital. Disinfection of the DSA room would have a significant impact on medical and non-medical resources, together with workforce. The team thus opted for US-guided IVCF implantation for both remaining cases.

Up to the point of submission, we believe that this is the first bedside US-guided IVCF implantation reported case in severe COVID-19 patients on the isolation ward. We would like to summarize our experience pertaining to thrombosis prevention and treatment in severe and critical COVID-19 patients as follows:

  1. More attention should be paid to the prevention and treatment of DVT and PE, in spite of the current shortage of critical medical resources
  2. During the current COVID-19 epidemic, an US-guided IVCF implantation on the isolation ward may be considered in patients who fulfill criteria for implantation
  3. Full preparation is needed to achieve bedside IVCF implantation: pre-assessment of the feasibility of a percutaneous approach through the femoral vein; assessment of whether the inferior vena cava is unobstructed; evaluation of whether there is vena cava variation; fasting for 12 h before surgery (giving an ordinary enema 1 h before surgery is another alternative choice). Vascular surgeons need to take level 3 protective measures before entering the isolation ward and strictly follow protective protocol to avoid contamination.



  Conclusion Top


A color US scan is recommended for severe and critical COVID-19 patients with a high PADUA index and/or Caprini index. If the patients have reached an IVCF implantation indication, we strongly recommend opting for an US-guided bedside IVCF implantation strategy on the isolation ward instead of the conventional DSA method.

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Union hospital Wuhan, China. The informed consents of the participants were acquired.

Acknowledgments

The authors deeply thank all colleagues working in Union Hospital for supporting and collecting the valuable COVID-19 patients' data.

Financial support and sponsorship

This research was supported by National Natural Science Foundation of China (NO.82000729 to C.C. and NO.81873529 to W.W.).

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Coronavirus Disease (COVID-2019) Situation Reports-119; 2021. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/. [Last accessed on 2021 Jan 11].  Back to cited text no. 1
    
2.
Klok FA, Kruip MJHA, Meer NJMvander, Arbous MS, Gommers DAMPJ, Kant KM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res 2020;191:145-7.  Back to cited text no. 2
    
3.
Poissy J, Goutay J, Caplan M, Parmentier E, Duburcq T, Lassalle F, et al. Pulmonary embolism in patients with COVID-19: Awareness of an increased prevalence. Circulation 2020;142:184-6.  Back to cited text no. 3
    
4.
DeYoung E, Minocha J. Inferior vena cava filters: Guidelines, best practice, and expanding indications. Semin Intervent Radiol 2016;33:65-70.  Back to cited text no. 4
    
5.
Uppal B, Flinn WR, Benjamin ME. The bedside insertion of inferior vena cava filters using ultrasound guidance. Perspect Vasc Surg Endovasc Ther 2007;19:78-84.  Back to cited text no. 5
    
6.
Poyiadji N, Shahin G, Noujaim D, Stone M, Patel S, Griffith B. COVID-19-associated Acute Hemorrhagic Necrotizing Encephalopathy: Imaging Features. Radiology. 2020;296:E119-E120.  Back to cited text no. 6
    
7.
Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, et al. 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The task force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Respir J 2019;54:1901647.  Back to cited text no. 7
    
8.
Cai C, Guo Y, You Y, Hu K, Cai F, Xie M, et al. Deep venous thrombosis in COVID-19 patients: A cohort analysis. Clin Appl Thromb Hemost 2020;26:1076029620982669.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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