PHLEGMASIA COMPLICATING PROPHYLACTIC PERCUTANEOUS INFERIOR VENA-CAVALINTERRUPTION - A WORD OF CAUTION

Purpose: The purpose of this study was to evaluate the incidence of th rombotic complications in patients with deep vein thrombosis (DVT) who were treated with percutaneous inferior vena caval interruption in pl ace of anticoagulation. Methods: A retrospective review of all percuta neously placed inferior vena cava filters for 1 year, August 1993 thro ugh July 1994, was performed. Results: Thirty-three percutaneous infer ior vena cava filters were placed in 32 patients. The underlying disea se was pulmonary embolism in 15 (47%) and DVT in 17 (53%) patients. Of patients with pulmonary embolism, 11 had a documented DVT, and four w ere not evaluated for DVT. There were 14 men and 18 women, with a mean age of 63.5 years (range 24 to 93 years). Indications for vena caval interruption were recurrent pulmonary embolism with therapeutic antico agulation (n = 2 [6%]), prophylactic insertion with documented pulmona ry embolism and therapeutic anticoagulation (n = 8 [25%]), documented pulmonary embolism and absolute contraindication to anticoagulation (n = 5 [16%]), documented DVT and absolute contraindication to anticoagu lation (n = 2 [6%]), prophylactic insertion with documented DVT and th erapeutic anticoagulation (n = 5 [16%]), and documented DVT with relat ive contraindication to anticoagulation (n = 10 [31%]). Of the 32 pati ents with inferior vena cava filters, 17 were not given anticoagulants (7 absolute contraindications, 10 relative contraindications), and 15 were given anticoagulants. Insertion of a percutaneous inferior vena cava filter in patients who were not given anticoagulants was followed by the development of phlegmasia cerulea dolens in four patients (24% ), which was bilateral in two patients; one patient eventually died. N o patients treated with inferior vena cava filter and anticoagulation had development of phlegmasia. Conclusions: Percutaneous inferior vena caval interruption effectively prevents pulmonary embolism in patient s with DVT but does not impact the underlying thrombotic process and i n fact may contribute to progressive thrombosis in patients who are no t given anticoagulants. Anticoagulation with intravenous heparin is sa fe and effective therapy for DVT in most patients. We believe that per cutaneous insertion of vena cava filters should not replace anticoagul ation in routine proximal DVT, and those patients who require an infer ior vena cava filter for failure of anticoagulation should continue to receive heparin to treat the primary thrombotic process. We caution t hat relative contraindications to anticoagulation should be carefully scrutinized before recommending vena cava interruption as a primary th erapy for DVT.