J Cardiol 2000; 36: 337 – 342

Massive Deep Vein Thrombosis
After Cesarean Section TreatedWith a Temporary Inferior Vena
Cava Filter: A Case ReportOsamu

NAKAJIMA, MD

Kumiko

ARISHIRO, MD

KayokoKANI, MD

Tomonori

MORIGUCHI, MD

ShigemiTAMOTO, MD

Hisashi AKIOKA, MD
WataruHIGASHIURA, MD＊

Hiroshi

SAKAGUCHI, MD＊

Shoichi OHUE, MD＊Abstract ─────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────
A 25-year-old woman suffered a massive deep vein thrombus in her left common iliac vein extending tothe inferior vena cava after an abdominal cesarean section. The massive and floating inferior vena cava
thrombus was considered to pose a high risk of pulmonary thromboembolism. After placement of a temporary inferior vena cava filter via the left brachial vein, thrombolytic therapy and anticoagulation therapy
were instituted. The filter successfully prevented pulmonary thromboembolism during thrombolytic therapy. This patient was confined to bed because the filter moved vertically with left shoulder joint abduction.
Although a temporary inferior vena cava filter is very useful for the prevention of pulmonary thromboembolism in a patient with deep vein thrombus, the appropriate range of activity for such a patient needs careful consideration.
─────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────J Cardiol 2000 ; 36（5）: 337−342

Key Words■ Thrombosis（deep vein）■ Pulmonary embolism■ Interventional cardiology（inferior vena cava filter）■ Complications（cesarean section）

INTRODUCTION
Deep vein thrombus is a major pathogenesis ofpulmonary thromboembolism which is sometimes
fatal and a proximal deep vein thrombus is thought
to carry a high risk of pulmonary thromboembolism1）. A permanent inferior vena cava filter isvery useful for the prevention of pulmonary thromboembolism in patients with deep vein thrombus,
but it may cause late onset of pulmonary thromboembolism. Temporary inferior vena cava filters

have recently become available for deep veinthrombus. One of their major advantages is thatpatients with a temporary inferior vena cava filter
inserted via a brachial vein can walk2,3）. This isimportant because the venous flow is accelerated bywalking, so that patients with lower limb deep veinthrombus are encouraged to walk for prophylaxis ofthrombus extension4,5）.
We describe a patient with a massive deep veinthrombus after cesarean section which was successfully treated with a temporary inferior vena cava──────────────────────────────────────────────
日生病院 第一内科，＊放射線科 : 〒 550−0012 大阪市西区立売堀 6−3−8
The First Department of Internal Medicine and ＊ Department of Radiology, Nissay Hospital, Osaka
Address for reprints : NAKAJIMA O, MD, The First Department of Internal Medicine, Nissay Hospital, Itachibori 6−3−8, Nishi-ku,
Osaka 550−0012
Manuscript received April 5, 2000 ; revised June 30, 2000 ; accepted July 13, 2000337

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Nakajima, Arishiro, Kani et alFig. 1 Abdominal enhanced computed tomography scanA massive thrombus（arrows）is seen in the inferior vena cava（left）and the left common iliac vein（right）.

filter.
CASE
A 25-year-old woman was admitted to our hospital on December 16, 1998, for a delivery. She had
been healthy except for an abortion because of ahydatid mole in June of the previous year. Her family history was unremarkable. She underwent anabdominal cesarean section because of weak pain
on December 18, 1998. She was given a diuretic（trichlormethiazide 2 mg daily）for mild hypertension starting soon after the operation, and began tocomplain of a painful swelling in her left thigh 7
days after the cesarean section.
She was referred to us on December 29. The
patient was 160 cm tall and weighed 58 kg, herblood pressure was 120/80 mmHg and her bodytemperature was 37.5 °C. Although she had apainful swelling in her left thigh, there was noHomans sign in her calf to suggest a deep veinthrombus below the knee. Blood examination
showed a red cell count of 4.45 × 106/mm3 and awhite cell count of 9,920/mm3. The hematocrit
reading was 35%. Chemical findings showedslightly increased lactate dehydrogenase（364 IU/l）and elevated C-reactive protein（21.1 mg/dl）levels.
Coagulation and fibrinolysis tests showed 607
mg/dl fibrinogen, 14.8μg /ml fibrin degeneration
products and at 4.2μg/ml D-dimer, whereas theother data, such as antithrombin Ⅲ（97%）, protein
C（116%）and protein S（120%）, were all within thenormal range. The patient was negative for
antiphospholipid antibody.

The diagnosis was deep vein thrombus in the left
femoral vein based on her symptoms and laboratory
findings. The previous weak pain and the subsequent abdominal cesarean section and administration of the diuretic were thought to constitute thebackground for the deep vein thrombus formation.
Duplex sonography of her left femoral veinrevealed that it was blocked by a thrombus.
Abdominal enhanced computed tomography andcavography revealed a massive thrombus in theinferior vena cava slightly distal to the orifices of
the renal veins（ Figs. 1, 2−left）. This massive
floating inferior vena cava thrombus was considered to pose a high risk of fatal pulmonary thromboembolism, so an inferior vena cava filter wasconsidered appropriate for the prevention of pulmonary thromboembolism during thrombolytictreatment.
In this patient, venous compression by the uterine and hemoconcentration due to diuretics weresuspected to be transient causes of the deep veinthrombus formation. Therefore, a permanent inferior vena cava filter, which cannot be removed after
the implantation, was unsuitable, so a temporary
inferior vena cava filter（Anthéor vena cava filter
catheter ; Meditech, Boston Scientific）
was inserted
into the inferior vena cava via the left brachial veinon December 29. The filter was placed just cranially to the orifices of the renal veins because the massive thrombus extended slightly distally to the orifices into the inferior vena cava from the left common femoral vein（Fig. 2−right）. After the insertion, intravenous administration of a recombinant
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Vein Thrombosis After Cesarean Section

339

Fig. 2 Cavograms（upper）
and schemata（lower）
The thrombus（arrows）extended slightly distally to the orifices（＊）of the renal veins in the inferior venacava from the left common iliac vein（left）. A temporary inferior vena cava filter was inserted into the inferior vena cava just cranially to the orifices（＊）of the renal veins via the left brachial vein（right）.
RV ＝ renal vein ; P ＝ renal pelvis ; IVC ＝ inferior vena cava ; TH ＝ thrombus ; R-IV ＝ right common
iliac vein ; F ＝ temporary IVC filter.

tissue plasminogen activator（GRTPA®, 24 million
U/48 hr）, heparin（10,000 U/day）and an oral anticoagulant（warfarin potassium, 2.5 mg/day）werestarted.
The filter could move vertically by half a vertebra height with left shoulder joint abduction, so theJ Cardiol 2000; 36: 337 – 342

patient was confined to bed while the filter system
was being used（Fig. 3）. Although the thrombus
was markedly reduced on the 7th day, a small
thrombus remained in the inferior vena cava, sothat urokinase（480,000 U/day）was also administered from the 13th to 15th day. On the 16th day,

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Nakajima, Arishiro, Kani et al

Fig. 3 Chest radiographs
The temporary inferior vena cava filter was inserted into the inferior vena cava via the left brachial vein（left）. The filter moved vertically by half a vertebra height with left shoulder joint abduction（right）. The
arrow indicates the end of the filter.

cavography showed that the thrombus in the inferior vena cava had been completely dissolved, andthe entire filter system was removed（Fig. 4）.
Ventilation-perfusion scintigram of the lungs immediately after filter removal showed normal results.
After continuous treatment with warfarin potassiumfor 6 months, the patient recovered completely
even though a part of the thrombus remained in her
left common iliac vein.
DISCUSSION

Fig. 4 Cavogram on the 16th day
The thrombus in the inferior vena cava has been completely dissolved.

Deep vein thrombus formation in our patient isthought to have occurred mainly as a result of confinement to bed after the cesarean section. In addition, hemoconcentration caused by diuretics after
the operation may also have been important in thedeep vein thrombus formation6）. As the free-floating massive inferior vena cava thrombus was considered to pose a high risk of pulmonary thromboembolism, inferior vena cava filter implantation
was indicated to prevent pulmonary thromboembolism. Clinical studies have shown that a permanent inferior vena cava filter can significantly
reduce the risk of pulmonary thromboembolism in
the early phase of proximal deep vein thrombus,
but may cause late onset of pulmonary thromboembolism7）. Linsenmaier et al.3）have mentioned that
temporary filters should be considered for young
patients with an otherwise normal life expectancy.
The patient was a relatively young female andJ Cardiol 2000; 36: 337 – 342

Vein Thrombosis After Cesarean Section

the cause of deep vein thrombus formation seemed
to be transient, so that transient protection against
pulmonary thromboembolism was thought to beappropriate. For these reasons, a temporary inferior
vena cava filter was selected. Although deep veinthrombus is usually caused by bed rest, patientswith lower limb deep vein thrombus are now
encouraged to walk for prophylaxis of thrombus
extension, because it accelerates venous flow4,5）.
The Anthéor vena cava filter catheter consists ofa basket filter made up of 6 Phynox, a nonferromagnetic alloy, wires with Biocarbon sheaths toform a self-expanding basket filter system, which
can be inserted via a brachial vein3,8）. The carbon
sheaths are designed to reduce intimal reaction. For
these reasons, a patient with a temporary inferior
vena cava filter is encouraged to walk. An experimental study of this filter has suggested that fibrotic
wall reactions start in the third week after insertion,
so that a temporary filter system should be removed
within 2 weeks9）. Because the filter was inserted via
the left brachial vein, our patient was able to walk.
However, we noticed that the filter moved vertically by half a vertebra height with left shoulder jointabduction（Fig. 3）. We therefore confined thepatient to bed for about 2 weeks to avoid any complications such as vascular injuries2）. Most temporary inferior vena cava filters are positioned caudally to the orifices of the renal veins, but in our要

patient the filter was positioned cranially because
the distance between the orifices of the renal veins
and the top of the inferior vena cava thrombus wasless than 50 mm and thus did not leave enoughspace to place an inferior vena cava filter.
Other studies have suggested that the Anthéor filter catheter should be removed within 2 weeks3,10）.
In our patient, however, we had to keep the filter
inserted for a relatively longer period of 16 days
because of the slow dissolution of the massive
thrombus. Even though some investigators haverecently recommended that a patient with a lower
limb deep vein thrombus should walk, we hesitatedto have our patient walk for the reasons mentioned
before. However, the resultant bed rest may havecontributed to the relatively longer period after thefilter insertion needed to dissolve the inferior vena
cava thrombus. Further studies are therefore needed
to determine the efficacy of combining a temporary
inferior vena cava filter with thrombolytic therapy
compared with thrombolytic therapy only.
Our patient was a good candidate for a temporary inferior vena cava filter, and the filter wasindeed successful for the prevention of pulmonary
thromboemblism. Appropriate activity of thepatient during thrombolytic therapy, however, especially in a case with a massive proximal deep veinthrombus and a filter which can move vertically,needs further consideration11）.
約

一時的下大静脈フィルタ−を用いた帝王切開後の巨大深部静脈血栓の 1 例
中 島伯

有城久美子

可児佳代子

森口知則

秋 岡壽

東 浦

阪 口

大上庄一

渉浩田本重美症例は 25 歳の女性で，帝王切開後に左総腸骨静脈から下大静脈にかけての巨大な深部静脈血栓症を発症した．本例の下大静脈血栓は，巨大な浮遊血栓であり，肺塞栓症の危険性が高いと判断し，一時的に下大静脈フィルターを左上腕静脈より留置した後，血栓溶解療法と抗凝固療法を行った．
また，フィルターが左肩関節の外転で上下に移動したことから，安全のため患者にはベッド上での安静を指示し，血栓溶解に 2 週間を要した．肺塞栓症予防のため安全に血栓溶解療法を施行するには，本例では一時的下大静脈フィルターが有効であった．しかし，下肢深部静脈血栓症は，歩行による下肢静脈血流の増大が血栓の発育を阻止することから，安静を保つべきではないとの考えがある．深部静脈血栓症例において，一時的下大静脈フィルター留置中の患者の安静度に関しては, 今後の検討を要するものと思われる．

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