Interruption and thrombectomy of inferior vena cava
Posted on Apr 15, 2014 in Thromboembolic disease | 0 comments
- It is important for a surgeon to learn how to determine the presence of a nonadherent thrombus in a large vein such as the inferior vena cava before clipping or tying it, because of the danger of causing a pulmonary embolus from the thrombus breaking off proximal to the clip or the ligature. To avoid this possible complication, after exposure the inferior vena cava should be palpated with extreme gentleness with the tip of the forefinger as shown. The presence of the thrombus partially occupying the lumen of the vena cava is readily detected by gentle pressure of the vein against the bodies of the lumbar vertebrae.
- The inferior vena cava must be opened in order to perform a thrombectomy. Before doing this it is advisable to place controls proximal and distal to the venotomy to control the gush of venous blood after removal of the thrombus. The tourniquet clamp has been found most useful for this purpose; two are placed around the vena cava in the open position. A transverse venotomy is performed since this permits an adequate thrombectomy and interferes much less with ligation of the large vessel than if a longitudinal incision is used. The exploring forefinger palpates the vena cava carefully to find the proximal end of the thrombus, then milks it distalward and out through the venotomy. This will be followed by a gush of blood which is readily controlled by closing the proximal tourniquet clamp. The distal portion of the thrombus is then removed by milking it proximally and using a large size Fogarty catheter if necessary. As a rule, blood will then gush from the distal end, but is quickly controlled by closing the distal tourniquet clamp.
- Two transfixion suture ligatures of linen or cotton are placed, one proximal and one distal to the venotomy. If possible they should be close to the nearest lumbar veins. It is believed that this type of venous thrombosis should always be treated by permanent interruption of the inferior vena cava after thrombectomy and that the venotomy should never be sutured to restore the caval continuity because of the danger of secondary thrombosis and pulmonary embolism. The flank incision through which these inferior vena caval procedures are accomplished is closed by suturing the divided muscles back together with interrupted linen or cotton sutures and careful closure of the skin with silk sutures. Drainage of the retroperitoneal area is rarely necessary. Postoperative anticoagulation with Coumadin for the period of hospitalization is recommended following any operative procedure for thromboembolism.
