I would like expert opinion on the following case:
84 yo male, with intermittent episodes of painless jaundice under investigation and known Hx of polycythemia rubra vera, under effective treatment with hydroxyurea (aspirin was halted some 2 weeks ago).
During diagnostic workup of the abdomen with CT + iv contrast, we identified a big thrombus within the supradiaphragmatic portion of IVC with extension to the right atrium (as confirmed with cardiac triplex ultrasound), without evidence of pulmonary embolism (CTPA performed) or DVT (lower extremity ultrasound performed). The patient was immediately started on therapeutic LMWH according to their weight. Further imaging with MRI-MRCP (in the context of investigating the cause of jaundice) showed an abrupt stop in the course of the common bile duct (possible periampullary or pancreatic mass), which will be further investigated with EUS.
Cardiac surgeons are planning to intervene to remove the thrombus in due time. The question is: does my patient need IVC filter placement, and if yes when is the optimal timing to do so?
Thank you in advance.
Athanasios Pantelis , I dont believe that IVC filter is necessary yet it may be hazardous because it will not prevent the thrombus that is already in the supradiaphragmatic part of IVC (in the atrium) to displace because it is already in the most dangerous place and in risk for sudden death. I recently operated on a patient with tumoral thrombus from liver cancer that was invading the left hepatic vein into the right atrium. We performed a successfull double intervention, cardiac and liver. I will send you some pictures of the intraoperative field and the cardiac US. In your particular case, I would deal with the cardiac thrombus first and then the pancreatic/biliary disease after. Good luck.
Athanasios Pantelis
There is no need for IVC filter because it will not avoid the displacement of the thrombus because it has already occurred. I have recently operated on a similar case with hepatocelullar carcinoma with tumoral thrombus in the left hepatic vein invading the right atrium. We did a conjoint operation with cardiac team and removed the thrombus from the atrium and IVC with simultaneous open abdomen and open chest surgery (see Figure with the atrium opened and thrombus in situ). IKn your particular case the thrombus may not be tumoral so you may deal with it first with cardiac team (if not, a sudden death may happen) and after you can deal with the pancreatic/biliary disease.
@Marcel Autran Cesar Machado: Thank you for your prompt response. Case of update: the pt had the thrombus removed by Cardiac Surgeons and is recovering in the CICU. Will resume investigation for possible periampullary tumor when he recovers and it is safe for him.
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