Vena caval filters are vascular devices used for the prophylaxis of deep vein thrombosis in patients with absolute contraindications to anticoagulation therapy. They have been used in the adult population since the late 60s, Reference Mobin-Uddin, Utley and Bryant1 usually deployed in the inferior vena cava in adult patients.
More recently, the placement of filters in the superior vena cava has been shown to be effective and safe, using the filters originally designed for the inferior vena cava. Reference Usoh, Hingorani and Ascher2
In paediatric patients, several small single centre reports Reference Kukreja, Gollamudi, Patel, Johnson and Racadio3–Reference Reed, Teitelbaum, Stanley, Mazer, Tonkin and Rollins5 showed that the use of filters in the inferior vena cava is feasible and effective, although concerns were raised regarding the potential risk for complications, such as vena cava perforation. Reference Rottenstreich, Revel-Vilk, Bloom and Kalish4
Case Report
A 15-year-old boy with a Philadelphia chromosome-positive acute lymphoblastic leukaemia (Ph+ ALL) was diagnosed with a central catheter-related deep vein thrombosis of the right subclavian and jugular veins. Concomitantly, he developed invasive pulmonary aspergillosis after first induction of chemotherapy, refractory to antifungal treatment due to a presumed catheter-related infection. As he had episodes of diffuse alveolar pulmonary haemorrhage, anticoagulation therapy was contraindicated.
Consequently, central venous catheter removal was deemed urgent. However, as the risk of pulmonary embolism during the procedure was considered high, deployment of a vena caval filter in the superior vena cava was planned prior to central venous catheter removal. This management plan was in accordance with institutional ethical guidelines, namely a multidisciplinary approach and a thorough discussion with both the parents and the patient.
On angiography, the superior vena cava was 50 mm in length and had a diameter of 22 mm. A Cordis OPTEASE™ filter was successfully deployed in superior vena cava via the right femoral vein with the hook pointing caudally (fig 1).
Figure 1. Deployed cordis OPTEASE™ inferior vena cava filter in the superior vena cava. Filter hook was positioned caudally for posterior removal through the femoral vein.
The central venous catheter was then removed without incidents and its position confirmed angiographically (fig 2). Over the following days, the patient rapidly improved from his systemic infection.
Figure 2. Deployed cordis OPTEASE™ inferior vena cava filter in the superior vena cava (SVC). Angiogram in the SVC excluded SVC perforation.
After excluding the presence of significant thrombi within the device, the filter was successfully retrieved after 19 days using a 15-mm ONE Snare™ via a 12Fr sheath.
Conclusions
In paediatric patients, the placement of retrievable filters in the superior vena cava using inferior vena cava filters is technically feasible and safe in carefully selected patients with upper deep vein thrombosis.
This procedure should be reserved for those patients with confirmed catheter-related upper deep vein thrombosis that require its urgent removal, whose use of anticoagulation or anti-aggregation therapy is contraindicated.
To the best of our knowledge, this procedure has not previously been reported in a child.
Financial support
This research received no specific grant from any funding agency, commercial, or not-for-profit sectors
Conflicts of interest
None.
