Endovascular caval interruption in pregnant patients with deep vein thrombosis of the lower extremity.

PURPOSE

The choice of therapy for deep vein thrombosis (DVT) of the lower extremity during pregnancy has been widely debated. Warfarin passes through the placenta to the fetus and may cause fetal complications and/or death. Heparin, in contrast, does not cross the placenta, but its long-term use may be impractical and may increase the risk of bleeding, osteoporosis, and neurologic complications. The use of inferior vena cava filters in pregnancy has only been described as case reports in the English medical literature; therefore, this study reviews our experience on this subject.

METHODS

We analyzed 18 pregnant patients who had Greenfield filters (GFs) inserted for DVT of the lower extremity, pulmonary embolism (PE), or both. The DVT diagnosis was made by means of duplex imaging. Conventional full-dose intravenous heparin was initiated until the filter was inserted, followed by subcutaneous heparin until labor, and continued for 6 weeks postpartum in 13 patients who were breast-feeding. Warfarin was given postpartum in the other five patients.

RESULTS

The mean age of the patients was 25 years. The indications for GF insertion included 3 patients who had a PE while on anticoagulation, 2 patients with significant bleeding caused by anticoagulation, 4 patients with free-floating iliofemoral DVT, 2 patients with heparin-induced thrombocytopenia, and 7 patients with iliofemoropopliteal DVT occurring 1 to 3 weeks before labor, for prophylactic reasons. Fourteen of 18 cases were diagnosed in the third trimester of the patient's pregnancy. Filters were inserted via the right internal jugular vein by means of a cut-down technique in the first four patients (stainless steel filters) and percutaneously in 14 patients. The mean fluoroscopy time during filter insertion was less than 2 minutes. There was no fetal or maternal morbidity or mortality. During long-term follow-up (mean, 78 months), no PE or filter-related complications were encountered.

CONCLUSION

GF insertion in pregnant patients with DVT of the lower extremity is safe and effective. Its prophylactic use in pregnant patients who have extensive iliofemoral DVT right before labor may be justified.