Abstract We report a patient with recurrent deep vein thrombosis (DVT) for last 8 years. He maintained therapeutic level of international normalized ratio with oral anticoagulants and aspirin. However he continued to have recurrent massive DVT, which necessitated infrarenal inferior vena cava (IVC) filter placement with catheter directed thrombolysis (CDT). Subsequently the patient presented with extension of the thrombus into the infrarenal IVC, the IVC filter and beyond the IVC filter. The patient was managed with a suprarenal IVC filter deployment and CDT. Introduction Data on deep vein thrombosis (DVT) in India are limited;1 more so on catheter-directed thrombolysis (CDT), especially with a dual IVC filter. As of 2007, three cases of dual filter placement with thrombus removal (not CDT) were reported — all three of them had at least one temporary filter. In 1998, Greenfield et al reported 21 cases of double IVC filter placement,2 19 of them for a failed infra-renal filter. Ours is unique, for our patient had recurrent DVT episodes, but never pulmonary embolism or migration or fracture of the previously placed filter (filter failure). Suprarenal IVC filters are deployed less commonly, and we have been unable to find case reports of a permanent suprarenal filters being deployed prior to thrombolysis (CDT) for a patient with permanent infra-renal filter thrombus and acute DVT. Case History This 43-year-old male had complaints of pain and swelling of the left thigh and calf following a road accident in June 2001. Twenty-four days later, he was found to have occlusion of the left common femoral (70%) and popliteal artery. Patient was medically managed. In September 2001, the patient had sudden onset pain and increasing swelling of the left leg. Doppler of the left lower limb venous and arterial system demonstrated left-sided femoro-popliteal DVT extending to the left iliac vein; the arterial findings remaining the same. Workup for acquired and inherited thrombophilia was negative (Table 1). He was placed on Acetrom and aspirin with therapeutic international normalized ratio (INR) levels maintained. In August 2003, the left femoro-popliteal artery was grafted with the right saphenous venous graft (SVG). He later developed varicose veins (as a sequela of DVT) of the left lower limb with a non-healing ulcer in June 2005. In August 2005, the patient developed acute severe pain of the left lower limb. Doppler demonstrated acute or chronic thrombus in the left popliteal, femoral and iliac vein. The patient underwent infra-renal inferior vena cava (IVC) filter (Trapease, Cordis Corporation, Johnson & Johnson, Miami, Florida) placement and catheter directed thrombolysis (CDT) of the DVT. Following CDT, the venogram demonstrated a stenosis of the left iliac vein. He underwent angioplasty and stenting (10 mm x 100 mm Luminexx Stent, Bard, Tempe, Arizona) of the left iliac vein. Three months later, the patient had severe pain and swelling of the left lower limb. A dual-phase aorto-iliac and lower limb CT angiography and venography revealed occlusion of the left iliac venous stent with extensive DVT of the left ileo-femoral and popliteal veins, with intact arterial graft. A small thrombus was found in the IVC filter as well. The patient was managed medically. In February 2009, the patient presented with acute onset, severe pain and swelling of the right lower limb. Doppler study demonstrated DVT involving the femoro-popliteal vein. A CDT was planned. The venogram demonstrated extensive thrombus involving the popliteal vein, femoral vein, and iliac vein. Thrombus was seen extending into the infra-renal IVC, through the IVC filter and above the IVC filter. A suprarenal IVC filter placement followed by CDT was therefore planned using right trans-jugular access. An ALN retrievable IVC filter (ALN Implants Chirurgicaux®, Ghisonaccia, France) was deployed between the right renal vein (higher than left renal vein) and hepatic vein. CDT was carried out with in-situ filter in the vena cava. After 48 hours of thrombolysis, the thrombus load in the right lower limb was significantly reduced. No venous anatomical abnormalities were noted. The patient showed significant symptomatic improvement. He was discharged on oral anticoagulation on the 7th day, but the patient did not return for his post-treatment angiogram. Discussion Inferior venacaval interruptions by a filter have generally been indicated in patients with documented venous thromboembolism (VTE) who have contraindications to anticoagulation or complications due to anticoagulation or recurrent VTE despite therapeutic anticoagulation.3 Placement is also done in poorly compliant patients and in patients with underlying VTE with a free-floating proximal DVT, an ileocaval thrombus or prior to thrombolytic therapy (as in our patient).4 Trauma, surgical, and obstetric patients with high risk for VTE, in whom mechanical and drug prophylaxis is not practicable, have filters placed prophylactically.3 Filter placements are usually infrarenal in location; But in cases of pregnancy,5 renal vein and ovarian vein thrombosis,6 IVC duplication,7 extrinsic or intrinsic infrarenal IVC narrowing, or in patients with thrombus extending to infrarenal IVC or filter thrombus,8 as in ours, suprarenal deployment has been performed with no change in rates of complications like filter migration, venacaval thrombosis, or recurrent pulmonary embolism.3,8 Double filters have been deployed in instances of IVC duplication,9,10 IVC filter thrombosis,11 or when infrarenal temporary IVC filters have trapped a thrombus.12,13 In the case of IVC thrombosis,11 mechanical thrombectomy was performed along with temporary suprarenal venacaval protection. In the first of the two reports of temporary filters with thrombi, a temporary suprarenal filter was deployed to prevent dissemination of thrombi during the removal of the previous filter.12 In the second case, a permanent filter was deployed in the same infrarenal position of the previously placed temporary filter after thrombus capture and removal, along with the filter.13 In the Greenfield study, double filter placement had been done in 21 patients, 19 of whom had a failed infrarenal filter.2 No thrombolytic therapy was instituted. Our patient had an intact infrarenal filter, with no pulmonary embolism. A permanent suprarenal filter was deployed prior to thrombolysis with urokinase to afford protection from acute pulmonary thomboembolism from a recurrent DVT propagating through the permanent infrarenal filter (placed six years ago), in spite of adequate anticoagulation. As observed in many studies, an IVC filter increases the risk of recurrent DVT at the cost of preventing acute pulmonary embolism, as was seen in our patient. Chronic DVT causes post thrombophlebtic syndrome (PTS),14 an under-recognized cause of high morbidity, which our patient suffered from, but improved after thrombolytic therapy. Even with an incidence of VTE about 24 per 100,000 hospital admissions in India1, data are limited in regard to suprarenal venacaval interruption procedures and CDT in acute DVT. Our patient merited aggressive endovascular CDT after placement of a suprarenal filter because of failed anticoagulation and PTS due to previous DVT. _________________________ From Seven Hills Hospital, Vizag, AP, India. Manuscript submitted June 27, 2009, provisional acceptance given July 16, 2009, accepted September 2, 2009. Address for correspondence: Sibasankar Dalai, MD, OP No-12, First Floor, Seven Hills Hospital, Rock Dale Layout, Vizag, AP 530017, India . E-mail: email@example.com Disclosure: The authors report no conflicts of interest regarding the content herein.