Endovascular management of Adams-DeWeese clip complications: A case of successful inferior vena cava recanalization after four decades

Abstract

Inferior vena cava (IVC) clips, historically used for pulmonary embolism prevention, can cause long-term complications, including chronic venous hypertension and nonhealing wounds. We present the case of a 74-year-old man with massive abdominal wall and lower extremity edema and a nonhealing venous ulcer 50 years after Adams-DeWeese clip placement. Successful management was achieved through balloon angioplasty without iliocaval reconstruction, resulting in improved venous outflow, resolution of edema, and complete wound healing. Postprocedure imaging confirmed IVC patency with intact clip integrity. This case demonstrates that balloon angioplasty without reconstruction can effectively manage long-term complication of permanent IVC clips.

Pulmonary embolism (PE) is the most severe complication of venous thromboembolic disease and represents the third most common¹ cause of cardiovascular death, with an incidence of 1.15 per 1000 individuals in the United States.² The Adams-DeWeese clip, introduced in the 1960s, is an extraluminal U-shaped device that partially narrows the inferior vena cava (IVC) lumen while maintaining limited flow through small channels (∼3-4 mm) to trap emboli. Before the introduction of IVC filters in 1973, surgical methods like the Adams-DeWeese clip were commonly used.³ Despite its initial efficacy, long-term complications associated with these permanent devices have emerged over the years, including chronic venous insufficiency, recurrent thrombosis, and wound healing issues.⁴

In this report, we present a unique case of IVC clip presenting with massive abdominal and lower extremity edema with resultant nonhealing venous wounds, highlighting the long-term sequelae of historical venous thromboembolism management techniques. Successful treatment with balloon angioplasty only releases of the clip and iliac veins demonstrates a minimalistic approach to the treatment of legacy device sequelae. The patient provided written informed consent for publication of this case.

Case report

A 74-year-old man initially presented with massive abdominal wall and lower extremity edema. Owing to these physical examination findings, he initially was worked up for cirrhosis, which was negative. Upon our initial examination, he had severe bilateral lower extremity edema with brawny edema and circumferential hemosiderin deposition to the level of his knees. The edema extended to the level of his upper abdominal wall with varicosities along the abdominal wall and both legs. He also had a well-healed right side retroperitoneal incision. When asked, he told of a history of provoked PE and deep vin thrombosis in 1970s after a prolonged hospitalization and bed rest for extensive burn wounds, during which he underwent an open surgery for prevention of further embolization. Computed tomography (CT) with intravenous contrast showed patent Adams-DeWeese clip in his infrarenal IVC (Fig 1, A and B). His medical history was otherwise significant for sick sinus syndrome, congestive heart failure, and paroxysmal atrial fibrillation. He had been maintained on anticoagulation after resolution of his burn wounds. At that time, he did not desire intervention, and was treated conservatively with compression and diuretics, with resolution of his abdominal wall edema and improvement of his lower extremity edema.

Fig 1.

Computed tomography (CT) images of a closed inferior vena cava (IVC) clip. (A) Coronal view of the predilated IVC clip. (B) Axial view of the predilated IVC clip.

Months later, he was referred to our clinic with a chronic, nonhealing left heel ulcer first noted in 2014, associated with a pathological avulsion fracture of the calcaneus. At intervention, the wound measured 2.0 × 2.5 × 0.4 cm with granulation tissue and minimal slough. Despite prolonged care, including debridement, negative-pressure therapy, and topical antimicrobials, the ulcer persisted. The venous clinical severity score was 21 and the Clinical, Etiological, Anatomical, Pathophysiological classification was C6, Es, As, Po. Noninvasive arterial studies showed normal distal perfusion. This longstanding wound, along with severe bilateral edema, prompted endovascular release of the clip with possible iliocaval reconstruction. Venous duplex showed no acute deep vin thrombosis, and repeat CT scan confirmed continued IVC clip patency.

Under general anesthesia, ultrasound-guided access was obtained through the right internal jugular vein and bilateral common femoral veins. Bentson wires from each site traversed the IVC clip easily. Venography through the common femoral veins showed patent iliac veins with near occlusion of the IVC just cephalad to the confluence of the iliac veins, consistent with the known position of the IVC clip (Fig 2), along with substantial collateralization.

Fig 2.

Initial venogram demonstrating predilatation of the inferior vena cava (IVC).

Intravascular ultrasound examination was not used because venography provided adequate visualization of luminal expansion and flow restoration. A stent was not placed across the IVC clip because balloon angioplasty restored satisfactory luminal expansion and brisk flow without residual stenosis on completion venography.

Preprocedural CT scan showed IVC occlusion at the clip level (<2 mm lumen) and narrowed iliac veins (3-4 mm). Balloon angioplasty with a 10 × 40 mm Conquest balloon was performed across the Adams-DeWeese clip site, showing an angiographic waist with resolution. Sequential dilation with a 20 × 40 mm Atlas balloon at the same clip location achieved incremental expansion without rupture, expanding the IVC lumen to 12 to 14 mm (Fig 3). Both common and external iliac veins were treated with 12 × 40 mm Conquest balloons to address webs and narrowing, achieving 10–12 mm final diameters. Balloon sizing was based on CT measurements and venography with gradual upsizing to minimize rupture risk. Completion venography through the bilateral common femoral sheaths showed significantly improved flow through the iliac veins and IVC, with reduced filling of the venous collaterals (Fig 4). We elected to forego iliocaval reconstruction owing to the substantial improvement in flow on venography and awaited the clinical result. The patient was discharged home later that day. Two weeks after recanalization of the IVC, the patient reported significant improvement in his lower extremity edema and had complete healing of his surgical wound (Fig 5, A). A postoperative CT scan with intravenous contrast during the venous phase showed a patient IVC with expansion of the lumen through the Adam-DeWeese clip. The clip remained unbroken with the suture used to secure and close the device seemingly still intact, but with some luminal gain post angioplasty (Fig 5, B). The patient remains asymptomatic at 6 months. He will continue yearly follow-up with a vascular surgeon, and long-term surveillance will include duplex ultrasound examinations every 6 to 12 months, with additional cross-sectional imaging if symptoms recur. He will be maintained on lifelong anticoagulation and compression.

Fig 3.

Atlas balloon (20 mm) with waist formation during dilation.

Fig 4.

Completion of venogram after inferior vena cava (IVC) intervention. (A) Right-sided angioplasty with a 10 × 4 mm Conquest percutaneous transluminal angioplasty (PTA) balloon. (B) Left-sided angioplasty with a 10 × 4 mm Conquest PTA balloon.

Fig 5.

Postintervention venograms. (A) Postangioplasty venogram of the inferior vena cava (IVC) and iliac veins. (B) Postdilatation imaging of the IVC clip.

Discussion

The evolution of PE prevention through vena cava interruption began in the mid-20th century, initially achieved through IVC ligation, followed by the development of IVC clips, which partially occluded the cava, such as the one seen in our patient, the Adams-DeWeese IVC clip. This surgical method involved placement of the clip around the IVC, effectively narrowing the venous lumen to prevent massive pulmonary embolism while maintaining venous outflow through five 3-mm channels.³ Despite its clinical benefits, the IVC clip was associated with several complications, including significant edema, phlebitis, stasis dermatitis, and varicosities.⁴ A study of 55 patients with an IVC clip monitored over a period of 5 to 12 years reported persistent postoperative leg swelling in 18% of cases.⁵ Additionally, research conducted by Couch et al⁶ on 83 patients indicated a 28% incidence of persistent leg swelling at a the 1-year follow-up after IVC clip placement. Our patient presented significant bilateral lower extremity edema and a nonhealing wound secondary to longstanding venous hypertension, more than 50 years after Adams-DeWeese clip placement.

There is no consensus on the management of IVC stenosis or occlusion, and encountering caval interruption devices is rare in practice today. There are few reported cases in the literature of management of the long-term complications of these clips. In 2014, O'Donnell et al⁷ performed an angioplasty through an Adams-DeWeese for acute on chronic IVC thrombosis with Angiojet thrombectomy and balloon angioplasty. Other cases report patients with longstanding Adams-DeWeese IVC clips and venous disease with successfully placed balloon-expandable stents at the IVC clip and bilateral iliac veins as reconstruction.^5,6 A similar case by Su et al⁸ described successful endovascular release of an Adams-DeWeese clip through femoral access in preparation for percutaneous mitral valve repair. Our case is the only case we found in our literature review with postprocedure imaging of the clip and confirmed continued patency after angioplasty only, resulting in outflow sufficient enough for wound healing. There are no established guidelines for managing Adams-DeWeese clip-related IVC obstruction. In our case, gradual balloon angioplasty achieved luminal gain without rupture, with adequacy judged by loss of balloon waist, restored flow, and reduced collaterals rather than full normalization. Expansion to 12 to 14 mm was sufficient for symptom relief and wound healing. Stenting was avoided given uncertain patency with a fixed clip, but may be considered if residual stenosis, recoil, or perforation occurs. This good outcome demonstrates this modality is effective for improvement in venous hypertension to improve wound healing.

Conclusions

This case demonstrates the successful endovascular management of complications from Adams-DeWeese clip placement through balloon angioplasty without reconstruction of the iliac veins and IVC, demonstrating that angioplasty alone is an option to significantly improve venous outflow to allow for distal lower extremity wound healing. Our experience adds to the limited literature on managing long-term sequelae of permanent IVC clips and highlights the importance of history and physical examination in patients with longstanding venous disease.

Funding

None.

Disclosures

None.