What is the best next step for a patient with severe pulmonary hypertension and a possible thrombus in the inferior vena cava?

Management of IVC Thrombus in Severe Pulmonary Hypertension

The best next step for this 93-year-old patient with severe pulmonary hypertension and a possible thrombus in the proximal IVC is to initiate therapeutic anticoagulation and consider placement of an IVC filter. 1

Assessment of the Current Situation

This patient presents with:

• Severe pulmonary hypertension (estimated pulmonary arterial systolic pressure of 73 mmHg)
• Significantly elevated right atrial pressure (15 mmHg)
• Dilated inferior vena cava with <50% collapse upon inspiration
• Echogenic homogenous mass in proximal IVC consistent with thrombus

Management Algorithm

1. Immediate Anticoagulation

   • Initiate therapeutic anticoagulation without delay 1
   • For most patients, LMWH or fondaparinux is recommended over UFH 1
   • If oral anticoagulation is appropriate, a NOAC (apixaban, dabigatran, edoxaban, or rivaroxaban) is preferred over VKA 1
   • For patients with severe renal impairment, avoid NOACs and consider UFH followed by VKA 1

2. Consider IVC Filter Placement

   • IVC filters should be considered in cases of PE recurrence despite therapeutic anticoagulation 1
   • Given the patient's severe pulmonary hypertension and proximal IVC thrombus, an IVC filter would help prevent further embolic events 1
   • If anticoagulation is contraindicated, an IVC filter becomes even more important 1

3. Further Diagnostic Evaluation

   • Confirm the IVC thrombus with contrast-enhanced CT if not already done
   • Assess for evidence of pulmonary embolism which may have contributed to the pulmonary hypertension
   • Evaluate right ventricular function to assess severity and prognosis

Important Considerations

Benefits of IVC Filter in This Case

• Reduces risk of further pulmonary embolism in a patient already with severe pulmonary hypertension 1
• May prevent worsening of pulmonary hypertension due to additional embolic events 2
• Particularly important given the patient's advanced age and likely limited cardiopulmonary reserve

Caveats and Pitfalls

• IVC filters alone are insufficient; anticoagulation should still be used unless contraindicated 1
• IVC filters may increase the risk of recurrent DVT (20.8% vs 11.6% at 2 years in the PREPIC trial) 1
• Retrievable filters should be evaluated periodically for potential removal once the risk period has passed 1
• Filter occlusion can occur, especially in hypercoagulable states, leading to significant complications 3, 4

Age Considerations

• At 93 years, the patient's advanced age increases both the risk of complications from pulmonary embolism and from interventions
• Careful assessment of comorbidities and bleeding risk is essential before initiating anticoagulation
• The decision for IVC filter placement should consider life expectancy and quality of life goals

Follow-up Management

• If anticoagulation is initiated, monitor closely for therapeutic effect and bleeding complications
• Regular clinical follow-up at 3-6 months to assess for signs of chronic thromboembolic pulmonary hypertension progression 5
• Consider echocardiographic monitoring of pulmonary pressures and right ventricular function

This approach balances the immediate need to prevent further embolic events while addressing the underlying thrombus with appropriate anticoagulation, taking into account the patient's severe pulmonary hypertension and advanced age.