Case Report. A 38-year-old man was admitted to our hospital with suspected deep vein thrombosis of the right lower limb without prior immobilization history, and a history of 18 years of 1-pack-a-day smoking as a cardiovascular risk factor. The patient had a normal hematogram, a normal thromboplastin time, an INR of 1.0 and a D-dimer level of 2,738 ng/ml (normal < 500 ng/ml). Local lysis with urokinase with the catheter in the right femoral vein was initiated in the emergency room and continued throughout the following 6 days.
Computed tomography (CT) on the third day after admission showed multiple pathological para-aortic lymphadenopathies between the aorta and inferior vena cava, and a thrombosis of the right pelvic veins extending to the lower parts of the inferior vena cava and up to the renal veins without significant vena cava or iliac vein external compression. One day later, a CT-guided biopsy of a lymph node and its histopathology revealed evidence of a seminoma, and a left orchidectomy was performed on the sixth day after admission.
Immediately following orchidectomy, a triple chemotherapy (BEP: bleomycin, etoposide, cisplatin) was administered for three days. During chemotherapy, the patient received therapeutic doses of heparin. On the first post-chemotherapy day, the patient suffered an acute inferior myocardial infarction with multiple thrombotic occlusions without atherosclerotic plaques (Figure 1), which was confirmed by intravascular ultrasound. Urgent coronary aspiration was performed with simultaneous intracoronary bolus injection of eptifibatide.
Transoesophageal echocardiography revealed no evidence of patent foramen ovale. Two weeks after admission, since both the right femoral vein and inferior vena cava remained occluded (Figure 2), we performed aspiration of the thrombus in the inferior vena cava via the right femoral vein using an 11 Fr Aspirex catheter, which is designed for aspiration of emboli in lager vessels. The Aspirex is an 11 Fr over-the-wire, single-use catheter that is compatible with a 0.035 inch Terumo guidewire (Figure 3). It has three function capabilities, namely: (1) permanent suction via a spiral catheter with a 40,000 rotations/minute and a 180 ml/minute suction capacity; (2) fragmentation into very small particles by entry of the material in the L-Slit at the top of the catheter; and (3) continuous transport of the debris out of the vessel in a waste bag. We did not use any vena cave filter because the passage of a high-profile cava filter catheter via the occluded vena cava could have resulted in an embolization.
This procedure achieved flow in the inferior vena cava (Figures 3 and 4), and additional management with local thrombolytic therapy and systemic anticoagulation was applied for an additional 2 days. The control venography after the 2 days showed continued patency of the femoral and iliac veins and the IVC (Figure 5). Because there was no evidence of pulmonary embolism under systemic anticoagulation, we did not implant any prophylactic vena cava filter, which itself could cause further thrombus formation in the vena cava. No stenting of the vena cava was performed; tumor therapy was only recently established, the chance of metastasis shrinkage was high, and there was no evidence of significant external compression.
Twenty-two days after admission, the patient was discharged on oral anticoagulation therapy with normalization of the right extremity. At 4-month follow up, there was no evidence of vena cava thrombosis recurrence or pulmonary embolism.

Discussion. A conclusive explanation of these cancer-associated complications is difficult due to putative multiple factors, which may play a role in this setting. We assume that the pathogenesis of the two phenomena, namely the venous thrombosis and the myocardial infarction, are different. The venous thrombosis can be explained by factors of reduced blood flow due to narrowed veins resulting from the lymphadenopathies, which was not significant in our patient, and by the existence of hypercoagulability in cancer patients. On the other hand, the myocardial infarction due to in situ thrombosis could have been an adverse effect of the chemotherapy superimposed upon the cancer-induced hypercoagulopathy. Several cases of arterial occlusive events (cerebral and myocardial infarction) have been reported to be associated with the chemotherapeutic agents bleomycin, etoposide and cisplatin that were administered to our patient. The chronological factor with our patient, namely myocardial infarction just one day after the first chemotherapy cycle, supports this association.
To our knowledge, the application of the Aspirex catheter for percutaneous thrombectomy of the inferior vena cava has not been reported. Its therapeutic advantages in parallel use with lytic therapy remains to be defined.