Spontaneous migration of an inferior vena cava filter resulting in cardiac tamponade and percutaneous filter retrieval

Vena Cava Filters: A Synopsis of Complications and Related Topics

Deep venous thrombosis and pulmonary embolism constitute common preventable causes of morbidity and mortality. The incidence of venous thromboembolism (VTE) continues to increase. Standard anticoagulation therapy may reduce the risk of fatal PE by 75% and that of recurrent VTE by over 90%. For patients who are not candidates for anticoagulation, a vena cava filter (VCF) may be beneficial. Despite a good overall safety record, significant complications related to VCF are occasionally seen. This review discusses both procedural and non-procedural complications associated with VCF placement and use. We will also discuss VCF use in the settings of pregnancy, malignancy, and the clinical need for more than one filter.

Right Ventricular Perforation and Subsequent Cardiac Tamponade Caused by IVC Filter Strut Fracture Migration

Cardiac tamponade, if not recognized and treated immediately, is a life threatening condition with various etiologies. Most common causes of cardiac tamponade encountered in emergency rooms are due to trauma, post myocardial infarction wall rupture, cancer and all other causes of pericardial effusion. Iatrogenic causes of cardiac tamponade include anticoagulation and procedures related. Currently there is a general comfort level amongst physicians that inferior vena cava (IVC) filters are not associated with significant complications. However, one of the feared life-threatening immediate complications of IVC filter placement is complete migration of the filter to the heart, with possible risk for cardiac arrhythmia, cardiac tamponade, and death. IVC filter strut fracture and migration to the heart and pulmonary arteries is another possible cause of cardiac tamponade and needs to be added to the differential diagnosis in the setting of tamponade signs and symptoms in a patient with history of IVC filter placement. We present a case of IVC filter strut fracture and migration to the right ventricle with penetration of the free wall causing cardiac tamponade with subsequent successful percutaneous retrieval. We hope to raise awareness through this case of the rare but potentially fatal complications of IVC filter placement and to advise regarding the judicious use of IVC filters.

The PCQP Score for Volume Status of Acutely Ill Patients: Integrating Vascular Pedicle Width, Caval Index, Respiratory Variability of the QRS Complex and R Wave Amplitude

Introduction

Techniques for measuring volume status of critically ill patients include invasive, less invasive, or noninvasive ones. The present study aims to assess the accuracy of noninvasive techniques for measuring volume status of critically ill patients.

Patients and Methods

A total of 111 critically ill patients admitted to the emergency department and undergoing central venous catheterization were included in the study. Five parameters were measured including vascular pedicle width (VPW), diameter of inferior vena cava, caval index, respiratory changes in QRS, and P wave amplitude. Patients with risk factors which could decrease the accuracy of central venous pressure (CVP) value were excluded from study. We compared these parameters with static CVP parameter. Finally, based on the afore-mentioned parameters, PCQP role in criteria was designed.

Results

In detecting loss of circulating blood volume, area under the curve of VPW was 0.92 (90%, confidence interval [CI]: 0.85-0.99), diameter of inferior vena cava was 0.82 (90%, CI: 0.72-0.91), caval index was 0.9 (90%, CI: 0.82-0.98), and changes in QRS and P waves were 0.88 (95%, CI: 0.81-0.95) and 0.73 (95%, CI: 0.63-0.82), respectively. PCQP role in criteria was designed according to these parameters, and at its best cutoff point (score 6), VPW had a sensitivity of 97.4% (95%, CI: 84.57-99.99) and specificity of 83.6% (95%, CI: 72.65-90.86) for the detection of loss of circulating blood volume (<8 cmH₂O).

Conclusion

PCQP score could be a reliable and noninvasive technique for the assessment of volume status in critically ill patients.

Embolization of Inferior Vena Cava Filter Tyne and Right Ventricular Perforation: A Cardiac Missile

Inferior vena cava (IVC) filter is a medical device placed in patients with proven pulmonary embolism or those with risk of embolization. Although many IVC filters are designed for removal after patient recovery, in many instances they are never retrieved. We present a case of a 22-year-old woman who underwent placement of an IVC filter as a prophylactic measure following a C-6 spinal injury that rendered her a quadriplegic. A tyne from the filter later fractured and embolized to the right ventricle, leading to perforation and subsequent large symptomatic pericardial effusion. The tyne was retrieved through a subxiphoid pericardial window, and the patient had an uneventful recovery. She later underwent retrieval of the entire filter.

Retrievable inferior vena cava filters can be placed and removed with a high degree of success: Initial experience

OBJECTIVES

Evaluate the success rate of retrievable inferior vena cava filter (IVC) removal in a tertiary care practice.

BACKGROUND

Retrievable IVC filters became readily available in the United States following Food and Drug Administration approval in 2003, and their use has increased dramatically. They represent an attractive option for patients with contraindications to anticoagulation who may only need short-term protection against pulmonary embolism.

METHODS

All patients who had undergone placement of a retrievable IVC filter at Mayo Clinic between 2003 and 2005 were retrospectively reviewed to evaluate our initial experience with retrievable inferior vena cava filters at a large tertiary care center.

RESULTS

During a three-year-period of time, Mayo Clinic, Rochester, MN placed 892 IVC filters of which 460 were retrievable. Of the 460 retrievable filters placed (249 Günther Tulip®, 207 Recovery®, and 4 OptEase®), retrieval was attempted in 223 (48.5%). Of 223 initial attempts, 196 (87.9%) were initially successful and 27 (12.1%) were unsuccessful. Of the 27 unsuccessful initial retrieval attempts, 23 (85.2%) were because of the presence of significant thrombus within the filter and 4 (14.8%) were because of tilting and strut perforation. Of the 23 filters containing significant thrombus, 9 (39.1%) were later retrieved after a period of anticoagulation and resolution of the thrombus.

CONCLUSIONS

Retrievable IVC filters can be removed with a high degree of success. Approximately one in ten retrievable IVC filter removal attempts may fail initially, usually because of significant thrombus within the filter. This does not preclude possible removal at a later date.

CV, de Oliveira Jr. MT. Intracardiac embolization of inferior vena cava filter associated with right atrium perforation and cardiac tamponade

Insertion of inferior vena cava filters has been well established in literature, reducing occurrence of pulmonary embolism after an episode of deep venous thrombosis in patients with contraindication to anticoagulation. There are a small number of complications related to procedure and embolization is rare. In this context, we described a case of intracardiac embolization associated with cardiac tamponade.

A Policy of Dedicated Follow-Up Improves the Rate of Removal of Retrievable Inferior Vena Cava Filters in Trauma Patients

Retrievable Inferior Vena Cava Filters (IVCF) for prophylaxis against pulmonary embolus have been associated with low rates of removal. Strategies for improving the rates of retrieval have not been described. We hypothesized that a policy of dedicated follow-up would achieve a higher rate of filter removal. Trauma and Nontrauma patients who had a retrievable IVCF placed during 2006 were identified. A protocol existed for trauma patients with chart stickers, arm bracelets, and dedicated follow-up by nurse practitioners from three trauma teams. No protocol existed for nontrauma patients. Statistical analysis was performed using χ2 analysis or analysis of variance. One hundred sixty-seven retrievable IVCFs were placed over 12 months; 91 in trauma patients and 76 in nontrauma patients. Trauma patients were more likely to have their IVCF removed than nontrauma patients, 55 per cent versus 19 per cent, P < 0.001. There were differences between the three trauma teams, with removal rates of 44 per cent, 42 per cent, and 86 per cent respectively ( P < 0.05). On multivariate analysis young age and trauma patient status were independent predictors of filter removal. A policy of dedicated follow-up of patients with IVCFs can achieve significantly higher rates of filter removal than have been previously reported. Similar policies should be adopted by all centers placing retrievable IVCFs to maximize retrieval rates.

[Vena cava filters in trauma patients]

BACKGROUND

The introduction of removable inferior vena cava filters (IVCF) has created new options for the prevention of pulmonary embolisms in surgical trauma patients. We have observed increasing use in trauma patients.

PATIENTS AND METHODS

A retrospective analysis was carried out of 49 trauma patients out of 85 who received IVCFs at our level 1 trauma centre in 2008.

RESULTS

The indications for IVCF placement were multiple trauma in 33 patients, severe head injury in 13 and spinal injury in 3 patients. Of the patients 34 underwent successful removal, 11 (22%) patients had had no retrieval attempt by December 2009 and attempts at removal were unsuccessful in 3 patients. The mean age of the patients was 33.3 years.

CONCLUSION

In 2008 the vast majority of IVCFs were inserted for prophylaxis in trauma patients. To increase the number of retrieved IVCFs, responsibility for the removal should be clarified in every hospital. The indications, advantages, safety and also the design of IVCFs are still under debate. A randomized controlled trial is needed to determine the appropriate use and indications for this potentially useful device in trauma patients.

Crux vena cava filter

Inferior vena cava filters are widely accepted for pulmonary embolic prophylaxis in high-risk patients with contraindications to anticoagulation. While long-term complications have been associated with permanent filters, retrievable filters are now available and have resulted in the rapid expansion of this technology. Nonetheless, complications are still reported with optional filters. Furthermore, device tilting and thrombus load may prevent retrieval in up to 30% of patients, thereby eliminating the benefits of this technology. The Crux vena cava filter is a novel, self-centering, low-profile filter that is designed for ease of delivery, retrievability and improved efficacy while limiting fatigue-related device complications. This device has been proven safe and user-friendly in an ovine model and has recently been implanted in human subjects.

Optional vena cava filter with disengaging centering struts: retrieval in an animal model

An optional inferior vena cava (IVC) filter prototype was evaluated for safety and long-term retrievability as an initial feasibility study in an animal model. This filter has four centering struts that have the ability to disengage from the filtering cone portion, allowing the legs to slide out of endothelial growth. Retrieval of six filters in three animals was successful up to 27 weeks. There was no substantial filter tilt, migration, or IVC damage. In conclusion, this filter design may help overcome some of the shortcomings in currently approved optional IVC filters, including long-term retrieval difficulties, tilting, or migration.

Evaluation of wall motion and dynamic geometry of the inferior vena cava using intravascular ultrasound: implications for future device design

PURPOSE

To use intravascular ultrasound (IVUS) to define the wall motion of the inferior vena cava (IVC) during normal respiratory cycles and evaluate its dynamic geometry during Valsalva maneuvers.

METHODS

Between September 2005 and October 2006, 10 patients who were having IVC filters placed underwent IVUS prior to filter implantation. With the anesthetized patient in a supine position, a 10-second IVUS recording of IVC motion below the renal veins was made during both normal respiratory cycles and Valsalva maneuvers. Diameters (n = 100 measurements) were measured from the epicenter of the lumen in both a long and short axis. Changes in diameters were evaluated using a Student t test for paired data; variations in IVC wall motion circumference of the vessel were compared using an analysis of variance for repeated measurements. Intra-/interobserver variability was analyzed with Bland-Altman plots.

RESULTS

The mean IVC diameter was 14.3+/-4.1 mm in the short axis and 23.2+/-3.5 mm in the long axis. There was significant variation in infrarenal IVC wall movement about the circumference, with 1.4+/-0.2 mm (range 0.6-1.8) displacement in the short axis and 1.0+/-0.2 mm (range 0.2-1.4) displacement in the long axis during the normal respiratory cycle (p = 0.04). In the short axis, the IVC diameter significantly increased with Valsalva from 14.3+/-4.1 to 19.6+/-1.2 mm (p = 0.0001); in the long axis, the diameter increased from 23.2+/-3.5 to 24+/-1.2 mm (p = 0.02). With Valsalva, there was a significantly greater change in the short axis (30.9%+/-4.8%) compared to the long axis (3.4%+/-2.2%; p = 0.0001). There were no significant differences in the interobserver and intraobserver measurements.

CONCLUSION

In the supine position, the IVC is elliptical and deforms anisotropically during the normal respiratory cycle. The greatest displacement (36%) is in the short axis during a Valsalva maneuver. These profound changes within the venous system will require intracaval devices to have active fixation to prevent migration. Devices should be designed to accommodate these changes to prevent fatigue failure.

Right ventricular gunshot wound with retrograde embolization

There have been numerous reports concerning gunshot wounds to the heart over the years. Many reports discuss bullets that have embolized and have migrated antegrade. However, there has never been a case reported on the retrograde embolization of a bullet from the right ventricle into the inferior vena cava. This case report involves a 15-year-old boy who was accidentally shot in the chest. The bullet entered at the mid-manubrial area, and penetrated the anterior wall of the right ventricle causing a tamponade. A chest x-ray film confirmed a bullet in the right ventricle. The patient was stabilized in the emergency department, and taken to the operating room for an emergent mediastinal exploration with evacuation of pericardial tamponade and repair of the right ventricle. After the tamponade was relieved, a Trans-Esophageal Echocardiogram was performed to locate the bullet, which could not be found in the ventricle. Chest and abdominal radiography were performed to locate the bullet. X-ray films confirmed that the bullet had migrated retrograde down into the inferior vena cava. Interventional radiology and vascular surgery departments were consulted. The consensus was to snag the bullet under fluoroscopic guidance, and pull it down into the right femoral vein for easy retrieval. The chest was closed and the patient was transferred from the surgery department to the interventional radiology department. Under fluoroscopy, the bullet was pulled down into the right common femoral vein. The bullet was extracted per venorrhaphy. The patient was extubated within hours after surgery and discharged home within 72 hours of surgery.