Migration of a Greenfield filter to the pulmonary artery: A case report

Migration of an Inferior Vena Cava (IVC) Filter Into the Intrahepatic IVC: A Case Report

The use of Inferior Vena Cava (IVC) filters is increasing for patients who cannot otherwise receive anticoagulation for a deep vein thrombosis (DVT) or pulmonary embolism (PE). In this case, a 60-year-old man presenting with abdominal pain was found to have migration of his IVC filter into his intrahepatic IVC. Interventional radiology (IR) and vascular surgery were consulted as the migrated IVC filter was felt to be the likely cause of the patient’s pain. Consideration was given to transferring the patient to a liver transplant center to retrieve the migrated filter. When patients with a history of IVC filter placement present to the emergency department, a high index of suspicion for IVC filter complication should be maintained and there should be a low threshold for ordering CT imaging. If a severe IVC filter complication is discovered, patients may ultimately require transfer to a center with hepatic surgery capability for definitive treatment given the complex vasculature involved.

Multicenter investigation of the incidence of inferior vena cava filter fracture

PURPOSE

Inferior vena cava filter fracture (FF) may cause life-threatening complications, including cardiac tamponade, although the actual prevalence remains unclear. Therefore, we investigated the incidence of FF.

MATERIALS AND METHODS

Data on fracture incidence with filter brands, filter positions [suprarenal (SR) vs. infrarenal (IR)], and follow-up durations were collected from the databases of eight hospitals.

RESULTS

Of 532 patients, Günther Tulip (GT), Trap/OptEase (TE/OE), ALN and VenaTech (VT) were implanted in 345, 147, 38 and 2 patients, respectively. Of these, filter retrieval was attempted in 110 (21.7%) patients and was successful in 106 (96.4%). Of the remaining 426 patients, FFs were observed in two (0.7%) of 270 GT filters and 19 (14.1%) of 135 TE/OE filters. Fragment embolization occurred in one patient with a GT filter (50.0%) and three with a TE/OE filter (15.8%) with a total follow-up interval of 718.0 ± 1019.4 days. FF occurred more frequently in TE/OE than in GT filters (p < 0.001). Kaplan-Meier estimates showed significantly higher fracture-free rates for GT than TE/OE (p < 0.001) and IR-TE/OE than SR-TE/OE (p < 0.05).

CONCLUSIONS

TE/OE filters are not suitable for permanent implantation due to the relatively early and high fracture rates.

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.

Case report of a mysterious myocardial mass: an aetiological conundrum

Introduction

Atypical chest pain is frequently an aetiological conundrum, and missing a diagnosis of underlying cardiac disease can have detrimental consequences. The investigation of this may rule out cardiac disease but often provides no clear answers to the underlying pathology.

Case presentation

An 80-year-old man with a background of bilateral inguinal hernia repairs but no cardiac disease presented to his general practitioner with intermittent chest pain of approximately 15 min duration, felt inside his chest under his right nipple. His episodes of chest discomfort had increased in frequency, occurring both at rest and upon exertion. He was seen by the cardiology team at his local hospital and reassured following normal coronary angiography and outpatient echocardiography. The pain persisted, so cardiac magnetic resonance imaging (MRI) was arranged to exclude the underlying myocardial disease. This demonstrated a mass within the right ventricular free wall, which MRI was unable to characterize. Follow-up cardiac computed tomography showed this to be a metallic object within the right ventricular wall, but despite thorough examination of his medical and social history, there remains no obvious explanation to its aetiology other than potentially due to clip migration from his hernia repair.

Discussion

Metallic foreign bodies within the myocardium are described in case reports but almost entirely in the setting of intentional self-injury. There is no previous case evidence of migration of distal surgical clips to the heart, but there appears to be no other clear aetiology for this gentleman’s pathology, thus representing a novel description of iatrogenic injury.

Thromboprophylaxis in patients with pelvic and acetabular fractures: A short review and recommendations

The management of thromboprophylaxis in patients with pelvic and acetabular fractures remains a highly controversial topic within the trauma community. Despite anticoagulation, venous thromboembolism (VTE) remains the most common cause of surgical morbidity and mortality in this high-risk patient group. Although various thromboprophylactic regimes are employed, evidence relating to the most effective method remains unclear. Controversies surrounding screening, the use of prophylactic inferior vena cava filters (IVCF) and chemothromboprophylaxis in polytraumatised patients, particularly those with pelvic and acetabular fractures, form the basis of considerable debate. With the absence of a well-designed clinical trial and the presence of ongoing controversies within the literature, this review will explore current treatment options available to trauma surgeons and highlight differing scientific opinions, providing an update on the role of screening and current available preventative measures. We cover existing as well as recent advances in chemical thromboprophylactic agents and discuss external mechanical compression devices, the usefulness of serial duplex ultrasonography and the role of extended chemothromboprophylaxis on discharge. The evidence behind prophylactic IVCF is also considered, along with reported complication profiles. We conclude with a proposed protocol for use in major trauma centres, which can form the basis of local policy for the prevention of VTE in trauma patients with pelvic and acetabular fractures.

Experience with the Recovery Filter as a Retrievable Inferior Vena Cava Filter

PURPOSE

This study evaluates clinical experience with the Recovery filter as a retrievable inferior vena cava (IVC) filter.

MATERIALS AND METHODS

One hundred seven Recovery filters were placed in 106 patients with an initial clinical indication for temporary caval filtration. Patients were followed up to assess filter efficacy, complications, eventual need for filter removal, time to retrieval, and ability to remove the filter.

RESULTS

The patient cohort consisted of 62 men and 44 women with a mean age of 48 years (range, 18-90 y). Mean implantation time was 165 days. Indications for filter placement in patients with deep vein thrombosis (DVT) and/or pulmonary embolism (PE) included contraindication to anticoagulation (n = 33), complications of anticoagulation (n = 8), poor cardiopulmonary reserve (n = 6), large clot burden (n = 3), and PE while receiving anticoagulation (n = 1). Indications for filter placement in patients without proven PE or DVT included immobility after trauma (n = 35); recent intracranial hemorrhage, neurosurgery, or brain tumor (n = 18); and other surgical or invasive procedure (n = 3). Three patients (2.8%) had symptomatic PE after placement of the Recovery filter. No caval thromboses were detected. No symptomatic filter migrations occurred. Recovery filter removal was attempted in 15 of 106 patients (14%) at a mean of 150 days after placement. The Recovery filter was successfully retrieved in 14 of 15 patients (93%); one removal was unsuccessful at 210 days after placement. Ninety-two filters (87%) currently remain in place.

CONCLUSIONS

Although all the filters were placed with the intention of being removed, a large percentage of filters were not retrieved. The Recovery filter was safe and effective in preventing PE when used as a retrievable IVC filter.

Inferior Vena Caval Filters: Key Considerations

Surgical interruption of the inferior vena cava (IVC) as a means to prevent pulmonary embolism and its consequences has been entertained since the end of the 19th century. Initial methods were crude, however, but their deficiencies led to the development of newer techniques. Despite increasing indications and use of permanent IVC filters there remains controversy regarding their efficacy and complications. The purpose of this article is to review the pertinent literature and, it is hoped, aid in the development of a rational approach to the use of IVC filters. The evolving data regarding the retrievable filters are also discussed.

Percutaneous Retrieval of a Greenfield Filter after Migration to the Left Pulmonary Artery

A Titanium Greenfield filter migrated to the left pulmonary artery during its deployment in a 67-year-old woman. The filter was successfully removed percutaneously without complications with use of an Amplatz Goose Neck snare and the 12-F sheath from the Greenfield filter kit.

Diagnosis of myocardial perforation by a Greenfield filter made by transesophageal echocardiography

Greenfield filters have been successfully used to prevent pulmonary embolism in selected patients. However, various complications have been described. A patient is presented in whom a Greenfield filter migrated to the right atrium, and subsequently perforated the right atrial wall. The diagnosis was made by transesophageal echocardiography and the filter removed surgically. This case emphasizes the role of transesophageal echocardiography in the management of migrated Greenfield filters.

Transvenous retrieval of a Greenfield filter lodged in the tricuspid valve

A 77-year-old man had an inferior vena cava Greenfield filter placed for bilateral deep venous thrombosis acquired during a complicated hospitalization for a hip fracture. The filter migrated and lodged at the level of the tricuspid valve. We describe a transvenous retrieval approach which is safer and performed under more controlled technique than previously reported.

Long-term results of vena cava filters: experiences with the LGM and the Titanium Greenfield devices

PURPOSE

Vena cava filter (VCF) application is the method of choice to prevent recurrent pulmonary embolism in patients with deep venous thrombosis. Because of the reported complications after VCF placement we summarize our long-term follow-up results with the LGM and Titanium Greenfield (TG) devices.

METHODS

Eighty-seven LGM VCF and 17 TG VCF were placed in 104 patients (average age 64 years). The follow-up examinations were performed by color-coded duplex sonography, plain radiographs, cavography, and computed tomography (CT). The maximum observation time was 81 months.

RESULTS

Filter migration occurred in 11% (8/76) of the LGM VCF and 15% (2/13) of the TG VCF. Vena cava thrombosis was seen in 17% (13/76) of the patients with an LGM VCF and in 31% (4/13) of those with a TG VCF. The patency rate was 95% (72/76) for the LGM VCF and 92% (12/13) for the TG VCF. Pulmonary embolism was noted in 3 patients after LGM VCF insertion and in no patient after TG VCF insertion.

CONCLUSION

A VCF should only be inserted in a patient after pulmonary embolism and when there is strict proof of the indication.

Tricuspid insufficiency after intracardiac migration of a Greenfield filter: case report and review of the literature

We report the only known case of intracardiac vena cava filter migration resulting in valvular dysfunction. Echocardiographic evaluation documented the filter stenting open the tricuspid valve, with wide-open regurgitation. This case, as well as 22 cases of filter migration reported in the English literature, are used as a background to review prevention and treatment strategies.

Vena cava filter disruption and central migration due to accidental guidewire manipulation: a case report

Vena cava filters are now widely used as a safe and effective means of reducing the risk of pulmonary embolus in patients hospitalized with acute stroke or trauma. We report a case of traumatic disruption of vena cava filter resulting from guidewire manipulation with migration of the main structure to the heart after successful initial placement of the filter.

Proximal migration of vena caval filters: report of two cases with operative retrieval

Operative retrieval of two proximally migrated vena caval filters was performed in two patients, ages 42 and 45 years, respectively. In the first patient the filter was encrusted in the right ventricle, and in the second one the filter was found in the pulmonary artery. Both filters were retrieved under cardiopulmonary bypass via an incision in the right atrium and the pulmonary artery, respectively. These two observations underscore the risk of increased unwarranted indications and consequent higher complication rates of vena caval filters.

Prospective anatomic study of the inferior vena cava and renal veins: comparison of selective renal venography with cavography and relevance in filter placement

PURPOSE

To compare the sensitivity of selective renal venography with that of cavography in the detection of variant anatomic structures of the renal vein that may affect the placement of inferior vena caval (IVC) filters and to define IVC dimensions.

PATIENTS AND METHODS

Flush cavography, selective bilateral renal venography, and bilateral iliac venography were performed in 108 patients referred for IVC filter placement or vena cavography. Infrarenal IVC length and width were determined with a sizing catheter during cavography. Anomalies were considered significant if they altered placement or selection of the vena cava filter or if they represented a potential collateral pathway for clot to bypass a filter.

RESULTS

Variant anatomic structures in the renal vein were found in 11% of patients with cavography and in 37% of patients with selective renal vein injection. Detected anomalies included circumaortic veins (n = 11), multiple veins (n = 25), retroaortic veins (n = 2), and a partially duplicated IVC (n = 1). Selective venography depicted anomalies not suspected at standard cavography in 28 cases (26%); in 20 cases (18% of population) they were significant. The average infrarenal width was 20 mm on the anteroposterior view and was 17 mm on the lateral projection.

CONCLUSION

IVC anomalies are common, and selective renal venography can depict significant anomalies in renal vein anatomic structures not shown at standard cavography.

Evolution of a new device for the prevention of pulmonary embolism

The embolus trap (ET) is a new device that interrupts the inferior vena cava (IVC) for the prevention of pulmonary embolism. It has a central column from which six wires extend in two tiers. The adjacent wires are formed into loops with hooks at the distal ends that grip the vein wall. Each tier contains three wire loops, and the loops are staggered circumferentially between the tiers. The ET was implanted into the IVC in 26 dogs via a femoral or jugular venotomy. IVC patency was evaluated by venacavagrams. Autologous clots were embolized via the femoral vein to test the efficacy of the ET. The animals were followed for 1 to 4 months prior to postmortem examination. The ET remained patent in all animals and consistently trapped the thromboemboli while preserving blood flow. Lysis of the trapped emboli was observed in 4 to 6 weeks. There was no evidence of malpositioning, penetration through the vein wall, or migration of the ET.

Management and prevention of thromboembolic events in patients with cancer-related hypercoagulable states: a risky business

OBJECTIVE

To determine the optimal strategy for managing and preventing thromboembolic events in malignancy-associated hypercoagulable states.

DESIGN

A Markov-based decision and cost-effectiveness analysis was performed. The authors explicitly considered consequences of embolic and bleeding events, filter complications, and cancer-related excess mortality. Data were drawn from the current literature. The main outcome measure for each strategy was the quality-adjusted life expectancy and the total average variable costs.

SUBJECTS

Patients with advanced malignancies prone to develop thromboembolic events, patients with acute proximal deep venous thrombosis (DVT), and patients who have survived a first episode of pulmonary embolism (PE).

INTERVENTIONS

The authors considered three different interventions: 1) OBSERVATION, in which neither anticoagulant therapy nor filter placement is pursued, 2) ANTICOAGULATION, in which long-term anticoagulant therapy is started immediately, and 3) VENA CAVAL FILTER.

MAIN RESULTS

Vena caval filter was the preferred strategy for every malignancy studied, yielding an 11% gain in quality-adjusted life expectancy, compared with observation, for patients with acute DVT, and an 18% gain for patients having survived a PE. Anticoagulant therapy yielded gains of 9% and 16%, respectively. Compared with anticoagulant therapy, filter was less costly due to the avoidance of additional expenses incurred by bleeding events. Prophylactic therapy was the least effective of the three strategies examined.

CONCLUSIONS

Vena caval filter placement and long-term anticoagulation therapy yield similar outcomes in the setting of cancer-related hypercoagulable states. However, filter insertion is less expensive than anticoagulation. Given the short life expectancy and morbidity of patients with end-stage malignancy, patient preferences for health states must be considered in the decision-making process. If active treatment is pursued, vena caval filter should be used as a primary therapy. Prophylactic therapy is not warranted in any circumstance.

Transvenous retrieval of misplaced stainless steel Greenfield filters

Transvenous retrieval was attempted in five patients following surgical misplacement of stainless steel Greenfield filters. Four filters were located within the right atrium, and one was in the left hepatic vein. All retrievals were attempted within 5 days of placement. Retrieval was successful for the four filters in the right atrium and failed for the filter in the left hepatic vein. One air embolism occurred; this was the only filter- or retrieval-related complication. Transvenous retrieval is a safe and effective minimally invasive method of removing misplaced filters.

LGM vena cava filter: objective evaluation of early results

One hundred one LG-Medical (LGM) vena cava filters were placed in 97 patients at four institutions. Placement was a complete technical success in 90% (91 of 101). In 6% of attempts, LGM filter insertion was complicated by incomplete opening of the filter. Pulmonary embolism after filter placement was not definitely demonstrated in any patient. The probability of inferior vena cava patency was 92% at 6 months after filter insertion. Thrombosis at the insertion site was seen in eight of 35 patients (23%) evaluated with duplex ultrasound or venography. Thrombus was observed in 37% of filters at follow-up examination, with cephalic extension of thrombus above the filter in 20% of all patients examined. Filter migration (greater than 1 cm) was seen in 12%; significant angulation was observed in only one patient (2%). In vitro experimentation demonstrated that incomplete opening of the LGM filter during placement can be avoided, in part, by brisk retraction of the insertion cannula. The low-profile introducer system of the LGM filter allows increased alternatives in selecting the site for filter insertion. The low-profile system also makes outpatient filter placement a possibility. No significant difference in the prevalence of thrombosis at the insertion site following LGM filter insertion was noted compared with previous results reported for percutaneous transfemoral placement of the Greenfield filter. The nonopaque sheath does not permit careful localization prior to filter deposition. Modification of the LGM filter to include a radiopaque sheath is suggested.

Surgical treatment of acute deep venous thrombosis

In patients with venous thrombotic disease and in whom anticoagulation or thrombolytic therapy is inappropriate, ineffective, or even contraindicated, insertion of vena caval filters or venous thrombectomy must be considered. The primary indication for the placement of vena caval filters is in patients who have developed a pulmonary embolus and in whom anticoagulation is either contraindicated or in whom anticoagulation must be discontinued because of the development of bleeding complications. At the present time, either the Greenfield filter placed through a jugular, femoral, or axillary venotomy or the bird's nest filter are appropriate and appear to be the most effective and least fraught with complications. The use of venous thrombectomy has waxed and waned over the last several decades. At the present time, the procedure is advocated mainly for lower limb venous thrombosis which is extensive enough to threaten limb viability. On occasion, it may be appropriate to extend the indications for venous thrombectomy to include femoral thrombosis of less than 10 days duration or iliac thrombosis of less than 3 weeks duration with floating thrombi at the level. Technical modifications which improve the patency of the obliterated veins which are predisposed to rethrombosis include the creation of a temporary arteriovenous fistula and meticulous care in removing the entire clot. The patient should be treated with anticoagulants postoperatively to prevent a recurrence of the problem. The main theoretical advantage of venous thrombectomy is a reduced incidence of postthrombotic syndrome. Objective data to support this contention do not exist.

Transvenous Interruption of the Inferior Vena Cava. New Model of Vena Cava Filter. Preliminary Results in 143 Cases

A new device for transvenous interruption of the inferior vena cava is described. Based upon the Greenfield filter, upward- and downward-facing hooks prevent movement of the filter within the vein. Results of the use of the device in 143 patients after 3 months are presented and compared to other filters.