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

An Internal Hernia With Small Bowel Volvulus From an Inferior Vena Cava Filter Wire Strut: A Rare Cause of Acute Abdomen

The use of inferior vena cava (IVC) filters has been increasingly prevalent. Although they are relatively safe with clear indications, they are not without complications. Late-onset complications include IVC filter migration, IVC wire fracture, wire strut penetration, and perforation of organs in its vicinity. In this report, we present the case of a patient with small bowel volvulus secondary to an IVC wire strut migration, causing tethering of the mesentery and vascular compromise to the small bowel.

Inferior Vena Cava Filter Migration to the Left Internal Iliac Vein

Inferior vena cava filter placement is an important method for managing deep venous thrombosis of the lower extremities and has a high risk of pulmonary embolism. Filter migration is rare but potentially fatal. We describe a case of migration of an inferior vena cava filter to the left internal iliac vein. The filter perforated the internal iliac vein, resulting in hemorrhagic shock, and was removed with open surgery. To our knowledge, this is the first reported case of migration of an inferior vena cava filter to an internal iliac vein.

Heart block and cardiac embolization of fractured inferior vena cava filter

Objective:

A 66-year-old man underwent a placement of an inferior vena cava filter before a gastric surgery 9 years prior, presented to the emergency room with a complete atrioventricular block. Chest x-ray and transthoracic echocardiogram showed struts migrating to right ventricle with tricuspid regurgitation. Cardiothoracic surgery was consulted and declined an open surgical intervention due to the location of the embolized fragments and the patient’s overall condition. It was also felt that the fragments had migrated chronically and were adhered to the cardiac structures.

Methods:

The patient underwent a dual-chamber permanent pacemaker implantation. Post-implant fluoroscopy showed no displacement of the inferior vena cava filter struts due to the pacemaker leads indicating that the filter fracture had likely been a chronic process.

Results:

This case highlights a rare combination of complications related to inferior vena cava filter fractures and the importance of assessing for such fractures in chronic placements. Inferior vena cava filter placement for a duration greater than 1 month can be associated with filter fractures and strut migration which may lead to, although rare, serious or fatal complications such as complete atrioventricular conduction system disruption and valvular damage including significant tricuspid regurgitation.

Conclusions:

Assessing for inferior vena cava filter fractures in chronic filter placement is important to avoid such complications. When possible, retrieval of the filter should be considered in all patients outside the acute setting in order to avoid filter-related complications. Filter retrieval rates remain low even when a retrievable filter is in place and the patient no longer has a contraindication to anticoagulation.

Retrievable IVC filters - Friend or foe

Venous thromboembolism is a common condition with widely varied outcomes. Pulmonary embolism is associated with a case-fatality rate of up to 8%, increasing up to 18-fold in massive PE. Pharmacological treatment of VTE with anticoagulant medication (AC) is the first line therapy of choice. Retrievable inferior vena cava filters (IVCF) are indicated as a short-term replacement for AC in certain circumstances. Most of the evidence concerning IVCF pertains to permanent filters and older filter models. Limited evidence for retrievable IVCF results in poor consensus regarding indications, follow-up and retrieval. Complications increase with dwell-time and retrieval success rates decline. Professional bodies advocate strict guideline adherence and robust strategies for filter monitoring to maximise retrieval rate.

Fractured inferior vena cava filter strut presenting with ST-segment elevation and cardiac tamponade

The fracture of an inferior vena cava filter strut and its migration to the heart is a rare sequela of implanted inferior vena cava filters. Perforation through the right ventricle into the pericardium with resultant cardiopulmonary compromise is even less frequent. We report the case of a 53-year-old man who presented with chest pain and hypotension consequent to cardiac tamponade. A fractured inferior vena cava filter strut had migrated and perforated his right ventricle. The fractured strut was successfully removed by means of cardiac surgery. Inferior vena cava filters should be placed when necessary to minimize the risk of pulmonary embolism, and regular radiologic monitoring should be performed; however, the eventual extraction of retrievable filters should be considered. In addition to discussing the patient's case, we briefly review the relevant medical literature.

Tempofilter II implantation in patients with lower extremity fractures and proximal deep vein thrombosis

PURPOSE

We aimed to examine the efficacy and safety of Tempofilter II (B. Braun, Melsungen, Germany) implantation to prevent pulmonary embolism in patients with lower-extremity fractures and proximal deep vein thrombosis (DVT).

MATERIALS AND METHODS

The records of patients with lower limb fractures and proximal DVT who were implanted with Tempofilter II devices from May 2004 to August 2009 were reviewed. Data collected included success rate, occurrence of pulmonary embolism, retrieval rate, and complications.

RESULTS

A total of 176 eligible patients, including 129 males (73.3%) and 47 females (26.7%) with a median age of 42.0 years (interquartile range [IQR], 34.0-52.0 years) were included in the study. Filters were successfully implanted in 174 patients (98.9%). One patient experienced a pulmonary embolism after implantation and died. Filters were removed without complications in all other patients. Median filter implantation time was 27 days (IQR, 25.0-29.0 days). Visible organized thrombi were present on the surface of 144 (82.8%) of filters after removal, and the diameter of most thrombi (n=124) ranged from 0.5 to 1.0 cm. Filters migrated <2 cm in 104 patients (59.8%) and ≥ 2 cm in five patients (2.9%). In these five cases, three filters migrated into the right atrium and two migrated to the orifice of the renal veins.

CONCLUSION

Tempofilter II is safe and may be useful in cases of lower extremity fracture with proximal DVT for the prevention of pulmonary embolism. The filter is easily placed and retrieved, and associated with minimal complications.

Rates and predictors of plans for inferior vena cava filter retrieval in hospitalized patients

BACKGROUND

Use of inferior vena cava (IVC) filters has been increasing over time. However, because of the increased risk of deep vein thrombosis with permanent filters, placement of retrievable filters has been recommended. Little is known about the factors associated with planned retrieval of IVC filters.

OBJECTIVE

To describe rates and predictors of plans to retrieve IVC filters in hospitalized patients.

DESIGN

We identified all IVC filter placements from 2001-2006 at an academic medical center and reviewed medical charts to obtain data about patient characteristics, filter retrieval plans, and retrieval success rates. Multivariable logistic regression was used to identify independent predictors of planned filter retrieval in patients with retrievable filters.

RESULTS

Out of 240 patients who underwent placement of retrievable IVC filters, only 73 (30.4%) had documented plans for filter retrieval. Factors associated with lower rates of planned filter retrieval included a history of cancer [adjusted odds ratio (OR) and 95% confidence interval 0.2 (0.1-0.5)] and not being discharged on anticoagulants [OR 0.1 (0.1-0.3)]. In addition, 36 (21.6%) of patients without retrieval plans had no contraindications to retrieval. Of the 62 patients who underwent attempted filter retrieval, 25.8% of filters could not be successfully removed.

CONCLUSIONS

Only 30.4% of patients who underwent placement of a retrievable IVC filter had documented plans for filter removal. Although most patients had justifiable reasons for filter retention, 21.6% of patients had no clear contraindications to filter removal. Efforts to improve rates of filter retrieval in appropriate patients may help reduce the long-term complications of IVC filters.

Sudden cardiac death caused by migration of a TrapEase inferior vena cava filter: case report and review of the literature

CASE

A 43-year-old female presented with sudden onset of palpitations, chest pain, and shortness of breath associated with hypoxemia. A helical computed tomography (CT) scan of the chest revealed a large saddle pulmonary embolism. Intravenous tPA relieved the shortness of breath and improved the hypoxemia. Inferior vena cava (IVC) filter (TrapEase, Cordis Corp., Miami, FL, USA) was placed. On day 6 of her hospitalization, she went into cardiopulmonary arrest while walking back from the rest room. The patient died despite a prolonged attempt at cardiopulmonary resuscitation. At that time, ventricular tachycardia and then ventricular fibrillation were recorded. Autopsy of the heart showed the IVC filter entrapped within the tricuspid valve.

DISCUSSION

The incidence of IVC filter migration ranges from 0.3 to 6% with rare migration to the heart or lung (0.1-1.25%). Sudden cardiac death from migration of IVC filter is extremely rare. We report the first case of sudden cardiac death caused by migration of the TrapEase filter to the heart. There are two reports in the literature of death from migrating Greenfield and Antheor filters.

CONCLUSION

An IVC filter migration to the heart, although rare, can cause serious arrhythmia and sudden cardiac death.

Technical Error During Deployment Leads to Vena Cava Filter Migration and Massive Pulmonary Embolism

The Günther Tulip vena cava filter is a safe, effective, well-established device for pulmonary embolism prophylaxis. We report a patient in whom there was migration of the filter to the right atrium, 2 weeks after insertion, caused by a technical error during deployment. An attempt to retrieve the filter percutaneously failed, necessitating removal at open-heart surgery. The potential causes of migration are described and the lessons learned from this unusual case are outlined.

Intravascular ultrasound-guided bedside placement of inferior vena cava filters

Pulmonary emboli in a critically ill patient population is an occurrence that may be reduced with appropriate utilization of inferior vena cava (IVC) filters. Complications both during transfer or transport of critically ill patients who are dependent upon multiple intravenous drips, ventilators and intensive monitoring may be reduced with bedside placement of inferior vena cava filters. Over the last decade, investigators have been developing techniques for bedside IVC filter placement based on intravascular ultrasound techniques. We discuss and detail a single venous access technique of IVC filter placement using intravascular ultrasound.

Safety and efficacy of vena cava filters in trauma patients

Pulmonary embolism (PE), due to its sudden onset, notoriously difficult diagnosis, unpredictable nature and often fatal outcome, remains one of the most feared complications in surgical practice. Trauma patients with multisystem injuries, extremity or pelvic fractures and head or spinal cord injuries often pose a significant dilemma for the surgeon because of the inability to use conventional measures such as anticoagulation therapy and compression devices. On the other hand, the incidence of deep vein thrombosis (DVT) is high among trauma patients and the attendant risk of PE is an important cause of morbidity and mortality. Inferior vena cava (IVC) interruption by placement of diverse filtering devices has evolved over the past three decades. With the use of these devices, the risk of PE has been reduced dramatically. However, variable rates of complications are reported from their use. In this study, we review all the available data on IVC filter placement in trauma patients and we discuss the potential complications of IVC filters in order to understand better the risk/benefit ratio of their use.

Duodenal perforation with an inferior vena cava filter: an unusual cause of abdominal pain

The insertion of inferior vena cava (IVC) filters results in device migration at rates that exceed 50% in some studies, although the clinical significance of migration remains in question. These filters can also erode or penetrate the IVC wall, injuring adjacent retroperitoneal and abdominal structures. The risk of erosion or perforation is estimated to be as much as 25%, although clinical symptoms are observed far less frequently in patients with these complications. We describe the presentation, evaluation, and treatment of a patient with an IVC strut protruding into the duodenum. This case report discusses complications, presenting symptoms, and treatment of patients with IVC filters complications.

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.

Inpatient multitrauma rehabilitation in a U.S. military hospital

Rehabilitation serves a vital role in the care of multiply injured patients in the military, from diagnosis of occult injuries to gaining functional independence. Optimal rehabilitative care of the war casualties is predicated on diligent and rigorous training and evaluation of similar care during peacetime.

Vena caval filters: a comprehensive review

Hematologists are often asked to treat patients with venous thromboembolic disease. Although anticoagulation remains the primary therapy for venous thromboembolism, vena caval filters are an important alternative when anticoagulants are contraindicated. To assess the evidence supporting the utility of these devices, a comprehensive review of the English language literature was performed. Except for one randomized trial, the vena caval filter literature consists of case series or consecutive case series. The mean duration of follow-up for each of the 5 filter types varies from 6 to 18 months. All are about equally effective in the prevention of pulmonary embolism (2.6%-3.8%). Deep venous thrombosis (6%-32%) and inferior vena cava thrombosis (3.6%-11.2%) after filter placement vary widely among different filter types primarily because of differences in outcome assessment. Thrombosis at the insertion site is a common complication of filter placement (23%-36%). In view of the absence of randomized comparisons, no filter can be designated as superior in safety or efficacy. Vena caval filters represent a potentially important but poorly evaluated therapeutic modality in the prevention of pulmonary emboli. Randomized trials are necessary to establish the appropriate place for vena caval filters in the treatment of venous thromboembolic disease.

Vena caval filters: a comprehensive review

Hematologists are often asked to treat patients with venous thromboembolic disease. Although anticoagulation remains the primary therapy for venous thromboembolism, vena caval filters are an important alternative when anticoagulants are contraindicated. To assess the evidence supporting the utility of these devices, a comprehensive review of the English language literature was performed. Except for one randomized trial, the vena caval filter literature consists of case series or consecutive case series. The mean duration of follow-up for each of the 5 filter types varies from 6 to 18 months. All are about equally effective in the prevention of pulmonary embolism (2.6%-3.8%). Deep venous thrombosis (6%-32%) and inferior vena cava thrombosis (3.6%-11.2%) after filter placement vary widely among different filter types primarily because of differences in outcome assessment. Thrombosis at the insertion site is a common complication of filter placement (23%-36%). In view of the absence of randomized comparisons, no filter can be designated as superior in safety or efficacy. Vena caval filters represent a potentially important but poorly evaluated therapeutic modality in the prevention of pulmonary emboli. Randomized trials are necessary to establish the appropriate place for vena caval filters in the treatment of venous thromboembolic disease.

Accidental intraaortic placement of a Greenfield filter

A Greenfield vena cava filter was accidentally placed in the mid-abdominal aorta. It was manipulated to the aortic bifurcation, where it has been observed for >48 months. This case is the first example of arterial placement of a vena cava filter. This report describes the probable mechanisms for this aberrant placement, methods for prevention of this complication, and options for management of this problem.

Guidewire entrapment during Greenfield filter deployment

Prevention of pulmonary embolism by inferior vena cava filter has long been established. The Greenfield filter continues to be modified to improve deployment methods. A new filter design allows insertion through tortuous anatomy. We present, by way of a case report, a unique complication related to this design. The filter design, deployment technique, and the rationale behind them are discussed. Suggestions for avoiding this problem are provided.

Vena cava filter ensnarement and delayed migration: an unusual series of cases

PURPOSE

To review delayed and guidewire-induced morbidity associated with vena cava filters.

METHODS

The records from the Johns Hopkins Hospital, a tertiary care referral center, of all patients who had vena cava filter complications from August 1993 through July 1996 were retrospectively reviewed.

RESULTS

Five patients had filter migration or ensnarement with a guidewire. One patient had delayed extrusion of a filter strut into the duodenum. Four patients had filters ensnared by guidewires, including one during initial filter placement and one several years after placement.

CONCLUSIONS

Delayed complications of vena cava filters should be considered whenever unusual patient signs or symptoms cannot be easily explained, even in the absence of a history of filter placement. To prevent guidewire ensnarement of filters, simple techniques should modify endovascular procedures when vena cava filters are present.