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Pulmonary Vascular Disease |

IVC Filter Placement Complicated by Penetration of the Renal Veins and Migration of a Fracture Strut to the Anterior Pericardium

Punita Kaveti, MBBS; Avantika Chenna, MD; Ujwala Gunnal, MD; Saurabh Khurana, MD; Marshaleen Henriques-Forsythe, MD
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Internal Medicine, Morehouse School of Medicine, Marietta, GA


Chest. 2014;146(4_MeetingAbstracts):894A. doi:10.1378/chest.1993988
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Abstract

SESSION TITLE: Pulmonary Vascular Disease Student/Resident Case Report Posters II

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Inferior vena cava filter (IVCF) placement is recommended to prevent pulmonary embolism (PE) in patients with acute proximal deep vein thrombosis (DVT) who have contraindication to anticoagulation (1). The advent of retrievable filters has significantly increased the use of IVCFs over past three decade. IVCFs have been associated with complications during placement, indwelling and retrieval. We discuss a case of IVC filter migration and penetration in a 24 year old woman with antithrombotic syndrome.

CASE PRESENTATION: Our case is a 24-year-old woman with Antithrombin III deficiency, multiple episodes of PE despite coumadin therapy and an IVCF in-situ. She presented with pain in the chest, epigastrium and right upper quadrant, with two weeks of nausea, vomiting and melana. She was hemodynamically stable with mild epigastric tenderness. Chest Xray taken 2 years prior showed migrated IVC filter at L1-2. Repeat imaging studies on presentation demonstrated a fractured and displaced IVCF tine within the anterior pericardium. The IVCF tines penetrated the IVC wall, extended into the left and right renal veins and abutted the serosal surface of the duodenum. General and Cardiothoracic surgery were consulted. Endoscopy ruled out duodenal erosion or duodenocaval fistula. She underwent percutaneous trans-jugular removal of the fractured IVCF, which was missing one strut completely. A new IVC filter was placed without complications. Follow up with CT Surgery was scheduled to discuss plans for elective removal of the IVCF strut in her pericardium, however she was lost to follow up.

DISCUSSION: IVCFs are helpful in preventing PE but are associated with complications (2) (Table-1). IVCFs increase the risk of recurrent DVT yet, show no mortality benefit 2 years after placement. The complication rate of indwelling IVCFs increases with duration in-situ (3). IVCF placement was indicated in our patient, but she did not get regular radiologic surveillance and developed symptomatic complications three years after filter placement. She underwent major surgery for IVCF reconstruction but still has a filter strut in her anterior pericardium which is a threat for cardiac tamponade.

CONCLUSIONS: We should carefully evaluate the need for IVCF and consider retrieval whenever appropriate. Although IVCF complications are infrequent, patient safety measures warrant follow up and appropriate radiological surveillance to monitor for IVC migration and complications.

Reference #1: ACCP Guidelines, 9th Ed

Reference #2: Janjua M1, Younas F, Moinuddin I, Badshah A, Basoor A, Yaekoub AY, Matta F, Patel KC, Liang J, Hull RD, Stein PD: Outcomes with retrievable inferior vena cava filters. J Invasive Cardiol. 2010 May;22(5):235-9.

Reference #3: Lee JK, So YH, Choi YH, Park SS, Heo EY, Kim DK, Chung HS. Clinical course and predictive factors for complication of inferior vena cava filters. Thromb Res. 2014 Jan 9. pii: S0049-3848(14)00013-9. doi: 10.1016/j.thromres.2014.01.004.

DISCLOSURE: The following authors have nothing to disclose: Punita Kaveti, Avantika Chenna, Ujwala Gunnal, Saurabh Khurana, Marshaleen Henriques-Forsythe

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