Critical Care: Student/Resident Case Report Poster - Critical Care III |

Pop! A Fatal Case of Inferior Vena Cava Filter Penetration Into the Abdominal Aorta FREE TO VIEW

Kayur Shah, MD; Ivan Wong, MD; Zaureen Kapadia, MD; Ashwad Afzal, MD
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New York Methodist Hospital, Brooklyn, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):427A. doi:10.1016/j.chest.2016.08.440
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care III

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Inferior vena cava (IVC) filters are widely utilized to prevent pulmonary embolism (PE) in patients with deep venous thrombosis (DVT). Where implantation of IVC filters is associated with low morbidity and mortality, delayed complications such as IVC thrombus, device migration and IVC wall perforation can be life-threatening.

CASE PRESENTATION: A 61-year-old woman presented to our hospital with complaints of acute onset low back pain which she decribed as a “pop” associated with bilateral lower extremity weakness and difficulty walking for one day. Her medical history was significant for PE and DVT requiring IVC filtration due to complications from anticoagulation. On physical examination, she had 5/5 strength in all extremities, normal sensation, reflexes, and an unsteady gait. A computed tomography of the head and magnetic resonance imaging of the cervical, thoracic and lumbar spine were normal. On the medical floor, she had a syncopal episode and was found to be cold, diaphoretic, hypotensive and tachycardic. ECG showed sinus tachycardia with hyperacute T waves in all leads and ST segment elevations in leads III and aVF. Treatment for acute myocardial infarction was started. However, she decompensated and went into cardiac arrest. Advanced cardiovascular life support (ACLS) was initiated and alteplase was administered given the concern for acute PE. The family ultimately opted to terminate resuscitative measures and requested an autopsy. The autopsy revealed an IVC filter with one prong penetrating the IVC wall extending into the aortic lumen. Approximately, 300 milliliters of intraperitoneal and intrapelvic clotted blood was found. The pulmonary vessels were patent and the coronary arteries had mild atherosclerosis.

DISCUSSION: Penetration of the filter is needed to secure it into the IVC. However, it is pathologic once a limb protrudes over three millimeters beyond the caval wall. Nearly one-tenth of all penetrations are symptomatic with pain being the most common symptom. Our patient’s presentation with back pain and leg weakness could be explained by spinal cord ischemia. Her ST elevations on ECG is likely the result of coronary spasm as the autopsy did not reveal significant coronary artery disease.

CONCLUSIONS: IVC filter placement is instrumental to prevent potentially life-threatening PE. There is currently no absolute indications for discontinuation of IVC filters unless the filter itself becomes the source of patient morbidity. Consideration of IVC filter retrieval is necessary and depends on whether the risk of clinically significant PE is acceptably low and estimated to be less than the risk of leaving the filter in situ.

Reference #1: Jia Z, et al. Caval Penetration by Inferior Vena Cava Filters. Circulation. 2015;132:944-952

Reference #2: Kaufman JA, et al. Guidelines for the use of retrievable and convertible vena cava filters: Report from the Society of Interventional Radiology Multidisciplinary consensus conference. J Vasc Interv Radiol 2006;17:499-459

DISCLOSURE: The following authors have nothing to disclose: Kayur Shah, Ivan Wong, Zaureen Kapadia, Ashwad Afzal

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