Inferior vena cava filter limb embolization to the right ventricle: a case report

BACKGROUND

Inferior vena cava (IVC) filters are used to prevent pulmonary embolism (PE) in patients at a high risk for venous thromboembolism with a contraindication to anticoagulation. Inferior vena cava filters are associated with rare but significant long-term complications such as filter fracture and embolization.

CASE SUMMARY

We report the case of a 53-year-old female with an IVC filter inserted 8 years back for the management of recurrent bilateral PE resistant to anticoagulation. Imaging revealed an incidental finding of IVC filter limb fracture and migration to the right heart and the hepatic and renal veins. The patient remained asymptomatic with no impairment in cardiac, liver, or renal function. Due to a high operative risk, the broken IVC filter and embolized filter limbs were not retrieved.

DISCUSSION

There is no consensus on the management of intracardiac embolization of IVC filters. Intravascular fragments may be removed by endovascular or surgical approaches, depending on the anatomical location. Following IVC filter insertion, an appropriate follow-up must be put in place to ensure removal and limit clinical sequelae that are otherwise avoidable. A multidisciplinary approach to the management of IVC filter fracture and embolization is recommended.

Classification System for Inferior Vena Cava (IVC) Appearance Following Percutaneous IVC Filter Retrieval

OBJECTIVE

There is no classification system for describing inferior vena cava (IVC) injuries. The objective of this study was to develop a standardized grading system for venographic appearance of the IVC following percutaneous IVC filter retrieval.

METHODS

A classification system for the appearance of the IVC on cavograms following percutaneous IVC filter removal was developed consisting of two grading elements; luminal characteristics and extravasation. Luminal narrowing from 0% up to 50% from any cause is grade 1; narrowing between 50 and 99% is grade 2; occlusion is grade 3; and avulsion is grade 4. Absence of extravasation is grade A, contained extravasation is grade B, and free extravasation is grade C. This system was then applied retrospectively to pre- and post-IVC filter retrieval cavograms performed at a single institution from October 2004 through February 2019.

RESULTS

546 retrieval attempts were identified with 509 (93.2%) filters successfully retrieved. 449 cases (88.2%) had both pre-retrieval and post-retrieval imaging appropriate for application of the proposed classification system. Inter-rater reliability was 0.972 for luminal characteristics, 0.967 for extravasation, and 0.969 overall. Consensus grading demonstrated a distribution of 97.3% grade 1, 1.3% grade 2, 1.3% grade 3, and 0.0% grade 4 for post-retrieval luminal characteristics. For extravasation classification, 96.4% of the cases were classified as grade A, 2.7% grade B, and 0.9% grade C.

CONCLUSION

A classification system was developed for describing IVC appearance after IVC filter retrieval, and retrospectively validated using a single center dataset.

Right Ventricle Embolization of IVC Filter Fragments: An Incidental Finding

This case report describes a 52-year-old male patient, with the incidental finding of inferior vena cava filter (IVCF) fragments impacted into the right ventricle, secondary to IVCF fragmentation and subsequent embolization. While IVCFs are prescribed to prevent pulmonary embolizations when anticoagulation is either contraindicated, or has failed, IVCF embolizations to the heart represent an extremely rare, but potentially life-threatening complication. Of note, at the time of writing, the utility and effectiveness of IVCF are not fully established. Intracardiac embolizations of IVCF typically present with complications such as hypotension, cardiac tamponade, arrhythmias, ventricle perforation, bleeding, cardiac arrest, and death. To our knowledge, this is the first case report of an asymptomatic kidney transplant recipient found to have right ventricle embolizations of IVCF fragments through routine assessment. Additionally, this is also the first report of an asymptomatic patient who presented IVCF fragments embolized to the right ventricle and left gonadal vein in the same clinical setting.

Inferior vena cava filter – comprehensive overview of current indications, techniques, complications and retrieval rates

Summary: Inferior vena cava (IVC) filter has been used to manage patients with pulmonary embolism and deep venous thrombosis. Its ease of use and the expansion of relative indications have led to a dramatic increase in IVC filter placement. However, IVC filters have been associated with a platitude of complications. Therefore, there exists a need to examine the current indications and identify the patient population at risk. In this paper, we comprehensively reviewed the current indications and techniques of IVC filter placement. Further, we examined the various complications associated with either permanent or retrievable IVC filters. Lastly, we examined the current data on filter retrieval.

Endovascular retrieval of a Gunther-tulip vena cava filter migrated into the right atrium

A 72-year-old male underwent placement of a Gunther-tulip vena cava filter to prevent development of a pulmonary embolism. One month later, when we tried to retrieve the Gunther-tulip vena cava filter via a transjugular approach, the filter detached from the snare and became free in the outer sheath. The Gunther-tulip vena cava filter did not reopen in the inferior vena cava probably because it became entangled with a thrombus; rather, the filter migrated into the right atrium. The filter orientation rendered the transjugular approach inappropriate; we used a bilateral transfemoral approach to aid filter retrieval. It is necessary to be very cautious when reopening a filter that has closed within the sheath. Although the filter migrated into the heart, we retrieved it using a combined approach.

Analysis of patent, unstented lower extremity vein segment diameters in 266 patients with venous disease

OBJECTIVE

The objective of this study was to characterize the average maximum diameters of widely patent lower extremity vein segments in patients with underlying venous disease and the demographic factors that affect these diameters.

METHODS

Maximum axial diameters of each deep vein segment from the diaphragm to the knee were measured from computed tomography venography studies for all patients who underwent venous stent placement during a 20-year period at a single quaternary venous referral institution. Limbs containing only widely patent, unstented vein segments without variant anatomy were identified for inclusion. The final analysis involved diameter measurements from 870 imaging studies of 266 patients. Multivariate linear regression was used to identify factors associated with vein segment diameters.

RESULTS

Average vein segment diameters ranged from 7.8 mm for the left and right femoral veins to 27.9 mm for the long axis of the suprarenal inferior vena cava. Multivariate linear regression demonstrated that women had larger IVC, common iliac vein, and external iliac vein diameters, whereas men had larger common femoral veins. Laterality, height, weight, and sex also had statistically significant associations with the diameters of select vein segments.

CONCLUSIONS

This study provides an estimate of the average diameters of widely patent deep vein segments in the lower extremities from the diaphragm to the knees in patients with underlying venous disease and characterizes covariates that significantly affect vein diameter. These findings may help interventionalists better select devices for endovascular intervention.

Prophylactic inferior vena cava filters for operative pelvic fractures: a twelve year experience

INTRODUCTION

Conflicting evidence exists regarding the role of inferior vena cava filters (IVCFs) in the prevention of pulmonary embolism. The aim of this study was to review an institutional policy of prophylactic IVCF placement in all operative pelvic and acetabular fractures as a means of preventing PE by comparing it to a historical prepolicy period of significantly less aggressive IVCF placement.

METHODS

The trauma registry of a single level 1 trauma center was retrospectively queried for all pelvic or acetabular fractures for the prepolicy and intervention periods as defined as January 2003-December 2008 and January 2009-December 2014, respectively-yielding 231 patients for analysis. The primary and secondary outcomes measured were the incidence of PE and deep vein thrombosis.

RESULTS

The rate of prophylactic IVCF insertion significantly increased during the study period (p < 0.001). The incidence of pulmonary embolism (1.8% vs. 5.1%, p = 0.351) and DVT (19.3% vs. 10.3%, p = 0.231) were not significantly different when comparing the prepolicy and intervention cohorts. In patients with operative fractures, a nonsignificant trend of increasing incidence of DVTs was appreciated in patients with a prophylactic IVCF versus those without prophylactic IVCF (13 vs. 2, p = 0.222).

DISCUSSION

A policy of increased use of prophylactic IVCFs in patients with operative pelvic and acetabular fractures failed to reduce the incidence of PE or DVT. In contrast, several case reports and institutional series have published several risks associated with IVCF placement including failure to retrieve temporary IVCF.

CONCLUSION

The benefit of prophylactic IVCF in this patient population is unclear.

Migration of a fractured inferior vena cava filter strut to the right ventricle of the heart

Inferior vena cava (IVC) filters are increasingly used in patients with recurrent venous thromboembolism in whom anticoagulation is contraindicated or intolerable. Migration of fragments is a known complication of IVC filter use. We present a case of a 32-year-old man, who presented with right-sided chest pain believed to be caused by a migrated IVC fragment to the right ventricle. The filter was removed by an endovascular cook forceps with the assistance of intracardiac echocardiography. This case serves as an addition to the existing reports of successful removal of intracardiac fragments via minimally invasive endovascular approach, amid a larger number of intracardiac fragments that have been removed by an open-heart approach.

Inferior vena cava filter use and patient safety: legacy or science?

There has been a dramatic increase in vena cava filter (VCF) use over the past 20 years in the absence of evidence that filters provide a net patient benefit or are required in most cases. This increase is largely attributable to the availability of retrievable filters and expanded indications, particularly as primary prophylaxis in patients thought to be at high risk of pulmonary embolism. Substantial variability in VCF use, unrelated to patient clinical factors, has been shown between hospitals, from region to region, and among various countries. Despite the lack of direct evidence for the benefit of VCFs for any indication, it is appropriate to insert a retrievable VCF in patients with a recent proximal deep vein thrombosis and an absolute contraindication to therapeutic anticoagulation and then to remove the filter once the bleeding risk decreases and the patient has been anticoagulated. Unfortunately, a high proportion of retrievable filters are not removed, even after the reason for their placement has long passed. Retrievable filters are associated with substantial rates of complications if they are not removed, including penetration of the vena caval wall, fracture and embolization of filter fragments, and caval occlusion. Patient safety priorities and medical-legal concerns mandate careful selection of patients for VCF placement and removal shortly after anticoagulation has been initiated.

Medical literature, vena cava filters and evidence of efficacy

Up to 15% of all patients with venous thromboembolism (VTE) receive an inferior vena cava filter, and prophylactic placements are increasing. To determine whether current use of filters is based on robust evidence, a global review of the recent (2001–2012) literature on filters was undertaken. The MEDLINE database was searched for articles related to filters appearing during the period 2001–2012, updating a prior search of literature from 1975–2001. All retrieved articles were analysed, classified into predetermined categories and compared to the prior analysis; randomised and large (>100 patients with a filter) comparative non-randomised clinical studies were read in full. The 651 articles, vs 568 in the period 1975–2000, consisted mainly of retrospective series (37.8%), case reports (31.7%), reviews (14.7%, vs 6.7%, p<0.001), animal and/or in vitro studies (7.5%, vs 12.9%, p=0.002), and prospective series or trials (4.9%, vs 7.4%, p=0.07). Of 4 new randomised trials (RCT), none were designed to test the efficacy of the device; to date, only one RCT has attempted to ascertain efficacy, occurring during the period 1975–2000. Eleven large non-randomised studies compared clinical outcomes of patients with and without filters, in VTE patients (n=5) or prophylactic indications (n=6); two studies found statistically significant relationships between filter use and lower mortality rates, though none could demonstrate a causal relationship. Hence, the plethoric literature on filters parallels growing experience with these devices, but still fails to provide reliable evidence that filter use improves relevant clinical outcomes. No indication for filter placement is based on appropriate scientific evidence.

Severe tricuspid regurgitation due to valvular entrapment of an inferior vena cava stent

Endovascular venous stenting is increasingly performed for a variety of conditions. Inferior vena cava stent migration has been reported up to 6 months after placement; stent migration 6 months after implantation is uncommon. To our knowledge, this is only the second reported case of late stent migration with valve entrapment 1.

Cardiac Perforation by Migrated Fractured Strut of Inferior Vena Cava Filter Mimicking Acute Coronary Syndrome

We present a rare late complication after inferior vena cava filter (IVC) placement. A 52-year-old woman with an IVC presented with sudden onset of chest pain. Cardiac catheterisation and echocardiography revealed an embolised IVC filter strut penetrating the right ventricle. Endovascular retrieval was considered but deemed unsafe due to proximity to the right coronary artery and concern for migration to pulmonary circulation. Urgent removal of the strut was performed via sternotomy. The postoperative course was uneventful. Two weeks later, she was asymptomatic. Minimally invasive approaches have been described for retrieval of intact IVC filters that have migrated to the right heart but not for embolised filter fragments. We recommend traditional sternotomy as the preferred method of retrieval as it limits the likelihood of further migration or trauma.

The Role of Endovascular Stents in Dialysis Access Maintenance

Vascular stenosis is most often the culprit behind hemodialysis vascular access dysfunction, and although percutaneous transluminal angioplasty remains the gold standard treatment for vascular stenosis, over the past decade the use of stents as a treatment option has been on the rise. Aside from the 2 Food and Drug Administration-approved stent grafts for the treatment of venous graft anastomosis stenosis, use of all other stents in vascular access dysfunction is off-label. Kidney Disease Outcomes Quality Initiative recommends limiting stent use to specific conditions, such as elastic lesions and recurrent stenosis; otherwise, additional adapted indications are in procedure-related complications, such as grade 2 and 3 hematomas. Published reports have shown the potential use of stents in a variety of conditions leading to vascular access dysfunction, such as venous graft anastomosis stenosis, cephalic arch stenosis, central venous stenosis, dialysis access aneurysmal elimination, cardiac implantable electronic device-induced stenosis, and thrombosed arteriovenous grafts. Although further research is needed for many of these conditions, evidence for recommendations has been clear in some; for instance, we know now that stents should be avoided along cannulation sites and should not be used in eliminating dialysis access aneurysms. In this review article, we evaluate the available evidence for the use of stents in each of the aforementioned conditions leading to hemodialysis vascular access dysfunctions.

Percutaneous Removal of Filter-Induced Iliocaval Thrombus Using the AngioVac Device

Most percutaneous mechanical thrombectomy devices entail thrombolysis and/or thrombus fragmentation followed by subsequent aspiration, with the associated risks of bleeding and embolization. We describe the use of the AngioVac system (Angiodynamics, Latham, NY USA) for extraction of extensive iliocaval thrombus associated with an inferior vena cava filter followed by percutaneous inferior vena cava filter extraction in a patient with an absolute contraindication to thrombolysis. The AngioVac may be considered in this scenario as it does not require thrombolytics and can remove whole thrombus, thus overcoming some of the limitations of percutaneous mechanical thrombectomy devices in the setting of subacute and early chronic thrombus.

Inferior vena cava filter misplacement in the right atrium and migration to the right ventricle followed by successful removal using the endovascular technique: A case report and review of the literature

Inferior vena cava filters are effective for preventing the passage of thrombi into the pulmonary arteries in patients with pulmonary embolism and deep vein thrombosis. These filters are indicated in patients with contraindications to anticoagulant therapy or in patients with recurrent acute pulmonary embolism despite the administration of anticoagulant therapy. However, the occurrence of filter-related complications, such as filter migration to the heart, has been increasing. Herein, we report a case of OptEase inferior vena cava filter misplacement in the right atrium. Although the filter migrated to the right ventricle, it was successfully removed and repositioned in the inferior vena cava using endovascular techniques. Unfortunately, moderate tricuspid regurgitation developed, due to the damage to the tricuspid valve that was caused by the procedure. We have also reviewed the relevant literature and discussed the possible strategies for managing cases of filter migration to the heart and preventing filter misplacement.

Complex hybrid suprarenal inferior vena cava filter retrieval

The exponential rise in inferior vena cava (IVC) filter placement is associated with increased complications both during implantation and retrieval. In this report, a 64-year-old man was transferred from an outside hospital with cardiac tamponade secondary to a snare eroding into the right atrium. This complication occurred after attempted suprarenal IVC filter removal. The filter, entangled with the snare, was retrieved by a hybrid technique of mobilizing the liver to expose the suprarenal IVC, followed by using a snare and sheath to compress and extrude the filter. This is the first reported hybrid retrieval of a suprarenal IVC filter.

Geometric changes of the inferior vena cava in trauma patients subjected to volume resuscitation

OBJECTIVE

Dynamic changes in anatomic geometry of the inferior vena cava from changes in intravascular volume may cause passive stresses on inferior vena cava filters. In this study, we aim to quantify variability in inferior vena cava dimensions and anatomic orientation to determine how intravascular volume changes may impact complications of inferior vena cava filter placement, such as migration, tilting, perforation, and thrombosis.

METHODS

Retrospective computed tomography measurements of major axis, minor axis, and horizontal diameters of the inferior vena cava at 1 and 5 cm below the lowest renal vein in 58 adult trauma patients in pre-resuscitative (hypovolemic) and post-resuscitative (euvolemic) states were assessed in a blinded fashion by two independent readers. Inferior vena cava perimeter, area, and volume were calculated and correlated with caval orientation.

RESULTS

Mean volumes of the inferior vena cava segment on pre- and post-resuscitation scans were 9.0 cm(3) and 11.0 cm(3), respectively, with mean percentage increase of 48.6% (P < 0.001). At 1 cm and 5 cm below the lowest renal vein, the inferior vena cava expanded anisotropically, with the minor axis expanding by an average of 48.7% (P < 0.001) and 30.0% (P = 0.01), respectively, while the major axis changed by only 4.2% (P = 0.11) and 6.6% (P = 0.017), respectively. Cross-sectional area and perimeter at 1 cm below the lowest renal vein expanded by 61.6% (P < 0.001) and 10.7% (P < 0.01), respectively. At 5 cm below the lowest renal vein, the expansion of cross-sectional area and perimeter were 43.9% (P < 0.01) and 10.7% (P = 0.002), respectively. The major axis of the inferior vena cava was oriented in a left-anterior oblique position in all patients, averaging 20° from the horizontal plane. There was significant underestimation of inferior vena cava maximal diameter by horizontal measurement. In pre-resuscitation scans, at 1 cm and 5 cm below the lowest renal vein, the discrepancy between the horizontal and major axis diameter was 2.1 ± 1.2 mm (P < 0.001) and 1.7 ± 1.0 mm (P < 0.001), respectively, while post-resuscitation studies showed the same underestimation at 1 cm and 5 cm below the lowest renal vein to be 2.2 ± 1.2 mm (P < 0.01) and 1.9 ± 1.0 mm (P < 0.01), respectively.

CONCLUSIONS

There is significant anisotropic variability of infrarenal inferior vena cava geometry with significantly greater expansive and compressive forces in the minor axis. There can be significant volumetric changes in the inferior vena cava with associated perimeter changes but the major axis left-anterior oblique caval configuration is always maintained. These significant dynamic forces may impact inferior vena cava filter stability after implantation. The consistent major axis left-anterior oblique obliquity may lead to underestimation of the inferior vena cava diameter used in standard anteroposterior venography, which may influence initial filter selection.

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.