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J Vasc Surg Cases Innov Tech
J Vasc Surg Cases Innov Tech
Journal of Vascular Surgery Cases, Innovations and Techniques
2468-4287
Elsevier

S2468-4287(22)00177-0
10.1016/j.jvscit.2022.09.005
101029
Case report
Malpositioned inferior vena cava filter via dual access endovascular technique
Lucas Spencer BS a
VandenHull Angela BA b
Schultz Greg MD c
Kelly Patrick MD Patrick.Kelly@sanfordhealth.org
c∗
a University of South Dakota Sanford School of Medicine, Sioux Falls, SD
b Sanford Research, Sioux Falls, SD
c Division of Vascular Surgery, Sanford Health, Sioux Falls, SD
∗ Correspondence: Patrick Kelly, MD, Division of Vascular Surgery, Sanford Health, 1305 W 18 St, Sioux Falls, SD 57117 Patrick.Kelly@sanfordhealth.org
17 9 2022
12 2024
17 9 2022
10 6 10102914 6 2022
6 9 2022
8 9 2022
© 2022 Published by Elsevier Inc. on behalf of Society for Vascular Surgery.
2022

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
The use of inferior vena cava filters remains a valuable solution for patients with venous thromboembolism who have contraindications to anticoagulation therapy. Some of the most common complications associated with these devices include malposition or migration. In the present case report, we have described the case of a patient who had presented with an unretrievable, malpositioned filter with struts perforating her duodenum, aorta, and vertebral body. She subsequently underwent a two-surgeon endovascular procedure with complete extrication of the filter struts.

Keywords

Pulmonary embolism
IVC filter
Deep venous thrombosis
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pmcPulmonary embolism (PE) and deep vein thrombosis, collectively referred to as venous thromboembolism (VTE), are the leading cause of preventable hospital death in the United States.1 Pharmacologic anticoagulation is the most common therapy for patients with diagnosed VTE.2 However, many patients will develop contraindications to anticoagulation therapy, including acute bleeding, hemorrhagic stroke, or advanced liver disease, making inferior vena cava (IVC) filter placement a valuable alternative solution.3 The rate of IVC filter placement in patients with VTE has been estimated to be 12% to 17%.4, 5, 6 With the increasing popularity in the use of these temporary devices, the follow-up and surveillance of these patients is extremely vital.

IVC filter placement is a relatively low-risk procedure; however, complications can arise. The present studies have reported a complication rate from vascular access for IVC filter insertion at 4% to 11%.7 The most often reported complications have included device malposition, migration, fracture, and perforation.8 With long-term usage, IVC filter tilt has been the most common cause of failure to retrieve IVC filters leading to filter thrombosis.9 The reported evidence has supported the treatment of filter tilt for retrieval of the device with reimplantation of a second filter.8 However, the question of what will happen if the filter is unretrievable has remained. In the present case report, we have described the case of a patient who did not have a filter hook available for retrieval and had required a two-surgeon endovascular approach to reposition the perforating struts of the unretrievable filter. The patient provided written informed consent for the report of her case details and imaging studies.

Case report

In the present report, we have described the case of a 70-year-old female patient with a medical history of recurrent left leg deep vein thrombosis with multiple PEs. After undergoing right knee replacement surgery, she had developed an acute PE. She received anticoagulation therapy with warfarin to a therapeutic international normalized ratio. At 3 days after discharge, the patient had presented to the emergency department with acute gastrointestinal hemorrhage. The patient declined restarting anticoagulation therapy, and vascular surgery was consulted for IVC filter replacement.

She was found to have extensive iliofemoral vein thrombosis, which led to a diagnosis of May-Thurner syndrome. She subsequently underwent left common iliac vein stenting with a 14-mm × 8-cm Protege stent (Medtronic, Dublin, Ireland), tissue plasminogen activator lytic therapy, and placement of a Celect infrarenal IVC filter (Cook Medical Inc, Bloomington, IN). At the 1-month follow-up, the patient complained of right-sided back pain. Computed tomography (CT) scan showed the IVC filter in a severely angulated position but no signs of perforation. She underwent IVC filter retrieval with replacement of a new Gunther Tulip IVC filter (Cook Medical Inc) to the infrarenal position. She continued follow-up for various vascular-related symptoms, including superior venous thrombosis, varicose veins, and occasional edema, but was lost to follow-up at 5 years after her IVC filter placement.

At 8 years postoperatively, she had presented to the emergency department of an outside hospital with abdominal pain. A CT scan showed acute diverticulitis and an obliquely oriented IVC filter with its hook extending into the caval wall and the struts extending into the duodenum, aorta, and vertebral body (Fig 1). The embedded hook made the success of retrieval unlikely. She was treated for diverticulitis and was subsequently transferred to a hospital with endovascular abilities for intervention regarding her IVC filter. The patient underwent partial endovascular filter repositioning, with failure to extricate the perforating struts. It was apparent that additional proximal tension was required to dislodge the struts from the caval wall. Her sharp abdominal and flank pain continued after this initial attempt. Open surgery was the recommended treatment of choice for her symptoms. At 3 months, after deliberation, she elected to undergo another attempt at filter repositioning with a two-surgeon endovascular approach, instead of laparoscopic or open repair.Fig 1 Coronal and sagittal images of computed tomography (CT) scan showing malposition of the inferior vena cava (IVC) filter with the struts perforating medially into the aorta (red arrow), posteriorly into the vertebral body (yellow arrow), and anteriorly into the duodenum (green arrow).

For IVC filter repositioning, the patient was placed in the supine position and draped for dual access via the right internal jugular vein and right femoral vein. Because of her age and comorbidities, she was sedated with monitored anesthesia. Initially, an Amplatz goose neck snare (Medtronic, Dublin, Ireland) was used to secure the IVC struts with downward force. Catheters were successfully placed into the internal jugular vein. A 6F Oscor steerable guiding sheath (Oscor, Palm Harbor, FL) and a 6F Flexor Raabe guiding sheath (Cook Medical Inc) were placed in the femoral vein. A catheter was threaded through the IVC filter and pulled upward to maintain tension on the filter. A Terumo stiff glidewire (Terumo Medical Corp, Franklin Township, NJ) was placed within the femoral vein, looped inferiorly to the IVC filter, and used to extricate the struts in the caval wall by pulling caudally (Fig 2). Once the struts had been placed back within the caval walls, unsuccessful attempts were made to dislodge the hook from the caval wall. A venogram using a Soft-Vu 5F catheter (AngioDynamics, Latham, NY) with iodixanol contrast showed a stable position for the IVC filter with the retrieval hook still embedded in the wall (Fig 3). Multiple unsuccessful attempts were made to snare the filter hook. A CT scan was completed on postoperative day 1, which showed successful extrication of the strut that had been lodged within the vertebral body, a stable position of the strut within the duodenum, and successful extrication of the strut that had been within the aorta (Figs 4 and 5). The patient’s recovery was uncomplicated, and she was discharged on postoperative day 2, with no additional reports of abdominal pain at her 2-week and 1-month follow-up visits.Fig 2 Terumo stiff glidewire extricating the struts perforating the caval wall with downward tension.

Fig 3 Postoperative venogram showing stable position of the filter with no extravasation of contrast.

Fig 4 Sequential sagittal images of the postoperative computed tomography (CT) scan showing successful extrication of the strut that had been penetrating the vertebral body (red arrow) and the strut in a similar position within the duodenum (yellow arrow).

Fig 5 Sequential coronal images of the postoperative computed tomography (CT) scan showing the filter strut fully extricated from the aortic wall and back into the caval wall (red arrow).

Discussion

Malposition remains an important complication for patients who undergo IVC filter placement. Retrieval and placement of a new filter has remained the primary solution for malpositioned filters. Alternatively, for filters that are unretrievable, studies have reported on intraoperative manipulation of these filters using guide wires, balloons, and catheters.8, 9, 10, 11 Advanced retrieval techniques have been reported for patients with longer dwell times, filter malpositioning, and/or an embedded hook, with the reported data suggesting different techniques.12 The use of these advanced retrieval techniques has also been linked to increased complication rates, specifically, proximal migration to the heart, intimal injury leading to caval thrombosis, and caval perforation.13,14 A common theme among the cited cases, however, was a filter hook ready to pull superiorly and dislodging the embedded struts from the caval wall.

In the present report, the patient was not a candidate for simple retrieval because the hook had become embedded within the caval wall. We elected to reposition the struts inside the caval wall and monitor for changes. The two-surgeon and two-catheter approach was successful in relocating the struts from the caval wall to intraluminally because the transjugular tension allowed for the stiff guide wire to pull inferiorly and thus pull the perforating struts back into the intraluminal vena cava. Our techniques were successful in resolving our patient’s abdominal pain and saving her from undergoing an extensive open operation. With the use of endovascular procedures increasing and IVC filter placement increasing, complex IVC filter retrieval techniques should be in every vascular surgeon’s arsenal.

Conclusions

IVC filters will continue to be used for patients who cannot receive anticoagulation therapy. For patients who are not candidates for open surgery, or whose filters are unretrievable, complex endovascular techniques are available to reposition these devices without caval rupture. As shown in the present case, the incorporation of a two-surgeon approach to reposition such unretrievable IVC filters can be technically successful.

Author conflict of interest: none.

The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
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