The Journal of Emergency Medicine, Vol. 50, No. 3, pp. e151–e153, 2016 Copyright Ó 2016 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
Visual Diagnosis in Emergency Medicine
INFERIOR VENA CAVA FILTER MIGRATION Na Rae Ju, MD* and Lauren W. Conlon, MD† *Emergency Medicine Resident, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania and †Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania Reprint Address: Lauren W. Conlon, MD, Perelman School of Medicine at the University of Pennsylvania, Department of Emergency Medicine, Hospital of the University of Pennsylvania, 3400 Spruce St, Ground Ravdin, Philadelphia, PA 19104
Although IVC filters are widely used and clinically indicated in many patients, they are not without complications, including IVC penetration, IVC occlusion, filter movement, and filter fracture (1). Fracture of an IVC filter strut—one of the arms of the IVC filter—is estimated to occur in 2% to 10% of patients, while embolization of the filter or strut to a distant anatomic site is even less common (<1%) (1). There is discrepancy within the literature defining embolization, migration, and movement of a filter; we consider embolization interchangeable with migration, consistent with previous subject literature
CASE REPORT A 29-year-old woman with a history of multisystem trauma 4 years earlier complicated by pulmonary embolism status post–inferior vena cava (IVC) filter presented to the emergency department. She reported a 2-week duration of persistent midsternal chest pressure and 1 day of difficulty breathing. The patient had previously been seen at another hospital, where she reportedly had an unremarkable computed tomography scan of the chest for pulmonary embolism and was diagnosed with pericarditis. The patient’s symptoms persisted despite nonsteroidal antiinflammatory therapy and worsened on the day of presentation. The physical examination was unremarkable. Laboratory studies, including a complete blood cell count, basic metabolic panel, erythrocyte sedimentation rate, C-reactive protein, and troponin-I were unremarkable. A chest radiograph with an abnormal finding led to further imaging with a noncontrast computed tomography scan of the chest. The patient was diagnosed with migrated IVC filter struts. DISCUSSION IVC filters have been used since 1967 to prevent pulmonary emboli in patients with deep vein thrombosis.
Figure 1. Chest radiograph of an inferior vena cava filter strut (black arrow) within the pulmonary arteriole.
RECEIVED: 19 November 2014; FINAL SUBMISSION RECEIVED: 30 June 2015; ACCEPTED: 25 July 2015 e151
N. R. Ju and L. W. Conlon
Figure 2. (A) A computed tomography scan of the second inferior vena cava filter strut (black arrow). (B) A computed tomography scan of the same inferior vena cava filter strut (black arrow) 3 months later shows filter migration within the pericardium.
(1–3). Movement of the filter and or filter strut has been defined as any movement of >2 cm from the location of filter deployment (1). Accepting this definition of movement helps define significant movement and excludes minor adjustment in position (i.e., <2 cm). Movement of the filter or filter strut has a higher incidence than embolization, which is defined as postdeployment movement to a distant anatomic site (1,4). Occurrence is infrequent, but published case reports have documented dislodgement and migration of filter struts and intact IVC filters (2,3,5–10). Intracardiac migration of an IVC filter or strut is rare; however, when it occurs, the IVC filter or strut usually migrates to the right side of the heart (2,3,5–10). Embolization rates during IVC filter placement have significantly declined since 1996 after phasing out of the KimrayGreenfield filter, which was responsible for >90% of such intraprocedural embolization events (1). Faulty device design has been cited elsewhere as a contributor to filter migration, most commonly because of faulty venous tethering systems (4). Symptomatic patients with filter or filter strut embolization may present with chest pain, palpitations, dysrhythmias, or syncope (2,3,6–10). Filters that have been in place for longer periods of time are theoretically subject to greater stress and may be more likely to fracture; regular evaluation of filter integrity is suggested (11). There is no current standard of treatment for patients with filter or filter strut migration, especially regarding retrieval and follow-up. However, options for retrieval include percutaneous or surgical retrieval (2,5–9,12). Our patient had 2 fractured and dislodged IVC filter struts; the first in her pulmonary arteriole (Figure 1) and the second intracardiac or in a small vessel posterior to the ventricle (Figure 2A). She was admitted to the hospital and evaluated by the cardiology, cardiac surgery, and interventional radiology departments. Her troponin-T levels were trended and peaked at 0.045 ng/mL and quickly normalized. Additional imaging upon admission included a computed tomographic angiogram, which
revealed that the second strut was located posterior to the left atrium—likely in her pericardium and not in her coronary sinus. Attempts to remove the IVC filter struts were performed but were unsuccessful. The IVC filter remaining in the IVC was removed by interventional radiology; at that time, it was noted that 2 arms or struts of the IVC filter were missing. During her hospitalization, she continued to report intermittent episodes of chest pain and shortness of breath, which was thought to be caused by the migrated IVC filter strut in the left ventricle or pericardium. Her symptoms gradually improved during hospitalization. The treatment teams felt that she required no additional treatment or evaluation because the risk of any attempts to remove the IVC filter struts outweighed the benefits. She was seen at a follow-up appointment a few months later, where she continued to have intermittent symptoms but had no additional complications. A repeat computed tomography scan 3 months later revealed the IVC filter strut (Figure 2B) migrated within the pericardium. REFERENCES 1. Sella DM, Oldenburg WA. Complications of inferior vena cava filters. Semin Vasc Surg 2013;26:23–8. 2. Tam MD, Spain J, Lieber M, Geisinger M, Sands MJ, Wang W. Fracture and distant migration of the Bard Recovery filter: a retrospective review of 363 implantations for potentially life-threatening complications. J Vasc Interv Radiol 2012;23:199–2051. 3. Khurana D, Raza J, Abrol S, Coplan NL. Fractured inferior vena cava filter strut presenting with ST-segment elevation and cardiac tamponade. Tex Heart Inst J 2015;42:181–3. 4. Belenotti P, Sarlon-Bartoli G, Bartioli M, et al. Vena cava filter migration: an unappreciated complication. About four cases and review of the literature. Ann Vasc Surg 2011;25:1141. e9–114114. 5. Dardik A, Campbell KA, Yeo CJ, Lipsett PA. Vena cava filter ensnarement and delayed migration: an unusual series of cases. J Vasc Surg 1997;26:869–74. 6. Janjua M, Omran FM, Kastoon T, Alshami M, Abbas AE. Inferior vena cava filter migration: updated review and case presentation. J Invasive Cardiol 2009;21:606–10. 7. Owens CA, Bui JT, Knuttinen MG, et al. Intracardiac migration of inferior vena cava filters: review of published data. Chest 2009;136: 877–87.
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