Symptomatic perforation of a retrievable inferior vena cava filter after a dwell time of 5 years
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Symptomatic perforation of a retrievable inferior vena cava filter after a dwell time of 5 years Ed Parkin, MBChB, a Ferdinand Serracino-Inglott, MD, FRCS, a Nick Chalmers, FRCR, b and Vince Smyth, FRCS, ChM, a Manchester, United Kingdom Symptomatic caval perforation is a rare complication of inferior vena cava filter placement, and there is little evidence on which to base clinical practice in such circumstances. We report a case of caval wall perforation 5 years after insertion of a retrievable Günther Tulip filter (William Cook Europe, Bjaeverskov, Denmark) and describe the operative procedure involved in its removal. To our knowledge this is the first reported case of symptomatic caval perforation caused by a Günther Tulip filter. ( J Vasc Surg 2009;50:417-9.) Inferior vena cava (IVC) filter insertion is a relatively safe procedure, but certain devices have been associated with symptomatic caval wall perforation. We report a case of caval perforation caused by a Günther Tulip filter, with associated vertebral osteomyelitis, and outline the operative procedure involved in its removal. The safety of permanent placement of filters that are designed to be retrievable is also discussed. CASE REPORT A 21-year-old man presented in 2003 with a right ileofemoral deep vein thrombosis (DVT) with extension into the IVC. He subsequently developed multiple pulmonary emboli despite being anticoagulated. A Günther Tulip filter was deployed in the infra- renal IVC from a right jugular approach. This is a retrievable filter that is licensed for permanent implantation. The patient was dis- charged to the care of the referring hospital on oral anticoagulant medication. Retrieval was not attempted. The patient presented to his local hospital 5 years later with lower back pain. This was severe enough for him to require opiate analgesia administered by a patient-controlled analgesia pump. The result of the neurologic examination at that time was unre- markable. He was apyrexial. The C-reactive protein (CRP) level was raised at 108 mg/L. White blood cell count was within normal ranges at 7.8 10 9 /L. Blood culture grew methicillin-sensitive Staphylococcus aureus on two separate occasions, and he was ac- cordingly commenced on intravenous flucloxacillin. He was transferred to our unit and underwent a computed tomography (CT) scan. This showed the filter device inside the vena cava at the level of the second and third lumbar vertebrae (L2/L3; Fig 1). Three of the struts had penetrated through the wall of the IVC. One was embedded in the L2 vertebra, associated with reactive new bone formation. A second strut tip was lying within the aortic adventitia, and a third was within the duodenal wall. Magnetic resonance imaging showed loss of normal signal within the L2/L3 disc space. The patient’s clinical picture of severe back pain, positive blood cultures, a raised CRP, and radiologic evidence of local inflammation around the IVC filter resulted in a diagnosis of discitis with probable osteomyelitis. The filter required removal, but endovascular retrieval was viewed as hazardous given the extent of caval perforation. Preparation was made for operative removal, and oral anticoagulant medication was converted to an intravenous anticoagulant pump. The preaortic retroperitoneum was exposed by a standard transverse transperitoneal approach, and the left renal vein identi- fied and controlled with a sling. There was marked fibrosis over the IVC between the left renal vein and the iliac confluence, such that the vein wall could not be identified. On retraction of the duode- num to the right, one strut of the filter could be clearly seen protruding anteriorly out of the IVC (Fig 2), but there was no macroscopic breach of the duodenal wall. The IVC was dissected out at the level of the left renal vein and at the bifurcation sufficiently to permit clamping, and a plane between the fibrosis and the vein was preserved. At this stage, a second strut became palpable in the perivenous tissue adjacent to the aorta. The patient was anticoagulated, and the IVC and left renal vein were clamped before a longitudinal venotomy over the filter at the level of the anterior perforation (Fig 3). The filter body and apical hook were obscured by intimal fibrosis and endothelialization. After the filter was freed in the vein, the posterior extruded hook was anchored to the body of the L2 vertebra by extensive periosteal reaction, and retrieval required sustained longitudinal traction. The filter was removed intact without significant venous injury. The venotomy was closed with a running 5-0 polypropylene suture, and the abdomen was closed in the standard fashion. The patient was well enough to be discharged at 1 week; however, following microbiologic advice, the patient stayed to complete a 4-week course of intravenous antibiotics. He was given a further 2 weeks of oral flucloxacillin to take home. It was considered that although results of intraoperative culture swabs taken from inside the IVC were negative, the degree of local inflammation and two separate positive blood culture results was highly suggestive of an ongoing infective process associated with the IVC filter. At discharge the IVC was clinically patent, and the CRP level had fallen to 24 mg/L. From the Departments of Vascular and Endovascular Surgery, a and Radi- ology, b Manchester Royal Infirmary. Competition of interest: none. Correspondence: Mr E. Parkin, Department of Vascular and Endovascular Surgery, Manchester Royal Infirmary, Oxford Rd, Manchester, M13 9WL, UK (e-mail: [email protected]). 0741-5214/$36.00 Copyright © 2009 by the Society for Vascular Surgery. doi:10.1016/j.jvs.2009.03.002 417
Transcript of Symptomatic perforation of a retrievable inferior vena cava filter after a dwell time of 5 years
Symptomatic perforation of a retrievable inferiorvena cava filter after a dwell time of 5 yearsEd Parkin, MBChB,a Ferdinand Serracino-Inglott, MD, FRCS, a Nick Chalmers, FRCR, b andVince Smyth, FRCS, ChM, a Manchester, United Kingdom
Symptomatic caval perforation is a rare complication of inferior vena cava filter placement, and there is little evidence onwhich to base clinical practice in such circumstances. We report a case of caval wall perforation 5 years after insertion ofa retrievable Günther Tulip filter (William Cook Europe, Bjaeverskov, Denmark) and describe the operative procedureinvolved in its removal. To our knowledge this is the first reported case of symptomatic caval perforation caused by a
Günther Tulip filter. ( J Vasc Surg 2009;50:417-9.)Inferior vena cava (IVC) filter insertion is a relativelysafe procedure, but certain devices have been associatedwith symptomatic caval wall perforation. We report a caseof caval perforation caused by a Günther Tulip filter, withassociated vertebral osteomyelitis, and outline the operativeprocedure involved in its removal. The safety of permanentplacement of filters that are designed to be retrievable is alsodiscussed.
CASE REPORT
A 21-year-old man presented in 2003 with a right ileofemoraldeep vein thrombosis (DVT) with extension into the IVC. Hesubsequently developed multiple pulmonary emboli despite beinganticoagulated. A Günther Tulip filter was deployed in the infra-renal IVC from a right jugular approach. This is a retrievable filterthat is licensed for permanent implantation. The patient was dis-charged to the care of the referring hospital on oral anticoagulantmedication. Retrieval was not attempted.
The patient presented to his local hospital 5 years later withlower back pain. This was severe enough for him to require opiateanalgesia administered by a patient-controlled analgesia pump.The result of the neurologic examination at that time was unre-markable. He was apyrexial. The C-reactive protein (CRP) levelwas raised at 108 mg/L. White blood cell count was within normalranges at 7.8 � 109/L. Blood culture grew methicillin-sensitiveStaphylococcus aureus on two separate occasions, and he was ac-cordingly commenced on intravenous flucloxacillin.
He was transferred to our unit and underwent a computedtomography (CT) scan. This showed the filter device inside thevena cava at the level of the second and third lumbar vertebrae(L2/L3; Fig 1). Three of the struts had penetrated through thewall of the IVC. One was embedded in the L2 vertebra, associatedwith reactive new bone formation. A second strut tip was lyingwithin the aortic adventitia, and a third was within the duodenal
From the Departments of Vascular and Endovascular Surgery,a and Radi-ology,b Manchester Royal Infirmary.
Competition of interest: none.Correspondence: Mr E. Parkin, Department of Vascular and Endovascular
Surgery, Manchester Royal Infirmary, Oxford Rd, Manchester, M139WL, UK (e-mail: [email protected]).
0741-5214/$36.00Copyright © 2009 by the Society for Vascular Surgery.
doi:10.1016/j.jvs.2009.03.002wall. Magnetic resonance imaging showed loss of normal signalwithin the L2/L3 disc space.
The patient’s clinical picture of severe back pain, positiveblood cultures, a raised CRP, and radiologic evidence of localinflammation around the IVC filter resulted in a diagnosis ofdiscitis with probable osteomyelitis. The filter required removal,but endovascular retrieval was viewed as hazardous given theextent of caval perforation. Preparation was made for operativeremoval, and oral anticoagulant medication was converted to anintravenous anticoagulant pump.
The preaortic retroperitoneum was exposed by a standardtransverse transperitoneal approach, and the left renal vein identi-fied and controlled with a sling. There was marked fibrosis over theIVC between the left renal vein and the iliac confluence, such thatthe vein wall could not be identified. On retraction of the duode-num to the right, one strut of the filter could be clearly seenprotruding anteriorly out of the IVC (Fig 2), but there was nomacroscopic breach of the duodenal wall. The IVC was dissectedout at the level of the left renal vein and at the bifurcationsufficiently to permit clamping, and a plane between the fibrosisand the vein was preserved.
At this stage, a second strut became palpable in the perivenoustissue adjacent to the aorta. The patient was anticoagulated, andthe IVC and left renal vein were clamped before a longitudinalvenotomy over the filter at the level of the anterior perforation (Fig 3).The filter body and apical hook were obscured by intimal fibrosisand endothelialization. After the filter was freed in the vein, theposterior extruded hook was anchored to the body of the L2vertebra by extensive periosteal reaction, and retrieval requiredsustained longitudinal traction. The filter was removed intactwithout significant venous injury. The venotomy was closed with arunning 5-0 polypropylene suture, and the abdomen was closed inthe standard fashion.
The patient was well enough to be discharged at 1 week;however, following microbiologic advice, the patient stayed tocomplete a 4-week course of intravenous antibiotics. He was givena further 2 weeks of oral flucloxacillin to take home. It wasconsidered that although results of intraoperative culture swabstaken from inside the IVC were negative, the degree of localinflammation and two separate positive blood culture results washighly suggestive of an ongoing infective process associated withthe IVC filter. At discharge the IVC was clinically patent, and the
CRP level had fallen to 24 mg/L.417
JOURNAL OF VASCULAR SURGERYAugust 2009418 Parkin et al
At the 6-week follow-up, the patient was systemically well anddid not need regular analgesia for his back pain. A magneticresonance imaging scan performed at 12 weeks showed reducedheight of the L2/3 disc in keeping with degeneration; however,
Fig 1. A computed tomography scan at L2 vertebral level showsthe inferior vena cava (IVC) and adjacent periosteal reaction(arrow) due to a posterior filter strut.
Fig 2. An intraoperative photo shows the aorta (A) with protru-sion of the anterior filter strut out of the inferior vena cava (IVC).
Fig 3. An intraoperative photo with the inferior vena cava (IVC)open shows intimal fibrosis at the tip of the forceps. D, Duodenum.
there was no evidence of any pathology.
DISCUSSION
The treatment of choice for venous thromboembolismis anticoagulation, but this is sometimes insufficient, as inthe case described here where multiple pulmonary embolideveloped despite the patient’s compliance with a thera-peutic dose of oral anticoagulant medication. In such cir-cumstances, a caval filter is required to reduce the risk ofa fatal pulmonary embolism. Other indications for filterinsertion include chronic multiple pulmonary emboliwith associated pulmonary hypertension, DVT with acontraindication to anticoagulation, and prophylaxis inpatients at high risk of a DVT who are not suitable foranticoagulation.1,2
Although percutaneous insertion is a relatively safeprocedure, the long-term presence of an IVC filter is notwithout its complications. Caval filter insertion was initiallythought to follow a benign course3; however, substantialevidence in the literature contradicts this, with a risk ofrecurrent DVT of about 20% and an overall caval perfora-tion rate of 0.3%.4,5
The choice of filter depends upon the indication. Re-trievable devices are preferable when the reason for inser-tion is temporary, and permanent devices are used whenlong-term filtration is anticipated. This distinction has be-come blurred in recent years, with retrievable devices suchas the Günther Tulip now used for permanent implanta-tion. It has excellent short-term results6,7 and has an overallcaval perforation complaint rate of 0.04% (personal com-munication, William Cook Europe). However, data arelacking for long-term follow-up of Günther Tulip filters,with only one recent article looking at complications withprolonged dwell times.8 Although to our knowledge this isthe first reported case of symptomatic perforation of aGünther Tulip, similar cases have been described afterprolonged dwell times with other types of retrievable filter,9
and a recent review article concluded that the long-termsafety for the permanent implantation of retrievable devicesis unproven.10
In the patient presented here, an endovenous inflam-matory process had occurred in response to filter insertion,with neointimization around the filter. Three of the filterstruts had perforated through the wall of the IVC, with theposterior strut causing a periosteal reaction and subsequentosteomyelitis. This made endovascular retrieval impossible,leaving open surgical removal as the only safe method offilter removal.
To our knowledge this is the first reported case of asymptomatic caval perforation due to a Günther Tulipfilter and it occurred after a prolonged dwell time. Be-cause this device has only recently started being used forpermanent implantation, there is a lack of evidence in theliterature about late caval perforations and long-termsafety. We believe that each Günther Tulip filter insertedfor permanent filtration should be registered on a data-
base and any complications recorded prospectively.
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REFERENCES
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2. Hyers TM, Agnelli G, Hull RD, Morris TA, Samama M, Tapson V, et al.Antithrombotic therapy for venous thromboembolic disease. Chest2001;119:176-93.
3. Langan EM 3rd, Miller RS, Casey WJ 3rd, Carsten CG, Graham RM,Taylor SM. Prophylactic vena cava filters in trauma patients at high risk:follow-up examination and risk/benefit assessment. J Vasc Surg 1999;30:484-90.
4. Decousus H, Leizorovicz A, Parent F, Page Y, Tardy B, Girard P, et al.A clinical trial of vena caval filters in the prevention of pulmonaryembolism in patients with proximal deep vein thrombosis. Préventiondu Risque d’Embolie Pulmonaire par Interruption Cave Study Group.
N Engl J Med 1998;338:409-15.5. Hann CL, Streiff MB. The role of vena caval filters in the managementof venous thromboembolism. Blood Reviews 2005;19:179-202.
6. Piano G, Ketteler ER, Prachand V, DeValk E, Van Ha TG, Gewertz BL,et al. Safety, feasibility and outcome of retrievable vena cava filters inhigh risk surgical patients. J Vasc Surg 2007;45:784-8.
7. Keller IS, Meier C, Pfiffner R, Keller E, Pfammatter T. Clinical compar-ison of two optional vena cava filters. J Vasc Interv Radiol 2007;18:505-11.
8. Rosenthal D, Wellons ED, Hancock SM, Burkett AB. Retrievability ofthe Günther Tulip vena cava filter after dwell times longer than 180 daysin patients with multiple trauma. J Endovasc Ther 2007;14:406-10.
9. Veroux M, Tallarita T, Pennisi M, Veroux P. Late complication from aretrievable inferior vena cava filter with associated caval, aortic andduodenal perforation: a case report. J Vasc Surg 2008;48:223-5.
10. Berczi V, Bottomley JR, Thomas SM, Taneja S, Gaines PA, ClevelandTJ. Long-term retrievability of IVC filters: should we abandon perma-nent devices? Cardiovasc Intervent Radiol 2007;30:820-7.
Submitted Feb 3, 2009; accepted Mar 2, 2009.
