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Late erosion of a prophylactic Celect IVC filter into the aorta, right renal artery, and duodenal wall

2010; Elsevier BV; Volume: 52; Issue: 4 Linguagem: Inglês

10.1016/j.jvs.2010.04.065

1097-6809

Robert D. Becher, Matthew A. Corriere, Matthew S. Edwards, Christopher J. Godshall,

Acute Kidney Injury Research

We present the case of a patient with retrievable inferior vena cava (IVC) filter-related pseudoaneurysms of the infrarenal aorta and right renal artery, with associated erosion into the duodenal wall. The patient was seen 10 months following multiorgan trauma and placement of a prophylactic retrievable IVC filter (R-IVCF). Management required autogenous aortic reconstruction, caval repair, and subsequent right nephrectomy. This case demonstrates that R-IVCFs may be associated with significant risks, which is concerning, as a majority of prophylactic R-IVCFs placed after multisystem trauma are not removed. We present the case of a patient with retrievable inferior vena cava (IVC) filter-related pseudoaneurysms of the infrarenal aorta and right renal artery, with associated erosion into the duodenal wall. The patient was seen 10 months following multiorgan trauma and placement of a prophylactic retrievable IVC filter (R-IVCF). Management required autogenous aortic reconstruction, caval repair, and subsequent right nephrectomy. This case demonstrates that R-IVCFs may be associated with significant risks, which is concerning, as a majority of prophylactic R-IVCFs placed after multisystem trauma are not removed. Prophylactic insertion of inferior vena cava (IVC) filters accounts for more than half of all IVC filters placed into multisystem trauma patients with contraindications to anticoagulation.1Aziz F. Spate K. Wong J. Aruny J. Sumpio B. Changing patterns in the use of inferior vena cava filters: review of a single center experience.J Am Coll Surg. 2007; 205: 564-569Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar There has been an increase in the use of prophylactic IVC filters associated with the introduction of retrievable IVC filters (R-IVCFs), the majority of which are not removed.2Ray C.E. Mitchell E. Zipser S. Kao E.Y. Brown C.F. Moneta G.L. Outcomes with retrievable inferior vena cava filters: a multicenter study.J Vasc Interv Radiol. 2006; 17: 1595-1604Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar In this case, we describe a patient with R-IVCF-related pseudoaneurysms of the infrarenal aorta and right renal artery who presented 10 months following multiorgan trauma and prophylactic R-IVCF placement. Management consisted of autogenous aortic reconstruction, caval repair, and subsequent right nephrectomy. To date, the patient has recovered uneventfully. The patient is a 42-year-old gentleman who was involved in a motor vehicle collision (MVC) with associated multiorgan injuries. These included a closed head injury with subarachnoid hemorrhage that precluded prophylactic anticoagulation. With his expected prolonged hospitalization, a prophylactic retrievable inferior vena cava filter (Celect R-IVCF, Cook Medical, Bloomington, IN) was placed on hospital day 7 for pulmonary embolus (PE) prophylaxis in the absence of documented deep vein thrombosis (DVT); the patient had no active infection at the time. During filter placement, one strut was slightly angulated into the right renal vein, and the device positioned cephalad to the typical infrarenal caval location. We were called to evaluate, and attempts at repositioning were unsuccessful. Ultimately, it was felt to be in satisfactory position to prevent PE; subsequent imaging demonstrated no change in location. At the completion of his trauma hospitalization 3 months later, an additional unsuccessful attempt was made to retrieve the filter endovascularly. Multiple attempts to snare the hook of the filter failed; it was thought that the filter's retrieval hook was embedded in the anterior wall of the IVC, and manipulation did not change the angle of the filter to facilitate retrieval. The R-IVCF was left in place as a permanent device. Ten months after his MVC, the patient presented with left upper extremity edema and was diagnosed with left arm thrombophlebitis. During inpatient hospitalization, the patient underwent a computed tomography (CT) scan of the abdomen and pelvis as part of an evaluation of back pain. The CT demonstrated the superior aspect of the IVC filter in a retrohepatic caval position. The struts protruded outside the vena cava lumen and were associated with significant phlegmon, fluid collections, an infrarenal aortic pseudoaneurysm, and penetration into the duodenal wall (Fig 1, Fig 2).Fig 2Reformatted 3D CT scan image of the retrievable IVC filter showing extraluminal struts and aortic pseudoaneurysm.View Large Image Figure ViewerDownload Hi-res image Download (PPT) A follow-up CT scan 3 days later demonstrated increased pericaval fluid collections and new presumed septic emboli to the lungs, based on their rapid evolution and typical imaging appearance. There was concern that the aortic pseudoaneurysm associated with the IVC filter was infected, potentially seeded from his infected thrombophlebitis, prior instrumentation of the filter, his duodenum, or his abuse of illicit drugs. Operative intervention was indicated. A 2-day staged operative strategy was planned. Further attempt to remove the filter percutaneously was done to minimize the magnitude of the required open reconstruction, particularly given the patient's history of prior open Graham Patch for perforated peptic ulcer. On day 1, endovascular retrieval of the filter was attempted but proved unsuccessful. A host of combined instrumentation techniques were employed from the right internal jugular, right cephalic, and right femoral vein approach. We utilized balloons from two directions, a snare, and a snared wire looped around the filter struts. Strong force was successfully applied but did not successfully disengage the filter or change the position. On day 2, we proceeded with open repair of the aortic pseudoaneurysm and open removal of the R-IVCF. Upon entering the abdomen through a midline incision, no frank pus or abnormal fluid was encountered. A right-sided visceral mobilization was performed, including mobilization of the right colon, duodenum, head of the pancreas, and base of the mesentery from the cecum to the duodenojujunal junction. The extraluminal filter strut imbedded in the duodenal wall was encountered and detached from the wall. No leak was noted from the duodenum, and therefore, no formal repair was performed. The falciform, right triangular, and coronary ligaments around the liver were divided in order to mobilize the liver and facilitate control of the inferior vena cava superior to the filter. The exposure provided visualization of the aorta from the bifurcation to the superior mesenteric artery as well as the vena cava from the bifurcation to the retrohepatic portion. Significant phlegmon was encountered surrounding the aorta and inferior vena cava. After proximal and distal aortic control, a 4-cm segment of aorta containing the pseudoaneurysm was excised. Reversed, proximal, 4-cm left femoropopliteal vein was placed as an aortic interposition graft and found to be an appropriate size match. We then turned out attention to the filter extraction, which required retrohepatic caval control, bilateral renal vein control, and infrarenal caval control. A 6-cm anterior venotomy was made for good visualization, and the entire filter was then removed in one piece, with considerable effort required, using a Kelly clamp, as the filter was densely incorporated into the wall of the IVC. Within the caval lumen, there was reactive change of the wall, but there was no loose material, no thrombus, and the lumen was adequate. Therefore no cava was resected, and the cavotomy was repaired primarily. Due to bowel swelling, the patient's abdomen was dressed with a negative-pressure dressing; his fascia was closed on postoperative day 5. The patient was discharged home on postoperative day 20. One month later, follow-up contrast CT demonstrated a right renal artery pseudoaneurysm (Fig 3), which was not appreciated on the prior preoperative CT or intraoperatively during his aortic repair. Arteriography demonstrated a pseudoaneurysm arising from the right main renal artery bifurcation at the previous location of one of the filter struts. Although the strut had been in this location, we cannot exclude the possibility that the pseudoaneurysm was the result of surgical dissection during his prior operation. The patient was not considered a reasonable candidate for renal salvage given the concern for associated infection. Right nephrectomy was performed utilizing preoperative transcatheter embolization of the renal artery. We chose to embolize the renal artery preoperatively due to the marked inflammatory change noted in the same region one month prior, the large luminal defect in the renal artery hilar pseudoaneurysm by imaging, and recent aortic repair in the area of potential arterial control. To date, the patient continues to do well with normal renal function. He is asymptomatic with evidence of patency of his inferior vena cava and aortic repair. He has normal ankle-brachial indices. The use of IVC filters has evolved significantly since their inception in the late 1960s and early 1970s, created with the singular purpose of preventing PE. Since Greenfield's IVC filter was released in 1973,3Greenfield L.J. McCurdy J.R. Brown P.P. Elkins R.C. A new intracaval filter permitting continued flow and resolution of emboli.Surgery. 1973; 73: 599-606PubMed Google Scholar studies have indicated low mortality for these devices and improved safety.4Athanasoulis C.A. Kaufman J.A. Halpern E.F. Waltman A.C. Geller S.C. Fan C.M. Inferior vena caval filters: review of a 26-year single-center clinical experience.Radiology. 2000; 216: 54-66Crossref PubMed Scopus (323) Google Scholar However, multiple potential complications exist, both in the short and long term, for both permanent and retrievable devices.5Stein P.D. Alnas M. Skaf E. Kayali F. Siddiqui T. Olson R.E. et al.Outcome and complications of retrievable inferior vena cava filters.Am J Cardiol. 2004; 94: 1090-1093Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar, 6Miyahara T. Miyata T. Shigematsu K. Deguchi J. Kimura H. Ishii S. et al.Clinical outcome and complications of temporary inferior vena cava filter placement.J Vasc Surg. 2006; 44: 620-624Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar Our case report adds to the expanding body of literature documenting sequela and low retrieval rates from R-IVCFs (Table I, Table II). In our review of the medical and surgical literature, no previous reports of right renal artery pseudoaneurysm with infrarenal aortic pseudoaneurysm from a retrievable IVC filter have been published.Table IPublished removal rates of FDA-approved retrievable IVC filtersAuthor, yearFilters usedNumber insertedAttempted removal No. (%)Successful removal No. (%)Antevil et al, 2005Recovery, Günther-Tulip, OptEase16143 (27%)33 (20%)Ray et al, 2006Recovery, Günther-Tulip19794 (48%)80 (41%)Van Ha et al, 2007Recovery, Günther-Tulip9729 (30%)28 (29%)Karmay-Jones et al, 2007Recovery, Günther-Tulip, OptEase446115 (26%)90 (20%)Seshadri et al, 2008Günther-Tulip4219 (45%)11 (26%)Yunus et al, 2008Günther-Tulip, OptEase1675 (3%)4 (2%)Hermsen et al, 2008Recovery, G2 Filter System9239 (42%)30 (33%)Helling et al, 2009Recovery, Günther-Tulip, G2 Filter System12540 (32%)32 (26%)Ko et al, 2009Günther-Tulip94 (preprotocol); 61 (postprotocol)32 (34% preprotocol); 35 (57% postprotocol)28 (30% preprotocol); 31 (51% postprotocol)Johnson et al, 2009Recovery, Günther-Tulip, OptEase7215 (21%)13 (18%)IVC, Inferior vena cava. Open table in a new tab Table IIReports of complications with FDA-approved retrievable IVC filtersAuthor, yearFilter typeComplicationsMajor complication rateAntevil et al, 2005Recovery, Günther-Tulip, OptEaseFilter infection; IVC thrombotic occlusion; migration; PE3%Ray et al, 2006Recovery, Günther-TulipBreakthrough PE; IVC thrombosis; IVC wall penetration; thrombosis in filter6%Sadaf et al, 2007CelectPenetration of IVC; migrationCase reportKarmay-Jones et al, 2007Recovery, Günther-Tulip, OptEaseMigration; tilt; breakthrough PE; symptomatic caval occlusion2%Veroux et al, 2008RecoveryPerforation of IVC, duodenum, aortic wall with mural thrombus; complete thrombosis of IVC, left iliac veinCase reportHelling et al, 2009Recovery, Günther-Tulip, G2 Filter SystemIVC thrombosis; tilt6%Gupta et al, 2009G2 Filter SystemPerforation of IVC and aorta with mural thrombus; lumbar body penetration; migrationCase reportKo et al, 2009Günther-TulipBreakthrough PE; tilt; IVC thrombosis; IVC wall penetration; thrombosis in filter5%Johnson et al, 2009Recovery, Günther-Tulip, OptEaseNo reported complications0%Parkin et al, 2009Günther-TulipPerforation of IVC; vertebral osteomyelitisCase reportIVC, Inferior vena cava; PE, pulmonary embolus. Open table in a new tab IVC, Inferior vena cava. IVC, Inferior vena cava; PE, pulmonary embolus. Caval penetration is a well-known complication of various types of IVC filters, and while it occurs in up to 40% of cases, it is thought to be largely asymptomatic.7Ray C.E. Kaufman J.A. Complications of inferior vena cava filters.Abdom Imaging. 1996; 21: 368-374Crossref PubMed Scopus (103) Google Scholar However, multiple case reports highlight the range of potential complications once the integrity of the cava has been breeched.8Veroux M. Tallarita T. Pennisi M. Veroux P. Late complication from a retrievable inferior vena cava filter with associated caval, aortic, and duodenal perforation: a case report.J Vasc Surg. 2008; 48: 223-225Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 9Parkin E. Serracino-Inglott F. Chalmers N. Smyth V. Symptomatic perforation of a retrievable inferior vena cava filter after a dwell time of 5 years.J Vasc Surg. 2009; 50: 417-419Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar There are also reports of early caval penetration with Celect filters, within 9 days of placement.10Sadaf A. Rasuli P. Olivier A. Hadziomerovic A. French G.J. Aquino J. et al.Significant caval penetration by the celect inferior vena cava filter: attributable to filter design?.J Vasc Interv Radiol. 2007; 18: 1447-1450Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Caval penetration is both a short-and long-term complication, and as this case report highlights, the longer the duration of penetration, the potentially more severe the complications (Table II). This is troubling, as less than half of all R-IVCFs are removed,2Ray C.E. Mitchell E. Zipser S. Kao E.Y. Brown C.F. Moneta G.L. Outcomes with retrievable inferior vena cava filters: a multicenter study.J Vasc Interv Radiol. 2006; 17: 1595-1604Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar most often due to lack of patient follow-up (Table I). However, there are cases when mechanical factors such as strut penetration, filter migration, tilt, or residual thrombus preclude removal of these “retrievable” devices even with appropriate follow-up. The trend toward retrievable filters began in 2003, when permanent IVC filters were formally approved for percutaneous removal by the FDA.11Kaufman J.A. Retrievable vena cava filters.Tech Vasc Interv Radiol. 2004; 7: 96-104Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar Since then, dedicated retrievable filters have come onto the market, such as the Celect model placed into our patient. The prophylactic indication for IVC filter placement now accounts for more than half of all IVC filters inserted, a trend that began in the 1990s.12Knudson M.M. Ikossi D.G. Khaw L. Morabito D. Speetzen L.S. Thromboembolism after trauma: an analysis of 1602 episodes from the American College of Surgeons National Trauma Data Bank.Ann Surg. 2004; 240 (discussion 496-8): 490-496Crossref PubMed Scopus (358) Google Scholar Since FDA approval, retrievable devices have become increasingly popular.1Aziz F. Spate K. Wong J. Aruny J. Sumpio B. Changing patterns in the use of inferior vena cava filters: review of a single center experience.J Am Coll Surg. 2007; 205: 564-569Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar The largest recipient group for R-IVCFs is multisystem trauma patients, a high-risk group for developing venous thromboembolism (VTE). These patients have an incidence of DVT from 40% to 80%; of the patients that get PE, roughly 50% will occur within 8 days of the accident, and 89% within 21 days.13Geerts W.H. Bergqvist D. Pineo G.F. Heit J.A. Samama C.M. Lassen M.R. et al.Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).Chest. 2008; 133: 381S-453SCrossref PubMed Scopus (3430) Google Scholar, 14Owings J.T. Kraut E. Battistella F. Cornelius J.T. O'Malley R. Timing of the occurrence of pulmonary embolism in trauma patients.Arch Surg. 1997; 132 (discussion 866-7): 862-866Crossref PubMed Scopus (79) Google Scholar, 15Sing R.F. Camp S.M. Heniford B.T. Rutherford E.J. Dix S. Reilly P.M. et al.Timing of pulmonary emboli after trauma: implications for retrievable vena cava filters.J Trauma. 2006; 60 (discussion 734-5): 732-734Crossref PubMed Scopus (48) Google Scholar With such extraordinary risks for VTE, those major trauma patients with contraindications for anticoagulation would seem to theoretically benefit from prophylactic R-IVCF insertion. This theoretical benefit, however, has been argued against in the trauma literature12Knudson M.M. Ikossi D.G. Khaw L. Morabito D. Speetzen L.S. Thromboembolism after trauma: an analysis of 1602 episodes from the American College of Surgeons National Trauma Data Bank.Ann Surg. 2004; 240 (discussion 496-8): 490-496Crossref PubMed Scopus (358) Google Scholar and has not been demonstrated prospectively.16Girard T.D. Philbrick J.T. Fritz Angle J. Becker D.M. Prophylactic vena cava filters for trauma patients: a systematic review of the literature.Thromb Res. 2003; 112: 261-267Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar Formal guidelines for the use of R-IVCFs do exist but are based primarily on expert opinion, given the lack of clinical evidence.13Geerts W.H. Bergqvist D. Pineo G.F. Heit J.A. Samama C.M. Lassen M.R. et al.Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).Chest. 2008; 133: 381S-453SCrossref PubMed Scopus (3430) Google Scholar, 17Kaufman J.A. Kinney T.B. Streiff M.B. Sing R.F. Proctor M.C. Becker D.M. et al.Guidelines for the use of retrievable and convertible vena cava filters: report from the Society of Interventional Radiology multidisciplinary consensus conference.Surg Obes Relat Dis. 2006; 2: 200-212Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 18Rogers F.B. Cipolle M.D. Velmahos G. Rozycki G. Luchette F.A. Practice management guidelines for the prevention of venous thromboembolism in trauma patients: the EAST practice management guidelines work group.J Trauma. 2002; 53: 142-164Crossref PubMed Scopus (508) Google Scholar Furthermore, while the risks of VTE are highest within 3 weeks of an accident, the vast majority of R-IVCFs are not removed (Table I).2Ray C.E. Mitchell E. Zipser S. Kao E.Y. Brown C.F. Moneta G.L. Outcomes with retrievable inferior vena cava filters: a multicenter study.J Vasc Interv Radiol. 2006; 17: 1595-1604Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar Considering the expansion in the use of R-IVCFs since their introduction in the absence of demonstrated benefits to patient outcomes, a recently convened multidisciplinary research consensus panel agreed that the highest priority for all IVC-filter research is their prophylactic use in trauma.19Kaufman J.A. Rundback J.H. Kee S.T. Geerts W. Gillespie D. Kahn S.R. et al.Development of a research agenda for inferior vena cava filters: proceedings from a multidisciplinary research consensus panel.J Vasc Interv Radiol. 2009; 20: 697-707Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar Several authors have questioned the rationale and safety of expanding use of prophylactic R-IVCFs in surgical or trauma populations,6Miyahara T. Miyata T. Shigematsu K. Deguchi J. Kimura H. Ishii S. et al.Clinical outcome and complications of temporary inferior vena cava filter placement.J Vasc Surg. 2006; 44: 620-624Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 20Karmy-Jones R. Jurkovich G.J. Velmahos G.C. Burdick T. Spaniolas K. Todd S.R. et al.Practice patterns and outcomes of retrievable vena cava filters in trauma patients: an AAST multicenter study.J Trauma. 2007; 62 (discussion 24-5): 17-24Crossref PubMed Scopus (200) Google Scholar and a consensus statement from the American College of Chest Physicians recommended avoidance of prophylactic IVC filters in trauma patients.13Geerts W.H. Bergqvist D. Pineo G.F. Heit J.A. Samama C.M. Lassen M.R. et al.Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).Chest. 2008; 133: 381S-453SCrossref PubMed Scopus (3430) Google Scholar This case report demonstrates that prophylactic R-IVCFs may be associated with significant risks, although their use after multisystem trauma is increasing, and most are not removed. Prophylactic R-IVCF-supporters site decreased PE and a theoretic mortality benefit, while detractors highlight the lack of evidence, poor retrieval rates, and rare but significant complications such as those documented here. We urge caution in the prophylactic use of R-IVCFs in the trauma population until there are data demonstrating benefit of such a management strategy.