- Email: [email protected]
Delayed Retroperitoneal Arterial Hemorrhage after Inferior Vena Cava (IVC) Filter Insertion: Case Report and Literature Review of Caval Perforations by IVC Filters
ANNALSo/ VASCULAR SURGERY - - t
Int.fnltioell Jouml of YisculalSorge~]
Delayed Retroperitoneal Arterial Hemorrhage after Inferior Vena Cava (IVC) Filter Insertion: Case Report and Literature Review of Caval Perforations by IVC Filters E. Baylor Woodward, MD, 1 Alik Farber, MD, 1 Willis H. Wagner, MD, 1 David V. Cossman, MD, 1 J. Louis Cohen, MD, ~ Jeffrey Silverman, MD, 2 Phillip M. Levin, MDJ, and David M. Frisch, MD, J Los Angeles, California
Transvenous placement of inferior vena cava (IVC) filters has become commonplace in selected patients with deep venous thrombosis (DVT) and pulmonary embolism (PE). IVC filters have been shown to have excellent therapeutic efficacy and low complication rates. Penetration of the IVC by filter hooks or struts has been reported and commonly noted to be inconsequential. We report a laceration of a lumbar artery by a stainless steel Greenfield (SSG) filter strut that resulted in a near fatal hemorrhage, and review the world literature on caval perforation by IVC filters.
INTRODUCTION Venous t h r o m b o e m b o l i s m is a relatively c o m m o n disease with significant morbidity and mortality. Prevention of p u l m o n a r y embolism (PE) is best m a n a g e d by anticoagulation. In patients w h o h a v e a contraindication to anticoagulation or w h o de-
1Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA. 2Department of Radiology, Cedars-Sinai Medical Center, Los Angeles, CA. 3Department of Medicine, Cedras-Sinai Medical Center, Los Angeles, CA. Presented at the Annual Meeting of the Southern California Vascular Surgical Society, Santa Barbara, CA, April 27-29, 2001. Correspondence to: A. Farber, MD, Cedars-Sinai Medical Center, Vascular Associates, 8631 West 3rd Street, Suite 615, Los Angeles, CA 90048, USA. Phone: 310-652-8132, Fax: 310-659-3815, E-maih [email protected]. Ann Vase Surg 2002; 16:193-196 DOI: 10.1007/si0016-001-0150-4 9 Annals of Vascular Surgery Inc. Published online: February 26, 2002
velop PE w h e n adequately anticoagulated, inferior v e n a cava (IVC) filter p l a c e m e n t has b e e n recomm e n d e d . Transvenous IVC filter p l a c e m e n t has replaced surgical v e n a cava plication or ligation for the p r e v e n t i o n of PE. IVC filters h a v e b e e n s h o w n to h a v e excellent therapeutic efficacy and n u m e r ous reports h a v e d e m o n s t r a t e d that insertion of these devices can be accomplished with minimal morbidity and mortality. ~3 Penetration of the IVC wall by hooks or struts of certain filters has been described to occur in up to 4 0 % of cases. 2'4 While most of these are asymptomatic, some can cause devastating sequellae. We report a case of a significant retroperitoneal h e m o r r h a g e associated with d e p l o y m e n t of the stainless steel Greenfield (SSG) filter, a n d review the p e r t i n e n t world literature.
CASE REPORT A 3 l - y e a r - o l d w o m a n presented with right popliteal deep v e n o u s thrombosis (DVT). Her medical 193
194
Woodward et al.
history was significant for oral contraceptive use. She was admitted to the hospital and h e p a r i n was initiated. Despite a d e q u a t e anticoagulation, spiral chest c o m p u t e d t o m o g r a p h y (CT) revealed a n e w PE. A SSG filter was placed via the right femoral vein. A p r e d e p l o y m e n t v e n o g r a m did not s h o w a n y IVC abnormality. The filter was placed b e l o w the renal veins w i t h o u t difficulty. She was started on c o u m a d i n and was discharged with an international normalized ratio (INR) of 2.7. On the s e v e n t h post-operative day the patient presented to the e m e r g e n c y d e p a r t m e n t with right abdominal and flank pain. She was n o r m o t e n s i v e and her e x a m was r e m a r k a b l e for mild right lower q u a d r a n t tenderness. Her h e m o g l o b i n a n d INR were 13.5 g/dL and 3.2, respectively. An a b d o m i n a l ultrasound was u n r e m a r k a b l e . She was a d m i t t e d to the hospital for observation. T w e n t y - f o u r hours later, her a b d o m i n a l pain increased in intensity. A b d o m i n a l magnetic reson a n c e imaging (MRI) revealed a right retroperitoneal h e m a t o m a (Fig. 1). Her systolic blood pressure dropped to 70 m m H g a n d h e r heart rate rose to 120 beats/rain. Physical e x a m i n a t i o n at that time revealed pallor and a firm, t e n d e r right a b d o m i n a l mass. H e m o g l o b i n was 9.7 g/dL. She was vigorously resuscitated with packed red blood cells and fresh frozen plasma and t a k e n to the operating room. Exploration revealed a large, right-sided retroperitoneal h e m a t o m a displacing the right colon medially. U p o n entering the h e m a t o m a , the clot was evacuated and a single arterial bleeder was noted. The source of the bleeding was a lacerated l u m b a r artery located lateral to the v e n a cava. The bleeding vessel was s u r r o u n d e d by a small cavity that had the a p p e a r a n c e of a r u p t u r e d p s e u d o a n eurysm. The offending vessel was controlled with clips. No other source of bleeding was found. C o m p o n e n t s of the IVC filter were not seen a n d no obvious defects in the v e n a cava were noted. The patient recovered and was discharged h o m e on the i 0th postoperative day. A postoperative a b d o m i n a l film showed the [VC filter to be in good position at the level of L1 vertebral body (Fig. 2). The clips used to control the bleeding l u m b a r vessel were noted to be in the vicinity of the IVC filter hooks.
DISCUSSION IVC filters h a v e b e e n d e m o n s t r a t e d to be slightly m o r e efficacious t h a n anticoagulation therapy in p r e v e n t i n g PE. 5 Because of the c o n c o m i t a n t
Annals of Vascular Surgery
Fig. 1. Axial T2-weighted fast-echo fat-suppressed image just below the level of the IVC filter feet shows a large retroperitoneal hematoma adjacent to the IVC. The hemaroma extends into the adjacent retroperitoneum and there is evidence of hemorrhage within the right psoas muscle with compression of the ascending colon.
Fig. 2. Supine abdominal radiograph shows an IVC filter with the nose of the filter at the L1 pedicle level.
increased risk of r e c u r r e n t DVT, indication of IVC filter p l a c e m e n t has b e e n reserved for those patients w h o c a n n o t tolerate or fail anticoagulation therapy. Since the introduction of the MobbinUddin umbrella in the 1960s, a succession of filter designs has yielded c o m p a c t devices that allow for p e r c u t a n e o u s catheter-based d e p l o y m e n t . l Six types o f fVC filters are available in the United
Vol. 16, No. 2, 2002
States, all w i t h low c o m p l i c a t i o n rates.l,4,5 Complications of IVC filter p l a c e m e n t include those that are p e r i p r o c e d u r a l a n d those that are delayed. Periprocedural events include p u n c t u r e site c o m plications, delivery system complications, a n d filter malposition, tilting, or i n c o m p l e t e o p e n i n g . 1"4 A r e v i e w of 1,765 IVC filters d e p l o y e d over a 2 6 - y e a r period at the M a s s a c h u s e t t s General Hospital (MGH) yielded a 0.3% incidence of m a j o r p e r i p r o c e d u r a l complications. 1 Delayed complications of IVC filter p l a c e m e n t include r e c u r r e n t PE, IVC thrombosis, p h l e g m a s i a cerulea dolens, filter migration, filter disruption, a n d IVC p e n e tration. 2,4 W e report a case of s y m p t o m a t i c IVC p e n e t r a tion that resulted in massive near-fatal retroperit o n e a l h e m o r r h a g e . At l a p a r o t o m y , the o n l y bleeding source n o t e d was a lacerated l u m b a r artery f o u n d in the vicinity of the IVC filter. Alt h o u g h filter e l e m e n t s w e r e n o t seen, the IVC was n o t mobilized. The dips u s e d to ligate the b l e e d e r w e r e adjacent to the filter h o o k s (Fig. 2). The c h r o n i c p s e u d o a n e u r y s m cavity s u r r o u n d i n g t h e bleeding vessel strongly suggests t h a t the IVC filter pierced the artery u p o n d e p l o y m e n t a n d t h a t t h e p s e u d o a n e u r y s m r u p t u r e d 7 clays later, resulting in hemorrhage. Anticoagulation probably potentiated free r u p t u r e of the p s e u d o a n e u r y s m days after implantation. Delayed retroperitoneal hemorrhage as a result of a lacerated l u m b a r artery b y a Greenfield filter has b e e n p r e v i o u s l y described in a patient w h o also was a n t i c o a g u l a t e d . 6 Because five of the six filters available in t h e United States require h o o k s or struts to e n s u r e fixation to the IVC, a degree of caval p e n e t r a t i o n is necessary for filter a t t a c h m e n t . Respiratory m o t i o n a n d adjacent aortic pulsation m a y potentiate furt h e r caval p e n e t r a t i o n . 4 E x p e r i m e n t s in w h i c h b o t h the t i t a n i u m Greenfield a n d SSG filters w e r e d e p l o y e d in s h e e p s h o w e d that o v e r 12 m o n t h s all filters d e m o n strated IVC p e n e t r a t i o n at o n e or m o r e sites. Histological analysis revealed intimal r e m o d e l i n g , c h r o n i c i n f l a m m a t i o n , a n d adventitial t h i n n i n g a r o u n d h o o k sites. 7 In a r e v i e w of collected case series, IVC wall p e n e t r a t i o n was f o u n d to o c c u r in 4 . 4 % of SSG filters, 3.5% of t i t a n i u m Greenfield filters, 37% of S i m o n Nitinol filters, a n d 3 8 % of Bird's Nest (BN) filters. 2 In the M G H series, 9 o u t of 96 patients u n d e r g o i n g a u t o p s y h a d e v i d e n c e of IVC penetration. N o n e of these patients died as a result of this finding.1 A l t h o u g h IVC p e n e t r a t i o n is relatively c o m m o n , few patients develop s y m p t o m s . In a series of 84 Greenfield IVC filters, o n e d e l a y e d r e t r o p e r i t o n e a l
Caval perforations by IVCfilters
195
h e m a t o m a was noted. 8 In the M G H series of 1,73l patients 1 a n d in a separate series of 267 p a t i e n t s w h o w e r e treated w i t h a BN filter, 9 n o cases of s y m p t o m a t i c IVC p e n e t r a t i o n w e r e reported. Despite p a u c i t y of s y m p t o m a t i c IVC p e n e t r a t i o n in larger series, case reports a b o u n d . S y m p t o m a t i c aortic, l~ ureteral, tx't3 a n d d u o d e n a l p e n e t r a tion 141s h a v e b e e n described, a l t h o u g h n o n e of these was associated w i t h a r e t r o p e r i t o n e a l h e m a t o m a . A l t h o u g h e n d o v a s c u l a r m a n a g e m e n t of IVC filter complications has a role in certain clinical scenarios, t r a n s l u m i n a l t r e a t m e n t of IVC p e n e t r a t i o n has n o t b e e n reported. In a stable patient, w h o m a y be bleeding, a n g i o g r a p h y to establish t h e diagnosis a n d e n d o v a s c u l a r t r e a t m e n t , such as e m b olization or stent graft p l a c e m e n t , m a y be considered. H o w e v e r , in a n u n s t a b l e patient, vascular control is best afforded b y rapid o p e r a t i v e intervention. M e c h a n i c a l i n t e r r u p t i o n of t h e IVC b y p e r c u t a n e o u s l y placed filters has b e c o m e a r o u t i n e l y perf o r m e d p r o c e d u r e w i t h acceptable c o m p l i c a t i o n rates. A l t h o u g h IVC p e n e t r a t i o n by filters is c o m m o n , incidence of s y m p t o m a t i c caval p e n e t r a t i o n is v e r y low. W e report a case of s y m p t o m a t i c caval p e n e t r a t i o n by a SSG filter t h a t resulted in a delayed, life-threatening r e t r o p e r i t o n e a l h e m o r rhage. This is the s e c o n d r e p o r t of such a n e v e n t c a u s e d by a lacerated l u m b a r artery. Despite t h e rarity of this complication, it s h o u l d be c o n s i d e r e d in the differential diagnosis of a patient w i t h a k n o w n IVC filter w h o presents w i t h h e m o r r h a g i c shock.
REFERENCES 1. Athanasoulis CA, Kanfman JA, Halpern EF, et al. Inferior vena caval filters: review of a 26-year single-center clinical experience. Radiology 2000;216:54-66. 2. Streiff MB. Vena caval filters: a comprehensive review. Blood 2000;95:3669-3677. 3. Greenfield LJ, Proctor MC. Twenty-year clinical experience with the Greenfield filter. Cardiovasc Surg 1995;3:199-205. 4. Ray CE Jr, Kaufman JA. Complications of inferior vena cava filters. Abdom Imaging 1996;21:368-374. 5. Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena caval filters in the prevention of pulmona~' embolism in patients with proximal deep-vein thrombosis. N Engl J Med 1998;338:409-415. 6. Howerton RM, Watkins M, Feldman L. Late arterial hemorrhage secondary to a Greenfield filter requiring operative intervention. Surgery 1991;109:265-268. 7. Proctor MC, Greenfield LJ, Cho KJ, et al. Assessment of apparent vena caval penetration by the Greenfield filter. J Endovasc Surg 1998;5:251-258. 8. Greenfield LJ, Zocco J, Wilk J, et al. Clinical experience with the Kim-Ray Greenfield vena caval filter. Ann Surg 1977; 185:692-698.
196
Woodward et al.
9. Wojtowycz MM, Stoehr T, C r u m m y AB, et al. The Bird's Nest inferior vena caval filter: review of a single-center experience. J Vasc Interv Radio11997;8: l 7 l* 179. I 0. Chintalapudi UB, Gutierrez OH, Azodo MY. Greenfield filter caval perforation causing an aortic mural t h r o m b u s and femoral artery occlusion. Cathet Cardiovasc Diagn 1997;41: 53-55. 1 i. Kurgan A, Nunnelee JD, Auer AI. Penetration of the wall of an abdominal aortic a n e u r y s m by a Greenfield filter prong: a late complication. J Vasc Surg 1993;I8:303-306 12. Goldman HB, Hanna K, Dmochowski RR. Ureteral injury secondary to an inferior vena caval filter. J Urol 1996;156: 1763. 13. Flanagan D, Creasy T, Chataway F, et al. Caval umbrella causing obstructive uropathy. Postgraduate Medical J o u r n a l 1996;72(846):235-237.
Annals of Vascular Surgery
14. Sarkar MR, Lemminger FM. An unusual cause of tipper gastrointestinal haemorrhage - - perforation of a vena cava filter into the d u o d e n u m . Vasa 1997;26:305-307. 15. Bianchini AU, Mehta SN, Mulder DS, et al. Duodenal perforation by a Greenfield filter: endoscopic diagnosis. Am J Gastroenterol 1997;92:686-687. 16. Taheri SA, Kulaylat MN, J o h n s o n E, et al. A complication of the Greenfield filter: fracture and distal migration of two struts - - a case report. J Vasc Surg 1992;16:9699. I7. Zahrani HAA. Bird's nest inferior vena caval filter migration into the d u o d e n u m : a rare cause of upper gastrointestinal bleeding. J Endovasc Surg 1995;2:372-375. 18. Dardik A, Campbell KA, Yeo CJ, et al. Vena cava filter ensnarement and delayed migration: an unusual series of cases. J Vasc Surg 1997;26:869-874.
Int.fnltioell Jouml of YisculalSorge~]
Delayed Retroperitoneal Arterial Hemorrhage after Inferior Vena Cava (IVC) Filter Insertion: Case Report and Literature Review of Caval Perforations by IVC Filters E. Baylor Woodward, MD, 1 Alik Farber, MD, 1 Willis H. Wagner, MD, 1 David V. Cossman, MD, 1 J. Louis Cohen, MD, ~ Jeffrey Silverman, MD, 2 Phillip M. Levin, MDJ, and David M. Frisch, MD, J Los Angeles, California
Transvenous placement of inferior vena cava (IVC) filters has become commonplace in selected patients with deep venous thrombosis (DVT) and pulmonary embolism (PE). IVC filters have been shown to have excellent therapeutic efficacy and low complication rates. Penetration of the IVC by filter hooks or struts has been reported and commonly noted to be inconsequential. We report a laceration of a lumbar artery by a stainless steel Greenfield (SSG) filter strut that resulted in a near fatal hemorrhage, and review the world literature on caval perforation by IVC filters.
INTRODUCTION Venous t h r o m b o e m b o l i s m is a relatively c o m m o n disease with significant morbidity and mortality. Prevention of p u l m o n a r y embolism (PE) is best m a n a g e d by anticoagulation. In patients w h o h a v e a contraindication to anticoagulation or w h o de-
1Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA. 2Department of Radiology, Cedars-Sinai Medical Center, Los Angeles, CA. 3Department of Medicine, Cedras-Sinai Medical Center, Los Angeles, CA. Presented at the Annual Meeting of the Southern California Vascular Surgical Society, Santa Barbara, CA, April 27-29, 2001. Correspondence to: A. Farber, MD, Cedars-Sinai Medical Center, Vascular Associates, 8631 West 3rd Street, Suite 615, Los Angeles, CA 90048, USA. Phone: 310-652-8132, Fax: 310-659-3815, E-maih [email protected]. Ann Vase Surg 2002; 16:193-196 DOI: 10.1007/si0016-001-0150-4 9 Annals of Vascular Surgery Inc. Published online: February 26, 2002
velop PE w h e n adequately anticoagulated, inferior v e n a cava (IVC) filter p l a c e m e n t has b e e n recomm e n d e d . Transvenous IVC filter p l a c e m e n t has replaced surgical v e n a cava plication or ligation for the p r e v e n t i o n of PE. IVC filters h a v e b e e n s h o w n to h a v e excellent therapeutic efficacy and n u m e r ous reports h a v e d e m o n s t r a t e d that insertion of these devices can be accomplished with minimal morbidity and mortality. ~3 Penetration of the IVC wall by hooks or struts of certain filters has been described to occur in up to 4 0 % of cases. 2'4 While most of these are asymptomatic, some can cause devastating sequellae. We report a case of a significant retroperitoneal h e m o r r h a g e associated with d e p l o y m e n t of the stainless steel Greenfield (SSG) filter, a n d review the p e r t i n e n t world literature.
CASE REPORT A 3 l - y e a r - o l d w o m a n presented with right popliteal deep v e n o u s thrombosis (DVT). Her medical 193
194
Woodward et al.
history was significant for oral contraceptive use. She was admitted to the hospital and h e p a r i n was initiated. Despite a d e q u a t e anticoagulation, spiral chest c o m p u t e d t o m o g r a p h y (CT) revealed a n e w PE. A SSG filter was placed via the right femoral vein. A p r e d e p l o y m e n t v e n o g r a m did not s h o w a n y IVC abnormality. The filter was placed b e l o w the renal veins w i t h o u t difficulty. She was started on c o u m a d i n and was discharged with an international normalized ratio (INR) of 2.7. On the s e v e n t h post-operative day the patient presented to the e m e r g e n c y d e p a r t m e n t with right abdominal and flank pain. She was n o r m o t e n s i v e and her e x a m was r e m a r k a b l e for mild right lower q u a d r a n t tenderness. Her h e m o g l o b i n a n d INR were 13.5 g/dL and 3.2, respectively. An a b d o m i n a l ultrasound was u n r e m a r k a b l e . She was a d m i t t e d to the hospital for observation. T w e n t y - f o u r hours later, her a b d o m i n a l pain increased in intensity. A b d o m i n a l magnetic reson a n c e imaging (MRI) revealed a right retroperitoneal h e m a t o m a (Fig. 1). Her systolic blood pressure dropped to 70 m m H g a n d h e r heart rate rose to 120 beats/rain. Physical e x a m i n a t i o n at that time revealed pallor and a firm, t e n d e r right a b d o m i n a l mass. H e m o g l o b i n was 9.7 g/dL. She was vigorously resuscitated with packed red blood cells and fresh frozen plasma and t a k e n to the operating room. Exploration revealed a large, right-sided retroperitoneal h e m a t o m a displacing the right colon medially. U p o n entering the h e m a t o m a , the clot was evacuated and a single arterial bleeder was noted. The source of the bleeding was a lacerated l u m b a r artery located lateral to the v e n a cava. The bleeding vessel was s u r r o u n d e d by a small cavity that had the a p p e a r a n c e of a r u p t u r e d p s e u d o a n eurysm. The offending vessel was controlled with clips. No other source of bleeding was found. C o m p o n e n t s of the IVC filter were not seen a n d no obvious defects in the v e n a cava were noted. The patient recovered and was discharged h o m e on the i 0th postoperative day. A postoperative a b d o m i n a l film showed the [VC filter to be in good position at the level of L1 vertebral body (Fig. 2). The clips used to control the bleeding l u m b a r vessel were noted to be in the vicinity of the IVC filter hooks.
DISCUSSION IVC filters h a v e b e e n d e m o n s t r a t e d to be slightly m o r e efficacious t h a n anticoagulation therapy in p r e v e n t i n g PE. 5 Because of the c o n c o m i t a n t
Annals of Vascular Surgery
Fig. 1. Axial T2-weighted fast-echo fat-suppressed image just below the level of the IVC filter feet shows a large retroperitoneal hematoma adjacent to the IVC. The hemaroma extends into the adjacent retroperitoneum and there is evidence of hemorrhage within the right psoas muscle with compression of the ascending colon.
Fig. 2. Supine abdominal radiograph shows an IVC filter with the nose of the filter at the L1 pedicle level.
increased risk of r e c u r r e n t DVT, indication of IVC filter p l a c e m e n t has b e e n reserved for those patients w h o c a n n o t tolerate or fail anticoagulation therapy. Since the introduction of the MobbinUddin umbrella in the 1960s, a succession of filter designs has yielded c o m p a c t devices that allow for p e r c u t a n e o u s catheter-based d e p l o y m e n t . l Six types o f fVC filters are available in the United
Vol. 16, No. 2, 2002
States, all w i t h low c o m p l i c a t i o n rates.l,4,5 Complications of IVC filter p l a c e m e n t include those that are p e r i p r o c e d u r a l a n d those that are delayed. Periprocedural events include p u n c t u r e site c o m plications, delivery system complications, a n d filter malposition, tilting, or i n c o m p l e t e o p e n i n g . 1"4 A r e v i e w of 1,765 IVC filters d e p l o y e d over a 2 6 - y e a r period at the M a s s a c h u s e t t s General Hospital (MGH) yielded a 0.3% incidence of m a j o r p e r i p r o c e d u r a l complications. 1 Delayed complications of IVC filter p l a c e m e n t include r e c u r r e n t PE, IVC thrombosis, p h l e g m a s i a cerulea dolens, filter migration, filter disruption, a n d IVC p e n e tration. 2,4 W e report a case of s y m p t o m a t i c IVC p e n e t r a tion that resulted in massive near-fatal retroperit o n e a l h e m o r r h a g e . At l a p a r o t o m y , the o n l y bleeding source n o t e d was a lacerated l u m b a r artery f o u n d in the vicinity of the IVC filter. Alt h o u g h filter e l e m e n t s w e r e n o t seen, the IVC was n o t mobilized. The dips u s e d to ligate the b l e e d e r w e r e adjacent to the filter h o o k s (Fig. 2). The c h r o n i c p s e u d o a n e u r y s m cavity s u r r o u n d i n g t h e bleeding vessel strongly suggests t h a t the IVC filter pierced the artery u p o n d e p l o y m e n t a n d t h a t t h e p s e u d o a n e u r y s m r u p t u r e d 7 clays later, resulting in hemorrhage. Anticoagulation probably potentiated free r u p t u r e of the p s e u d o a n e u r y s m days after implantation. Delayed retroperitoneal hemorrhage as a result of a lacerated l u m b a r artery b y a Greenfield filter has b e e n p r e v i o u s l y described in a patient w h o also was a n t i c o a g u l a t e d . 6 Because five of the six filters available in t h e United States require h o o k s or struts to e n s u r e fixation to the IVC, a degree of caval p e n e t r a t i o n is necessary for filter a t t a c h m e n t . Respiratory m o t i o n a n d adjacent aortic pulsation m a y potentiate furt h e r caval p e n e t r a t i o n . 4 E x p e r i m e n t s in w h i c h b o t h the t i t a n i u m Greenfield a n d SSG filters w e r e d e p l o y e d in s h e e p s h o w e d that o v e r 12 m o n t h s all filters d e m o n strated IVC p e n e t r a t i o n at o n e or m o r e sites. Histological analysis revealed intimal r e m o d e l i n g , c h r o n i c i n f l a m m a t i o n , a n d adventitial t h i n n i n g a r o u n d h o o k sites. 7 In a r e v i e w of collected case series, IVC wall p e n e t r a t i o n was f o u n d to o c c u r in 4 . 4 % of SSG filters, 3.5% of t i t a n i u m Greenfield filters, 37% of S i m o n Nitinol filters, a n d 3 8 % of Bird's Nest (BN) filters. 2 In the M G H series, 9 o u t of 96 patients u n d e r g o i n g a u t o p s y h a d e v i d e n c e of IVC penetration. N o n e of these patients died as a result of this finding.1 A l t h o u g h IVC p e n e t r a t i o n is relatively c o m m o n , few patients develop s y m p t o m s . In a series of 84 Greenfield IVC filters, o n e d e l a y e d r e t r o p e r i t o n e a l
Caval perforations by IVCfilters
195
h e m a t o m a was noted. 8 In the M G H series of 1,73l patients 1 a n d in a separate series of 267 p a t i e n t s w h o w e r e treated w i t h a BN filter, 9 n o cases of s y m p t o m a t i c IVC p e n e t r a t i o n w e r e reported. Despite p a u c i t y of s y m p t o m a t i c IVC p e n e t r a t i o n in larger series, case reports a b o u n d . S y m p t o m a t i c aortic, l~ ureteral, tx't3 a n d d u o d e n a l p e n e t r a tion 141s h a v e b e e n described, a l t h o u g h n o n e of these was associated w i t h a r e t r o p e r i t o n e a l h e m a t o m a . A l t h o u g h e n d o v a s c u l a r m a n a g e m e n t of IVC filter complications has a role in certain clinical scenarios, t r a n s l u m i n a l t r e a t m e n t of IVC p e n e t r a t i o n has n o t b e e n reported. In a stable patient, w h o m a y be bleeding, a n g i o g r a p h y to establish t h e diagnosis a n d e n d o v a s c u l a r t r e a t m e n t , such as e m b olization or stent graft p l a c e m e n t , m a y be considered. H o w e v e r , in a n u n s t a b l e patient, vascular control is best afforded b y rapid o p e r a t i v e intervention. M e c h a n i c a l i n t e r r u p t i o n of t h e IVC b y p e r c u t a n e o u s l y placed filters has b e c o m e a r o u t i n e l y perf o r m e d p r o c e d u r e w i t h acceptable c o m p l i c a t i o n rates. A l t h o u g h IVC p e n e t r a t i o n by filters is c o m m o n , incidence of s y m p t o m a t i c caval p e n e t r a t i o n is v e r y low. W e report a case of s y m p t o m a t i c caval p e n e t r a t i o n by a SSG filter t h a t resulted in a delayed, life-threatening r e t r o p e r i t o n e a l h e m o r rhage. This is the s e c o n d r e p o r t of such a n e v e n t c a u s e d by a lacerated l u m b a r artery. Despite t h e rarity of this complication, it s h o u l d be c o n s i d e r e d in the differential diagnosis of a patient w i t h a k n o w n IVC filter w h o presents w i t h h e m o r r h a g i c shock.
REFERENCES 1. Athanasoulis CA, Kanfman JA, Halpern EF, et al. Inferior vena caval filters: review of a 26-year single-center clinical experience. Radiology 2000;216:54-66. 2. Streiff MB. Vena caval filters: a comprehensive review. Blood 2000;95:3669-3677. 3. Greenfield LJ, Proctor MC. Twenty-year clinical experience with the Greenfield filter. Cardiovasc Surg 1995;3:199-205. 4. Ray CE Jr, Kaufman JA. Complications of inferior vena cava filters. Abdom Imaging 1996;21:368-374. 5. Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena caval filters in the prevention of pulmona~' embolism in patients with proximal deep-vein thrombosis. N Engl J Med 1998;338:409-415. 6. Howerton RM, Watkins M, Feldman L. Late arterial hemorrhage secondary to a Greenfield filter requiring operative intervention. Surgery 1991;109:265-268. 7. Proctor MC, Greenfield LJ, Cho KJ, et al. Assessment of apparent vena caval penetration by the Greenfield filter. J Endovasc Surg 1998;5:251-258. 8. Greenfield LJ, Zocco J, Wilk J, et al. Clinical experience with the Kim-Ray Greenfield vena caval filter. Ann Surg 1977; 185:692-698.
196
Woodward et al.
9. Wojtowycz MM, Stoehr T, C r u m m y AB, et al. The Bird's Nest inferior vena caval filter: review of a single-center experience. J Vasc Interv Radio11997;8: l 7 l* 179. I 0. Chintalapudi UB, Gutierrez OH, Azodo MY. Greenfield filter caval perforation causing an aortic mural t h r o m b u s and femoral artery occlusion. Cathet Cardiovasc Diagn 1997;41: 53-55. 1 i. Kurgan A, Nunnelee JD, Auer AI. Penetration of the wall of an abdominal aortic a n e u r y s m by a Greenfield filter prong: a late complication. J Vasc Surg 1993;I8:303-306 12. Goldman HB, Hanna K, Dmochowski RR. Ureteral injury secondary to an inferior vena caval filter. J Urol 1996;156: 1763. 13. Flanagan D, Creasy T, Chataway F, et al. Caval umbrella causing obstructive uropathy. Postgraduate Medical J o u r n a l 1996;72(846):235-237.
Annals of Vascular Surgery
14. Sarkar MR, Lemminger FM. An unusual cause of tipper gastrointestinal haemorrhage - - perforation of a vena cava filter into the d u o d e n u m . Vasa 1997;26:305-307. 15. Bianchini AU, Mehta SN, Mulder DS, et al. Duodenal perforation by a Greenfield filter: endoscopic diagnosis. Am J Gastroenterol 1997;92:686-687. 16. Taheri SA, Kulaylat MN, J o h n s o n E, et al. A complication of the Greenfield filter: fracture and distal migration of two struts - - a case report. J Vasc Surg 1992;16:9699. I7. Zahrani HAA. Bird's nest inferior vena caval filter migration into the d u o d e n u m : a rare cause of upper gastrointestinal bleeding. J Endovasc Surg 1995;2:372-375. 18. Dardik A, Campbell KA, Yeo CJ, et al. Vena cava filter ensnarement and delayed migration: an unusual series of cases. J Vasc Surg 1997;26:869-874.