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Long-term Follow-up of Ectopic Intracardiac Greenfield Filter
Long-term Follow-up of Ectopic lntracarcliac Greenfield Filter* Luis F. Rodriguez, M.D.; and FrankS . Saltiel, M.D.
Greenfield 6lter inferior vena caval interruption is an effective approach for pulmonary embolism prophylaxis. Serious complications, however, have been documented following migration of these filters. We report a case of Greenfield 6lter migration to the right side of the heart. Evaluation of these filters, as well as indications for retrieval, are discussed. (Chest 1993; 104:611-12)
I
IVC =inferior vena cava
I
ntracaval filtration with the Greenfield device has become a well-established method for the prevention of pulmonary embolism in patients with deep vein thrombosis in whom anticoagulation is contraindicated, and it has been shown to be efficacious in 95 percent of cases. 1 There are , however, a number of serious complications associated with the use of this filter, including recurrent embolism, misplacement with a major vein, thrombus formation above the apex of the filter, and filter migration.• In this article, we present a case involving migration of a Greenfield filter into the right side of the heart. Because of inability to retrieve the filter percutaneously, the device was left in place and the patient was followed up for more than seven years. CASE REPORT
A 78-yeaN>ld woman with carcinoma of the cecum underwent an uneventful right hemicolectomy. Two weeks later, during hospital readmission for an enterocutaneous fistula repair, the patient developed a right pulmonary embolism (confirmed by ventilation perfusion scan and angiography). She was begun on a regimen of heparin anticoagulation, but this was discontinued five days later after the development of bleeding duodenal ulcers. Since she remained at high risk for recurrent pulmonary embolism, a Greenfield cava filter was placed percutaneously on postoperative day 16. Under fluoroscopic guidance, the filter was released at the L3 level of the inferior vena cava (IVC). However, fluoroscopic evaluation at the end of the procedure showed that the filter had migrated into the right side of the heart. The patient did not show signs of conduction disturbance or hemodynamic instability. She was taken to the ICU for observation, where she remained asymptomatic. An ECG obtained after filter migration revealed a new incomplete right bundle branch block pattern that persisted throughout her hospitalization. Two days after filter placement, percutaneous retrieval with hook and guide wire was attempted without success. She subsequently underwent IVC clipping. The patient did well postoperatively and had no evidence of recurrent pulmonary embolism. The patient has remained asymptomatic for more than 80 months. Serial chest radiographs reveal a Greenfield filter in the right side of the heart, which has remained unchanged over time. Serial ECGs reveal persistent incomplete right bundle branch block without other conduction abnormalities. At this time, transthoracic echocardiography shows the filter to be straddling the tricuspid valve (Fig 1). Although there is normal right ventricular systolic *From the Department of Surgery and Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, Calif. Reprint relJUB.Bts: Dr. Saltiel, Department of Cardiovascular Medi-
cine, Stanjord University Hospital, Stanford, CA 94305
FI G URE I. Transthoracic echocardiogram at 80 months. The Greenfield filter is seen straddling the tricuspid valve, with the main portion in the right ventricle. Both the right atrium and right ventricle are enlarged . function, both the right atrium and ventricle are enhtrKed, and severe tricuspid regurgitation is present.
DISCUSSION
In our review of the literature , we found a total of 18 reported cases of intracardiac Greenfield filter migration. 1 " Several of these ectopic filters have resulted in severe complications, including ventricular arrhythmias," penetration into the myocardial wall and tricuspid valve, • pericardia) tamponade,' and myocardial infarction as a result of right coronary artery dissection." Because of these complications, most reported cases of filter migration to the heart have been managed by filter retrieval , either percutaneously or surgically (generally when percutaneous retrieval was unsuccessful). Of these 18 reported cases, five filters were removed percutaneously, six surgically, and seven left in place. In two of the operatively treated patients, surgical removal did not occur until after the development of serious complications, namely, pericardia) tamponade and coronary dissection.5 ·6 In both cases, however, these complications arose a significant amount of time after filter migration (2 and 24 weeks, respectively). The primary reason for leaving the filter in place has been failure to retrieve the device percutaneously and poor operative riskY Bach et al' reported a case in which a right heart ectopic Greenfield filter resulted in multiple cardiac arrhythmias that were controlled with electrical cardioversion and antiarrhythmic medications. More recently, Gelbfish and Ascer" reported three cases in which filters were left in the right side of the heart without adverse consequences related to the ectopic devices. In one case, the patient was followed for 60 months without complications or change in filter location. Although the risk of serious complications related to filter migration appears to be high , the literature does not seem to substantiate the need for immediate surgical removal in all cases. Initial management should include fluoroscopically guided percutaneous filter retrieval when feasible, that is, right atrial localization and no evidence of valvular or CHEST I 104 I 2 I AUGUST. 1993
611
myocardial wall attachment. Schrwider and Bednarkiewicz,'' Tsai d al. '" and Yakes" havt• described techniques for pt•rcutaneous retrieval of ectopic Greenfield filters. Transesophagealechocardiography should be considered prior to retrit>val for localization, evaluation of valvular compromise, and assessment of wall penetration. When percutaneous retrieval is tmsuccessful or contrain done to detect any new conduction disturbances. Radiographic evaluation for evidt•rH.·e of further filter migration should also he done periodically. If changt• in filter position is noted, repeated echocardiography should he considered . Operative intervention should most likely lw limited to patients with intractablt• arrhythmias, valvular dysfunction. or evidence of tamponade. In summary, in an asymptomatic patient without evidence of further filter migration or increasing conduction system almormalities in whom percutaneous removal is unsucct•ssful or unfeasible, the morbidity associated with leaving the filter in place must he weighed against that of surgical rt>moval. REFERENCES CrePnfidd LJ, Zoem J. Wilk J, Sehrot>der TM, Elkins RC. Clinical experience with the Kimray-Greenfield vena cava filter. Ann Sur!! 1977; 185:692-98 2 Carahasi HA. Moritz 1\IJ, Jarrell BE. Complications enmuntered with tlw ust· of the Greenfield filter. Am J Surg 1987; 154:163-
68 3 Bach JR . Zaneuski R. Lee H . Cardiac arrhythmias from a malpositioned Greenfield filter in a tnmmatk quadriplegic. Am J Phys Med Rehahil 1990; 69:251-53 4 Castarwda F. Herrera M. CraAA AH, Salamonowitz E , Lund G, Castaneda-Zuniga \\'R , et a!. The migration of a Kimrav( :reenfield filter from the inferior vena cava to the right ventricle. Radiology 19&'3: 149:690 5 Lahey SJ, l\.ley<>r LP, Karchmer A\V, Cronin J. Czorniak 1\1, Ma~s PR, et al. Misplaced caval filter and subsequent pericardia! tamponade. Ann Thorae Sur!! 1991; 51:299-301 6 Puram B, Maley TJ, White NM. Rotman HH. Miller G. Acute myocardial infarction resulting from the migration of a Greenfit·ld filter. Chest 1990: 98: 1510-ll 7 Scurr JH, Jarrett PE . \Vastell C. The treatment of recurrent pulmonary embolism: experience with the Greenfield filter. Ann H Coli Surg 198.'3: 65:233-34 8 Celhfish CA. Ascer E. lntracardiac and intrapulmonary Greenfield filters: a long-term follow-up. J Vase Surg 1991: 14:614-17 9 Schneider PA , Bednarkiewicz M. Percutaneous retrieval of Kimray-Grt•t·nfield vena caval filter. Radiology 1985; 156:547 10 Tsai FY. Myt•rs TY. Ashraf A, Shah OC. Aberrant placement of a Kimray-Greenfield filter in the right atrium: percutaneous retrieval. Radiology 1988: 167:423-24 II Yakes \\'F. Percutaneous n·trieval of Kimray-Creenfield filter from the right atrium and placenwnt in inferior vena cava. RadioloJ..'Y 1988: 169:849-51 12 Akins C\\~ Thurer RL. Waltman AC, Margolit•s M!'l;. Schneider RC. A misplaced caval filter: its removal from the heart without cardiopulmonary bypass. Arch Surg 1980: 115:1133 13 lseh JH,Simmaker HR Jr. Embolization of a caval umhrella: dis~·ussion and report of successful removal from the ventricle. J Thorac Cardiovasc Sur!! 1976: 72:256-58 14 Hirsh SB. Harrington ER. Miller CM. Estioko MR. llaimov M. Accidental placement of the Greenfield filter in the ht•art: report of two eases. J Vase Surg 19H7: 6:609-10
612
Massive Hemoptysis Caused by a Ruptured Subclavian Artery Aneurysm* Ming-Ho \l'u. M.D .. FC.C .P: Wu-\IH ILii . M.D.: Mu- )i•n Un . M.D.: 11111I.Van-Song Chou. M.D.
We report a case of left subclavian artery aneurysm, which ruptured and penetrated through the left upper lung parenchyma causing massive hemoptysis and a left hemothorax. Through sternothoracotomy, tangential aneurysmorrhaphy under proximal control and left upper pulmonary lobectomy were performed. The patient is doing well after nearly three years of follow-up. (Chest 1993; 104:612-13) ,4.neurysms of the suhclm·ian artery are ran'. ,.n Rupture of
~ this artery causing massive hemoptysis appears to he an unusual prest•ntation . This prompted us to report on the clinical course and management of tlw case at hand. CASE HEPOHT A 50-y•·ar-old woman was rPfi•rn·d to the ~ational Cheng-Kung Unive rsity Hospital on July 19. 19H9. because of massive hemoptysis. Slw had chronic cough lin· one year and had lwgun to expectorate hlood-tinged sputum five days lwfore. When she visited a private dinit·. the che st x-ray film (Fig I) showed a mass density in the upper part of the left lung. Two days hefore this admission, massive hemoptnis occurred and she was transferred to a hospital. where the subsequent chest x-ray film (Fig 2) showed the mass density progn'ssiY~·Iy .-nlarged and a Jpft hemothor:lx. Upon referral to our hospital. the chest computed tomography scan revealed a *From the Division of Thoracic Sur!!ery, Department of Sur!!ery, ~ational Cheng Kung l ' nin•rsity Hospital. 1i1inan. Taiwan. Republic of China. Reprint rNflll'sls: Dr. \Vu , Dqmrlmenl of Sw·gery, National Cheng Ku Unit,ersity Hospital , 'f(Jinan, 1ilircan. ROC
Frcl'IIE I. Tht• mass dt•nsity in the left upper lung field indicates a left suhdavian artery aneurysm. Massive Hemoptysis Caused by Ruptured Subclavian Artery Aneurysm (Wu eta/)
Greenfield 6lter inferior vena caval interruption is an effective approach for pulmonary embolism prophylaxis. Serious complications, however, have been documented following migration of these filters. We report a case of Greenfield 6lter migration to the right side of the heart. Evaluation of these filters, as well as indications for retrieval, are discussed. (Chest 1993; 104:611-12)
I
IVC =inferior vena cava
I
ntracaval filtration with the Greenfield device has become a well-established method for the prevention of pulmonary embolism in patients with deep vein thrombosis in whom anticoagulation is contraindicated, and it has been shown to be efficacious in 95 percent of cases. 1 There are , however, a number of serious complications associated with the use of this filter, including recurrent embolism, misplacement with a major vein, thrombus formation above the apex of the filter, and filter migration.• In this article, we present a case involving migration of a Greenfield filter into the right side of the heart. Because of inability to retrieve the filter percutaneously, the device was left in place and the patient was followed up for more than seven years. CASE REPORT
A 78-yeaN>ld woman with carcinoma of the cecum underwent an uneventful right hemicolectomy. Two weeks later, during hospital readmission for an enterocutaneous fistula repair, the patient developed a right pulmonary embolism (confirmed by ventilation perfusion scan and angiography). She was begun on a regimen of heparin anticoagulation, but this was discontinued five days later after the development of bleeding duodenal ulcers. Since she remained at high risk for recurrent pulmonary embolism, a Greenfield cava filter was placed percutaneously on postoperative day 16. Under fluoroscopic guidance, the filter was released at the L3 level of the inferior vena cava (IVC). However, fluoroscopic evaluation at the end of the procedure showed that the filter had migrated into the right side of the heart. The patient did not show signs of conduction disturbance or hemodynamic instability. She was taken to the ICU for observation, where she remained asymptomatic. An ECG obtained after filter migration revealed a new incomplete right bundle branch block pattern that persisted throughout her hospitalization. Two days after filter placement, percutaneous retrieval with hook and guide wire was attempted without success. She subsequently underwent IVC clipping. The patient did well postoperatively and had no evidence of recurrent pulmonary embolism. The patient has remained asymptomatic for more than 80 months. Serial chest radiographs reveal a Greenfield filter in the right side of the heart, which has remained unchanged over time. Serial ECGs reveal persistent incomplete right bundle branch block without other conduction abnormalities. At this time, transthoracic echocardiography shows the filter to be straddling the tricuspid valve (Fig 1). Although there is normal right ventricular systolic *From the Department of Surgery and Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, Calif. Reprint relJUB.Bts: Dr. Saltiel, Department of Cardiovascular Medi-
cine, Stanjord University Hospital, Stanford, CA 94305
FI G URE I. Transthoracic echocardiogram at 80 months. The Greenfield filter is seen straddling the tricuspid valve, with the main portion in the right ventricle. Both the right atrium and right ventricle are enlarged . function, both the right atrium and ventricle are enhtrKed, and severe tricuspid regurgitation is present.
DISCUSSION
In our review of the literature , we found a total of 18 reported cases of intracardiac Greenfield filter migration. 1 " Several of these ectopic filters have resulted in severe complications, including ventricular arrhythmias," penetration into the myocardial wall and tricuspid valve, • pericardia) tamponade,' and myocardial infarction as a result of right coronary artery dissection." Because of these complications, most reported cases of filter migration to the heart have been managed by filter retrieval , either percutaneously or surgically (generally when percutaneous retrieval was unsuccessful). Of these 18 reported cases, five filters were removed percutaneously, six surgically, and seven left in place. In two of the operatively treated patients, surgical removal did not occur until after the development of serious complications, namely, pericardia) tamponade and coronary dissection.5 ·6 In both cases, however, these complications arose a significant amount of time after filter migration (2 and 24 weeks, respectively). The primary reason for leaving the filter in place has been failure to retrieve the device percutaneously and poor operative riskY Bach et al' reported a case in which a right heart ectopic Greenfield filter resulted in multiple cardiac arrhythmias that were controlled with electrical cardioversion and antiarrhythmic medications. More recently, Gelbfish and Ascer" reported three cases in which filters were left in the right side of the heart without adverse consequences related to the ectopic devices. In one case, the patient was followed for 60 months without complications or change in filter location. Although the risk of serious complications related to filter migration appears to be high , the literature does not seem to substantiate the need for immediate surgical removal in all cases. Initial management should include fluoroscopically guided percutaneous filter retrieval when feasible, that is, right atrial localization and no evidence of valvular or CHEST I 104 I 2 I AUGUST. 1993
611
myocardial wall attachment. Schrwider and Bednarkiewicz,'' Tsai d al. '" and Yakes" havt• described techniques for pt•rcutaneous retrieval of ectopic Greenfield filters. Transesophagealechocardiography should be considered prior to retrit>val for localization, evaluation of valvular compromise, and assessment of wall penetration. When percutaneous retrieval is tmsuccessful or contrain
68 3 Bach JR . Zaneuski R. Lee H . Cardiac arrhythmias from a malpositioned Greenfield filter in a tnmmatk quadriplegic. Am J Phys Med Rehahil 1990; 69:251-53 4 Castarwda F. Herrera M. CraAA AH, Salamonowitz E , Lund G, Castaneda-Zuniga \\'R , et a!. The migration of a Kimrav( :reenfield filter from the inferior vena cava to the right ventricle. Radiology 19&'3: 149:690 5 Lahey SJ, l\.ley<>r LP, Karchmer A\V, Cronin J. Czorniak 1\1, Ma~s PR, et al. Misplaced caval filter and subsequent pericardia! tamponade. Ann Thorae Sur!! 1991; 51:299-301 6 Puram B, Maley TJ, White NM. Rotman HH. Miller G. Acute myocardial infarction resulting from the migration of a Greenfit·ld filter. Chest 1990: 98: 1510-ll 7 Scurr JH, Jarrett PE . \Vastell C. The treatment of recurrent pulmonary embolism: experience with the Greenfield filter. Ann H Coli Surg 198.'3: 65:233-34 8 Celhfish CA. Ascer E. lntracardiac and intrapulmonary Greenfield filters: a long-term follow-up. J Vase Surg 1991: 14:614-17 9 Schneider PA , Bednarkiewicz M. Percutaneous retrieval of Kimray-Grt•t·nfield vena caval filter. Radiology 1985; 156:547 10 Tsai FY. Myt•rs TY. Ashraf A, Shah OC. Aberrant placement of a Kimray-Greenfield filter in the right atrium: percutaneous retrieval. Radiology 1988: 167:423-24 II Yakes \\'F. Percutaneous n·trieval of Kimray-Creenfield filter from the right atrium and placenwnt in inferior vena cava. RadioloJ..'Y 1988: 169:849-51 12 Akins C\\~ Thurer RL. Waltman AC, Margolit•s M!'l;. Schneider RC. A misplaced caval filter: its removal from the heart without cardiopulmonary bypass. Arch Surg 1980: 115:1133 13 lseh JH,Simmaker HR Jr. Embolization of a caval umhrella: dis~·ussion and report of successful removal from the ventricle. J Thorac Cardiovasc Sur!! 1976: 72:256-58 14 Hirsh SB. Harrington ER. Miller CM. Estioko MR. llaimov M. Accidental placement of the Greenfield filter in the ht•art: report of two eases. J Vase Surg 19H7: 6:609-10
612
Massive Hemoptysis Caused by a Ruptured Subclavian Artery Aneurysm* Ming-Ho \l'u. M.D .. FC.C .P: Wu-\IH ILii . M.D.: Mu- )i•n Un . M.D.: 11111I.Van-Song Chou. M.D.
We report a case of left subclavian artery aneurysm, which ruptured and penetrated through the left upper lung parenchyma causing massive hemoptysis and a left hemothorax. Through sternothoracotomy, tangential aneurysmorrhaphy under proximal control and left upper pulmonary lobectomy were performed. The patient is doing well after nearly three years of follow-up. (Chest 1993; 104:612-13) ,4.neurysms of the suhclm·ian artery are ran'. ,.n Rupture of
~ this artery causing massive hemoptysis appears to he an unusual prest•ntation . This prompted us to report on the clinical course and management of tlw case at hand. CASE HEPOHT A 50-y•·ar-old woman was rPfi•rn·d to the ~ational Cheng-Kung Unive rsity Hospital on July 19. 19H9. because of massive hemoptysis. Slw had chronic cough lin· one year and had lwgun to expectorate hlood-tinged sputum five days lwfore. When she visited a private dinit·. the che st x-ray film (Fig I) showed a mass density in the upper part of the left lung. Two days hefore this admission, massive hemoptnis occurred and she was transferred to a hospital. where the subsequent chest x-ray film (Fig 2) showed the mass density progn'ssiY~·Iy .-nlarged and a Jpft hemothor:lx. Upon referral to our hospital. the chest computed tomography scan revealed a *From the Division of Thoracic Sur!!ery, Department of Sur!!ery, ~ational Cheng Kung l ' nin•rsity Hospital. 1i1inan. Taiwan. Republic of China. Reprint rNflll'sls: Dr. \Vu , Dqmrlmenl of Sw·gery, National Cheng Ku Unit,ersity Hospital , 'f(Jinan, 1ilircan. ROC
Frcl'IIE I. Tht• mass dt•nsity in the left upper lung field indicates a left suhdavian artery aneurysm. Massive Hemoptysis Caused by Ruptured Subclavian Artery Aneurysm (Wu eta/)