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Symptomatic perforation of a retrievable inferior vena cava filter after a dwell time of 5 years
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 infrarenal IVC from a right jugular approach. This is a retrievable filter that is licensed for permanent implantation. The patient was discharged 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 unremarkable. 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 ⫻ 109/L. Blood culture grew methicillin-sensitive Staphylococcus aureus on two separate occasions, and he was accordingly 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 From the Departments of Vascular and Endovascular Surgery,a and Radiology,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
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 identified 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 duodenum 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.
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418 Parkin et al
DISCUSSION
Fig 1. A computed tomography scan at L2 vertebral level shows the 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 protrusion 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.
At the 6-week follow-up, the patient was systemically well and did not need regular analgesia for his back pain. A magnetic resonance imaging scan performed at 12 weeks showed reduced height of the L2/3 disc in keeping with degeneration; however, there was no evidence of any pathology.
The treatment of choice for venous thromboembolism is anticoagulation, but this is sometimes insufficient, as in the case described here where multiple pulmonary emboli developed despite the patient’s compliance with a therapeutic dose of oral anticoagulant medication. In such circumstances, a caval filter is required to reduce the risk of a fatal pulmonary embolism. Other indications for filter insertion include chronic multiple pulmonary emboli with associated pulmonary hypertension, DVT with a contraindication to anticoagulation, and prophylaxis in patients at high risk of a DVT who are not suitable for anticoagulation.1,2 Although percutaneous insertion is a relatively safe procedure, the long-term presence of an IVC filter is not without its complications. Caval filter insertion was initially thought to follow a benign course3; however, substantial evidence in the literature contradicts this, with a risk of recurrent DVT of about 20% and an overall caval perforation rate of 0.3%.4,5 The choice of filter depends upon the indication. Retrievable devices are preferable when the reason for insertion is temporary, and permanent devices are used when long-term filtration is anticipated. This distinction has become blurred in recent years, with retrievable devices such as the Günther Tulip now used for permanent implantation. It has excellent short-term results6,7 and has an overall caval perforation complaint rate of 0.04% (personal communication, William Cook Europe). However, data are lacking for long-term follow-up of Günther Tulip filters, with only one recent article looking at complications with prolonged dwell times.8 Although to our knowledge this is the first reported case of symptomatic perforation of a Günther Tulip, similar cases have been described after prolonged dwell times with other types of retrievable filter,9 and a recent review article concluded that the long-term safety for the permanent implantation of retrievable devices is unproven.10 In the patient presented here, an endovenous inflammatory process had occurred in response to filter insertion, with neointimization around the filter. Three of the filter struts had perforated through the wall of the IVC, with the posterior strut causing a periosteal reaction and subsequent osteomyelitis. This made endovascular retrieval impossible, leaving open surgical removal as the only safe method of filter removal. To our knowledge this is the first reported case of a symptomatic caval perforation due to a Günther Tulip filter and it occurred after a prolonged dwell time. Because this device has only recently started being used for permanent implantation, there is a lack of evidence in the literature about late caval perforations and long-term safety. We believe that each Günther Tulip filter inserted for permanent filtration should be registered on a database and any complications recorded prospectively.
JOURNAL OF VASCULAR SURGERY Volume 50, Number 2
REFERENCES 1. Grassi CJ, Swan TL, Cardella JF, Meranze SG, Oglevie SB, Omary RA, et al. Quality improvement guidelines for percutaneous permanent inferior vena cava filter placement for the prevention of pulmonary embolism. Society of Interventional Radiology Standards of Practice Committee. J Vasc Interv Radiol 2001;12:137-41. 2. Hyers TM, Agnelli G, Hull RD, Morris TA, Samama M, Tapson V, et al. Antithrombotic therapy for venous thromboembolic disease. Chest 2001;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 pulmonary embolism in patients with proximal deep vein thrombosis. Prévention du Risque d’Embolie Pulmonaire par Interruption Cave Study Group. N Engl J Med 1998;338:409-15.
Parkin et al 419
5. Hann CL, Streiff MB. The role of vena caval filters in the management of 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 in high risk surgical patients. J Vasc Surg 2007;45:784-8. 7. Keller IS, Meier C, Pfiffner R, Keller E, Pfammatter T. Clinical comparison of two optional vena cava filters. J Vasc Interv Radiol 2007;18: 505-11. 8. Rosenthal D, Wellons ED, Hancock SM, Burkett AB. Retrievability of the Günther Tulip vena cava filter after dwell times longer than 180 days in patients with multiple trauma. J Endovasc Ther 2007;14:406-10. 9. Veroux 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;48:223-5. 10. Berczi V, Bottomley JR, Thomas SM, Taneja S, Gaines PA, Cleveland TJ. Long-term retrievability of IVC filters: should we abandon permanent devices? Cardiovasc Intervent Radiol 2007;30:820-7. Submitted Feb 3, 2009; accepted Mar 2, 2009.
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 infrarenal IVC from a right jugular approach. This is a retrievable filter that is licensed for permanent implantation. The patient was discharged 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 unremarkable. 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 ⫻ 109/L. Blood culture grew methicillin-sensitive Staphylococcus aureus on two separate occasions, and he was accordingly 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 From the Departments of Vascular and Endovascular Surgery,a and Radiology,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
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 identified 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 duodenum 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.
417
JOURNAL OF VASCULAR SURGERY August 2009
418 Parkin et al
DISCUSSION
Fig 1. A computed tomography scan at L2 vertebral level shows the 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 protrusion 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.
At the 6-week follow-up, the patient was systemically well and did not need regular analgesia for his back pain. A magnetic resonance imaging scan performed at 12 weeks showed reduced height of the L2/3 disc in keeping with degeneration; however, there was no evidence of any pathology.
The treatment of choice for venous thromboembolism is anticoagulation, but this is sometimes insufficient, as in the case described here where multiple pulmonary emboli developed despite the patient’s compliance with a therapeutic dose of oral anticoagulant medication. In such circumstances, a caval filter is required to reduce the risk of a fatal pulmonary embolism. Other indications for filter insertion include chronic multiple pulmonary emboli with associated pulmonary hypertension, DVT with a contraindication to anticoagulation, and prophylaxis in patients at high risk of a DVT who are not suitable for anticoagulation.1,2 Although percutaneous insertion is a relatively safe procedure, the long-term presence of an IVC filter is not without its complications. Caval filter insertion was initially thought to follow a benign course3; however, substantial evidence in the literature contradicts this, with a risk of recurrent DVT of about 20% and an overall caval perforation rate of 0.3%.4,5 The choice of filter depends upon the indication. Retrievable devices are preferable when the reason for insertion is temporary, and permanent devices are used when long-term filtration is anticipated. This distinction has become blurred in recent years, with retrievable devices such as the Günther Tulip now used for permanent implantation. It has excellent short-term results6,7 and has an overall caval perforation complaint rate of 0.04% (personal communication, William Cook Europe). However, data are lacking for long-term follow-up of Günther Tulip filters, with only one recent article looking at complications with prolonged dwell times.8 Although to our knowledge this is the first reported case of symptomatic perforation of a Günther Tulip, similar cases have been described after prolonged dwell times with other types of retrievable filter,9 and a recent review article concluded that the long-term safety for the permanent implantation of retrievable devices is unproven.10 In the patient presented here, an endovenous inflammatory process had occurred in response to filter insertion, with neointimization around the filter. Three of the filter struts had perforated through the wall of the IVC, with the posterior strut causing a periosteal reaction and subsequent osteomyelitis. This made endovascular retrieval impossible, leaving open surgical removal as the only safe method of filter removal. To our knowledge this is the first reported case of a symptomatic caval perforation due to a Günther Tulip filter and it occurred after a prolonged dwell time. Because this device has only recently started being used for permanent implantation, there is a lack of evidence in the literature about late caval perforations and long-term safety. We believe that each Günther Tulip filter inserted for permanent filtration should be registered on a database and any complications recorded prospectively.
JOURNAL OF VASCULAR SURGERY Volume 50, Number 2
REFERENCES 1. Grassi CJ, Swan TL, Cardella JF, Meranze SG, Oglevie SB, Omary RA, et al. Quality improvement guidelines for percutaneous permanent inferior vena cava filter placement for the prevention of pulmonary embolism. Society of Interventional Radiology Standards of Practice Committee. J Vasc Interv Radiol 2001;12:137-41. 2. Hyers TM, Agnelli G, Hull RD, Morris TA, Samama M, Tapson V, et al. Antithrombotic therapy for venous thromboembolic disease. Chest 2001;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 pulmonary embolism in patients with proximal deep vein thrombosis. Prévention du Risque d’Embolie Pulmonaire par Interruption Cave Study Group. N Engl J Med 1998;338:409-15.
Parkin et al 419
5. Hann CL, Streiff MB. The role of vena caval filters in the management of 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 in high risk surgical patients. J Vasc Surg 2007;45:784-8. 7. Keller IS, Meier C, Pfiffner R, Keller E, Pfammatter T. Clinical comparison of two optional vena cava filters. J Vasc Interv Radiol 2007;18: 505-11. 8. Rosenthal D, Wellons ED, Hancock SM, Burkett AB. Retrievability of the Günther Tulip vena cava filter after dwell times longer than 180 days in patients with multiple trauma. J Endovasc Ther 2007;14:406-10. 9. Veroux 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;48:223-5. 10. Berczi V, Bottomley JR, Thomas SM, Taneja S, Gaines PA, Cleveland TJ. Long-term retrievability of IVC filters: should we abandon permanent devices? Cardiovasc Intervent Radiol 2007;30:820-7. Submitted Feb 3, 2009; accepted Mar 2, 2009.