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Errant percutaneous Greenfield filter placement into the retroperitoneum
Errant percutaneous Greenfield filter placement into the retroperitoneum Bruce A. Adye, MD, Rodney D. Raabe, M D , and Royce L. Zobell, M D ,
Spokane, Wash. Percutaneous Greenfield filter placement through a femoral vein approach resaxlted in errant retroperitoneal placement in a patient with pulmonary emboli. A properly positioned filter was then placed surgically through the tight internal jugular vein. The patient subsequently required removal of the errant retroperitoneal filter because ofgenitofemoral nerve irritation. Problems associated with percutaneous Greenfield filter placement and pertinent literature are discussed. (J VAse SURG 1990;12:60-1.) Greenfield filter placement has become a standard treatment procedure for pulmonary embolism occurring despite anticoagulation or when deep venous thrombosis is present in a patient in whom anticoagulation is contraindicated. Recent technical advances have allowed a percutaneous approach to filter placement, when this had previously been placed through a surgically exposed internal jugular or femoral vein. This case report presents a patient in whom a Greenfield filter was errantly placed in the retroFrom the Department of Surgery and the Depa~nent of Radiology, Sacred Heart Hospital. Reprint requests: Bruce A. Adye,MD, W. 104 Fifth Ave., Spokane, WA 99204. 24/37/19435
peritoneum resulting in genitofemoral nerve irritation and requiring subsequent removal.
CASE REPORT A 66-year-old man suffered pulmonary emboli documented by pulmonary angiography. On anticoagulation a large retroperitoneal pelvic hematoma developed, which required cessation of the heparin. He subsequently underwent percutaneous Greenfield filter placement by the radiology department through a right femoral vein approach. When the filter was released it was found to be outside the inferior vena cava in the retroperitoneum overlying the right psoas muscle. The patient was then taken to surgery, and a second Greenfield filter was placed in the inferior vena cava through a right internal jugular approach (Fig.
Fig. 1. Abdominal film shows the errant and properly placed Greenfield filters. 60
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Errant percutaneous Greenfieldfilter placement 61
Fig. 2. C T scan shows properly positioned Greenfield filter within inferior vena cava and the errant Greenfield filter located in the retroperitoneum overlying the psoas muscle.
1). There were no immediate problems as a result of the errant filter, but after discharge from the hospital the patient experienced tight flank, groin, and thigh pain, which was worse with activity. This discomfort seemed to be related to the distribution of the genitofemoral nerve (Fig. 2). Because of the discomfort, he required removal of the errant Greenfield filter through a tight flank retroperitoneal approach approximately 6 weeks later. After removal of the errant filter his discomfort totally resolved. DISCUSSION
Widespread use of the Greenfield filter has resuited from its relative ease of insertion and its efficiency. The incidence o f recurrent pulmonary erabolus after filter placement is approximately 5%, and inferior vena cava patency is maintained in approximately 98% of patients. 1 In general, procedure complications are few but are usually related to filter misplacement. Percutaneous Greenfield filter placement avoids the surgical incision and the expenses associated with surgical placement. The success ofpercutaneous filter placement has been documented in several reports. 2* However, a persistent problem associated with the percutaneous approach has been the development o f femoral vein thrombosis in from 5% to 41% of patients after percutaneous placement through the femoral vein. 30 This seems related to the requirement of a 24F introducer sheath, and may be improved as technical advances allow use of smaller ~:heaths.
Misplacement of caval filters has been described in the heart, lilac veins, hepatic veins, and renal veins. 1,7 To our knowledge, using a Medline computer literature search dating back to 1973 (the year of Greenfield filter introduction), this is the first report documenting errant percutaneous Greenfield filter placement into the retroperitoneum associated with peripheral nerve irritation. This case emphasizes the need for angiographic documentation o f catheter location and also the technical difficulties that can be encountered negotiating the iliac veins when passing the catheter from a femoral approach. REFERENCES 1. Greenfield LJ. Current indications for and results of Greenfield filter placement. J VASC SURG 1984;1:502-4. 2. Pals SO, Mirvis SE, De Orchis DF. Percutaneous insertion of the Khndray-Greenfield filter: technical considerations and problems. Radiology 1987;165:377-81. 3. Rose BS, Simon DC, Hess ML, Van Amen ME. Percutaneous transfemoral placement of the Kimray-Greenfield vena cava filter. Radiology 1987;165:373-6. 4. Pals SO, Tobin KO, Austin CB, Queral L. Percutaneous insertion of the Greenfield inferior vena cava filter: experience with ninety-six patients. J VASC SUt~G 1988;8:460-4. 5. Denny DF Jr, Dorfinan GS, Cronan JJ, Greenwood LH, Morse SS, Yoselevit M. Greenfield filter: percutaneous placement in 50 patients. AJR 1988;150:4270. 6. Kowlor A, Glanz S, Gordon DH, Sclafani SJ. Percutaneous insertion of the Kimray-Greenfield filter: incidence of femoral vein thrombosis. AJR 1987; 149:1065-6. 7. Allen HA, Cistemo SJ, Ottesen OE, Queral L, Dagher F. The Kimray-Greenfieldvena cava filter: a case of unusual misplacement. Cardiovasc Intervent Radiol 1982;5:82-4.
Spokane, Wash. Percutaneous Greenfield filter placement through a femoral vein approach resaxlted in errant retroperitoneal placement in a patient with pulmonary emboli. A properly positioned filter was then placed surgically through the tight internal jugular vein. The patient subsequently required removal of the errant retroperitoneal filter because ofgenitofemoral nerve irritation. Problems associated with percutaneous Greenfield filter placement and pertinent literature are discussed. (J VAse SURG 1990;12:60-1.) Greenfield filter placement has become a standard treatment procedure for pulmonary embolism occurring despite anticoagulation or when deep venous thrombosis is present in a patient in whom anticoagulation is contraindicated. Recent technical advances have allowed a percutaneous approach to filter placement, when this had previously been placed through a surgically exposed internal jugular or femoral vein. This case report presents a patient in whom a Greenfield filter was errantly placed in the retroFrom the Department of Surgery and the Depa~nent of Radiology, Sacred Heart Hospital. Reprint requests: Bruce A. Adye,MD, W. 104 Fifth Ave., Spokane, WA 99204. 24/37/19435
peritoneum resulting in genitofemoral nerve irritation and requiring subsequent removal.
CASE REPORT A 66-year-old man suffered pulmonary emboli documented by pulmonary angiography. On anticoagulation a large retroperitoneal pelvic hematoma developed, which required cessation of the heparin. He subsequently underwent percutaneous Greenfield filter placement by the radiology department through a right femoral vein approach. When the filter was released it was found to be outside the inferior vena cava in the retroperitoneum overlying the right psoas muscle. The patient was then taken to surgery, and a second Greenfield filter was placed in the inferior vena cava through a right internal jugular approach (Fig.
Fig. 1. Abdominal film shows the errant and properly placed Greenfield filters. 60
Volume 12 Number 1 b,~v 1990
Errant percutaneous Greenfieldfilter placement 61
Fig. 2. C T scan shows properly positioned Greenfield filter within inferior vena cava and the errant Greenfield filter located in the retroperitoneum overlying the psoas muscle.
1). There were no immediate problems as a result of the errant filter, but after discharge from the hospital the patient experienced tight flank, groin, and thigh pain, which was worse with activity. This discomfort seemed to be related to the distribution of the genitofemoral nerve (Fig. 2). Because of the discomfort, he required removal of the errant Greenfield filter through a tight flank retroperitoneal approach approximately 6 weeks later. After removal of the errant filter his discomfort totally resolved. DISCUSSION
Widespread use of the Greenfield filter has resuited from its relative ease of insertion and its efficiency. The incidence o f recurrent pulmonary erabolus after filter placement is approximately 5%, and inferior vena cava patency is maintained in approximately 98% of patients. 1 In general, procedure complications are few but are usually related to filter misplacement. Percutaneous Greenfield filter placement avoids the surgical incision and the expenses associated with surgical placement. The success ofpercutaneous filter placement has been documented in several reports. 2* However, a persistent problem associated with the percutaneous approach has been the development o f femoral vein thrombosis in from 5% to 41% of patients after percutaneous placement through the femoral vein. 30 This seems related to the requirement of a 24F introducer sheath, and may be improved as technical advances allow use of smaller ~:heaths.
Misplacement of caval filters has been described in the heart, lilac veins, hepatic veins, and renal veins. 1,7 To our knowledge, using a Medline computer literature search dating back to 1973 (the year of Greenfield filter introduction), this is the first report documenting errant percutaneous Greenfield filter placement into the retroperitoneum associated with peripheral nerve irritation. This case emphasizes the need for angiographic documentation o f catheter location and also the technical difficulties that can be encountered negotiating the iliac veins when passing the catheter from a femoral approach. REFERENCES 1. Greenfield LJ. Current indications for and results of Greenfield filter placement. J VASC SURG 1984;1:502-4. 2. Pals SO, Mirvis SE, De Orchis DF. Percutaneous insertion of the Khndray-Greenfield filter: technical considerations and problems. Radiology 1987;165:377-81. 3. Rose BS, Simon DC, Hess ML, Van Amen ME. Percutaneous transfemoral placement of the Kimray-Greenfield vena cava filter. Radiology 1987;165:373-6. 4. Pals SO, Tobin KO, Austin CB, Queral L. Percutaneous insertion of the Greenfield inferior vena cava filter: experience with ninety-six patients. J VASC SUt~G 1988;8:460-4. 5. Denny DF Jr, Dorfinan GS, Cronan JJ, Greenwood LH, Morse SS, Yoselevit M. Greenfield filter: percutaneous placement in 50 patients. AJR 1988;150:4270. 6. Kowlor A, Glanz S, Gordon DH, Sclafani SJ. Percutaneous insertion of the Kimray-Greenfield filter: incidence of femoral vein thrombosis. AJR 1987; 149:1065-6. 7. Allen HA, Cistemo SJ, Ottesen OE, Queral L, Dagher F. The Kimray-Greenfieldvena cava filter: a case of unusual misplacement. Cardiovasc Intervent Radiol 1982;5:82-4.