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Inferior Vena Cava (IVC) Rupture and Retroperitoneal Hemorrhage Caused by IVC Filter Migration
1102
•
August 2009
Letters to the Editor
JVIR
ous report of a retrieved migrated ring (1), the ring had migrated into the aortic arch and surgical incision necessitated total circulatory arrest. The present case demonstrates how proper planning and discussion between surgical and interventional radiology teams can lead to successful methods of foreign body retrieval while minimizing the risk to the patient. Acknowledgment: We acknowledge Dr. Subodh Verma, cardiothoracic surgeon for his collaboration in the surgical management of this patient. Reference 1. Sanisoglu I, Sagbas LE, Dran C, Caynak B, Akpinar TB. Migration of a rigid mitral valve ring. Ann Thorac Surg 2008; 86:1696.
Inferior Vena Cava (IVC) Rupture and Retroperitoneal Hemorrhage Caused by IVC Filter Migration
Figure 2. Intraoperative left anterior oblique fluoroscopic image shows the migrated ring grasped by the SOS Omni catheter and the snare, directly apposed to the sheath.
became clear upon discussion with the surgical team that annuloplasty rings are very stiff. Given the gradual narrowing of the distal aorta, and the smaller caliber of the iliofemoral arteries, it was our opinion that a femoral retrieval approach could lead to arterial wall damage, including possible dissection. We were also concerned that the smaller iliofemoral arteries would not accommodate the volume of the ring. Because repeat intervention on the mitral valve was necessary, mandating sternotomy with exposure of the ascending aorta and the use of cardiopulmonary bypass, it was believed that retrieving the ring and pulling it into the ascending aorta would enable safe and rapid removal of the migrated ring, with minimal increase in the cardiopulmonary bypass and surgical times. In a previ-
From: Ramadass Satya, MD, James Anderson, MD, Gonzalo Lievano, MD, Radhika J. Satya, MD Department of Radiology John Peter Smith Health Network 1500 S. Main St. Fort Worth, TX 76104 Editor: Over the years, inferior vena cava (IVC) filter procedures have demonstrated excellent therapeutic efficacy in preventing pulmonary embolism. However, several filter-related complications have been described on rare occasions; these have proved severe or even fatal. A 64-year-old white male patient weighing 135 lbs. with multiple medical problems including diabetes, alcohol abuse, seizure, mood disorder, and thrombocytopenia of unknown cause presented to the emergency room with shortness of breath. Computed tomography (CT) of the chest performed in the emergency room showed multiple small pulmonary emboli. A Doppler study of the lower extremities confirmed deep vein thrombosis involving bilateral popliteal and right posterior tibial veins. The patient was admitted with a diagnosis of deep vein thrombosis and pulmonary embolism. The patient was administered 5 mg of warfarin daily and intravenous heparin. The International Normalized Ratio (INR) on admission was normal, with a platelet count of 70. At this time, the patient was taking one tablet of low-dose aspirin daily for previous stroke. In view of a history of alcohol abuse and mood disorder, the patient was believed unlikely to be compliant with long-term oral anticoagulation; in addition, the patient was believed to be at increased risk of bleeding in the setting of full anticoagulation because of unknown thrombocytopenia, alcohol abuse, seizure, and stroke with increased risk of falling. A filter was believed to be indicated, and an infrarenal IVC filter was deployed immediately. Initial imaging of the IVC performed before filter placement showed an IVC diameter of 20 mm. After deployment of an IVC filter (TrapEase; Cordis, Miami Lakes, Florida), a cavogram showed infrarenal deployment of the filter and
None of the authors have identified a conflict of interest.
Figure 3.
Photograph of the retrieved mitral ring.
DOI: 10.1016/j.jvir.2009.05.001
Volume 20
Number 8
Figure 1. Abdominal coronal reconstruction of CT scan shows infrarenal position of the IVC filter 4 days after placement. The supporting legs are not free; all are attached to the apex and base.
confirmed that the legs of the filter were not deformed and did not protrude outside the IVC wall, nor were they stuck together. Anticoagulation was stopped after filter placement. The patient’s INR on the day of filter placement was 1.2. Four days after filter placement, an abdominal CT scan was obtained for evaluation of hypersplenism and low platelet count, which showed a normal infrarenal position of the filter. There was no abdominal pain or back pain reported by the patient at this time (Fig 1). Because the patient
Letters to the Editor
•
1103
was asymptomatic, he refused further treatment and requested discharge against medical advice. Nineteen days after filter placement, the patient presented to the emergency room with “excruciating” right flank pain that was ongoing for “a couple of days.” There was no history of warfarin use, steroid use, trauma, or central venous catheter placement in the interim period between filter placement and the onset of this symptom. The interim ranges of INR values and coagulation profile were as follows during the 3-week period after IVC filter insertion and before the complication occurred: INR, 1.14 –1.31; prothrombin time, 14.8 –18.2 sec; partial thromboplastin time, 25– 40 sec; platelet count, 38 –70 ⫻ 109/L. On the day the patient presented with flank pain, the coagulation profile was as follows: INR, 1.14; prothrombin time, 14.8 sec; partial thromboplastin time, 25.7 sec; and platelet count, 70 ⫻ 109/L. A helical scan of the abdomen showed evidence of retroperitoneal hemorrhage and free intraperitoneal fluid. In addition, there was evidence of significant filter deformity and migration of the filter to a suprarenal position (Fig 2). In view of these findings, the surgical team was consulted. The patient underwent transfusion of 6 U of packed red blood cells and two single platelet donor units and 6 U of fresh frozen plasma. Under general anesthesia, exploratory laparotomy showed migration of the filter into the suprarenal position adjacent to the hepatic vein confluence. There was complete disruption of the IVC wall, and it was clear that the hemorrhage originated from the IVC. There were three filter legs protruding 1–2 mm outside the IVC margin, but the filter was within the IVC and was compressed and deformed. When retrieved from the IVC, the filter sprung back to normal size. No broken supporting legs or deformity were seen. Clots were seen within and proximal to the filter. Thrombectomy was performed and the IVC was closed in two layers. Retroperito-
Figure 2. Axial (a) and coronal reconstruction (b) of CT scan shows suprarenal filter migration with large retroperitoneal hemorrhage 19 days after filter placement. The filter appears to be compressed and deformed.
1104
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Letters to the Editor
neal clots were evacuated. The patient tolerated the procedure well and the postoperative period was uneventful. The patient again refused further treatment and alternative options of a different type of filter and requested discharge against medical advice. The patient was prescribed 5 mg warfarin as anticoagulation therapy to protect against recurrent pulmonary embolism. Incidental reports of filter complications are particularly important in patients being considered for prophylactic IVC filter insertion. Retroperitoneal hemorrhage from migration of an IVC filter and fatal rupture of the IVC are extremely rare. The incidence of IVC filter migration ranges from 0.3% to 6%, with rare migration of the filter to the heart or lung (0.1%– 1.25%) (1). Fatal retroperitoneal hemorrhage resulting from IVC perforation is one of the most serious complications noted after TrapEase IVC filter placement in the setting of anticoagulation and thrombolytic therapy for treatment of pulmonary embolism (2). Other filter-related complications are filter migration, insertion site thrombosis, filter fracture, vessel wall perforation, strut erosion through the IVC wall, recurrent pulmonary embolism, IVC obstruction, and lower-extremity venous insufficiency (3). Filter occlusion may be caused by trapping of a clot from deep vein thrombosis or formation of clot as a result of the presence of the filter itself, and it is very difficult to determine the exact cause. However, its reported incidence varies widely from 0% to 28% (4). Filter migration is associated with potentially fatal consequences. The risks include migration to locations such as the heart or pulmonary artery. IVC rupture and retroperitoneal hemorrhage caused by IVC filter migration may occur, and further investigation is needed to determine predisposing causes to this complication.
August 2009
JVIR
eter dysfunction, preventing effective dialysis. Pulmonary embolism is a rare but most serious reported complication (1). The incidences of fibrin sheath formation have been reported to be as high as 76% in clinical practice during “pull-back” venography and 100% in experimental studies (2,3). Experimental studies have shown that fibrin sheath formation can start as early as within 24 hours, encases the catheter within 5–7 days, and attaches to the vein wall at the entry site (1,4). In many institutions, large numbers of hemodialysis catheters are removed as bedside procedures. On these occasions, no pull-back venography or fibrin sheath disruption is performed and any fibrin sheaths present are left intact as retained within the central veins. The incidence of retained fibrin sheaths under such circumstances consequently are unknown, but can be assumed to be no less those described in venographic series. It is very likely that many cases of retained fibrin sheaths remained unrecognized or possibly misinterpreted when present on routine imaging. This would not be surprising, given the paucity of imaging literature (4) coupled with limited knowledge among the imaging community on the appearance of retained fibrin sheaths outside of pull-back venography. Only recently has the transesophageal echocardiographic appearance of retained fibrin sheath been described (4). The present communication illustrates the computed tomographic (CT) appearance of a retained fibrin sheath. The author’s institution does not require institutional review board approval for retrospective case reports such as this.
References 1. Haddadian B, Shaikh F, Djelmami HM, et al. Sudden cardiac death caused by migration of a TrapEase inferior vena cava filter: case report and review of the literature. Clin Cardiol 2008; 31: 84 – 87. 2. Inuzuka K, Unno N, Yamamoto N, et al. Hemorrhagic shock with delayed retroperitoneal hemorrhage after deployment of an inferior vena cava filter: report of a case. Surg Today 2007; 37:618 – 621. 3. Tardy B, Mismetti P, Page Y, et al. Symptomatic inferior vena cava filter thrombosis: clinical study of 30 consecutive cases. Eur Respir J 1996; 9:2012–2016. 4. Streiff MB. Vena caval filters: a comprehensive review. Blood 2000; 95:3669 –3677.
Multidetector CT Appearance of Retained Fibrin Sheath From: Uei Pua, MBBS, MMed, FRCR, FAMS Department of Diagnostic Radiology Tan Tock Seng Hospital 11 Jalan Tan Tock Seng Singapore 308433 Editor: Fibrin sheath formation is the Achilles heel of hemodialysis catheters and gained its notoriety through causing cath-
The author has not identified a conflict of interest. DOI: 10.1016/j.jvir.2009.05.002
Figure 1. Coronal contrast-enhanced CT image of patient A shows a hypodense retained fibrin sheath extending from an attachment site in the wall of the right IJV down to the right atrium, forming a ghost image of the removed catheter (white arrows). The irregular appearance of the fibrin sheath (white arrows) may be a result of perisheath thrombus formation. The fibrin sheath is seen to attach eccentrically on the wall of the right IJV (not shown), consistent with the site of previous vascular access.
•
August 2009
Letters to the Editor
JVIR
ous report of a retrieved migrated ring (1), the ring had migrated into the aortic arch and surgical incision necessitated total circulatory arrest. The present case demonstrates how proper planning and discussion between surgical and interventional radiology teams can lead to successful methods of foreign body retrieval while minimizing the risk to the patient. Acknowledgment: We acknowledge Dr. Subodh Verma, cardiothoracic surgeon for his collaboration in the surgical management of this patient. Reference 1. Sanisoglu I, Sagbas LE, Dran C, Caynak B, Akpinar TB. Migration of a rigid mitral valve ring. Ann Thorac Surg 2008; 86:1696.
Inferior Vena Cava (IVC) Rupture and Retroperitoneal Hemorrhage Caused by IVC Filter Migration
Figure 2. Intraoperative left anterior oblique fluoroscopic image shows the migrated ring grasped by the SOS Omni catheter and the snare, directly apposed to the sheath.
became clear upon discussion with the surgical team that annuloplasty rings are very stiff. Given the gradual narrowing of the distal aorta, and the smaller caliber of the iliofemoral arteries, it was our opinion that a femoral retrieval approach could lead to arterial wall damage, including possible dissection. We were also concerned that the smaller iliofemoral arteries would not accommodate the volume of the ring. Because repeat intervention on the mitral valve was necessary, mandating sternotomy with exposure of the ascending aorta and the use of cardiopulmonary bypass, it was believed that retrieving the ring and pulling it into the ascending aorta would enable safe and rapid removal of the migrated ring, with minimal increase in the cardiopulmonary bypass and surgical times. In a previ-
From: Ramadass Satya, MD, James Anderson, MD, Gonzalo Lievano, MD, Radhika J. Satya, MD Department of Radiology John Peter Smith Health Network 1500 S. Main St. Fort Worth, TX 76104 Editor: Over the years, inferior vena cava (IVC) filter procedures have demonstrated excellent therapeutic efficacy in preventing pulmonary embolism. However, several filter-related complications have been described on rare occasions; these have proved severe or even fatal. A 64-year-old white male patient weighing 135 lbs. with multiple medical problems including diabetes, alcohol abuse, seizure, mood disorder, and thrombocytopenia of unknown cause presented to the emergency room with shortness of breath. Computed tomography (CT) of the chest performed in the emergency room showed multiple small pulmonary emboli. A Doppler study of the lower extremities confirmed deep vein thrombosis involving bilateral popliteal and right posterior tibial veins. The patient was admitted with a diagnosis of deep vein thrombosis and pulmonary embolism. The patient was administered 5 mg of warfarin daily and intravenous heparin. The International Normalized Ratio (INR) on admission was normal, with a platelet count of 70. At this time, the patient was taking one tablet of low-dose aspirin daily for previous stroke. In view of a history of alcohol abuse and mood disorder, the patient was believed unlikely to be compliant with long-term oral anticoagulation; in addition, the patient was believed to be at increased risk of bleeding in the setting of full anticoagulation because of unknown thrombocytopenia, alcohol abuse, seizure, and stroke with increased risk of falling. A filter was believed to be indicated, and an infrarenal IVC filter was deployed immediately. Initial imaging of the IVC performed before filter placement showed an IVC diameter of 20 mm. After deployment of an IVC filter (TrapEase; Cordis, Miami Lakes, Florida), a cavogram showed infrarenal deployment of the filter and
None of the authors have identified a conflict of interest.
Figure 3.
Photograph of the retrieved mitral ring.
DOI: 10.1016/j.jvir.2009.05.001
Volume 20
Number 8
Figure 1. Abdominal coronal reconstruction of CT scan shows infrarenal position of the IVC filter 4 days after placement. The supporting legs are not free; all are attached to the apex and base.
confirmed that the legs of the filter were not deformed and did not protrude outside the IVC wall, nor were they stuck together. Anticoagulation was stopped after filter placement. The patient’s INR on the day of filter placement was 1.2. Four days after filter placement, an abdominal CT scan was obtained for evaluation of hypersplenism and low platelet count, which showed a normal infrarenal position of the filter. There was no abdominal pain or back pain reported by the patient at this time (Fig 1). Because the patient
Letters to the Editor
•
1103
was asymptomatic, he refused further treatment and requested discharge against medical advice. Nineteen days after filter placement, the patient presented to the emergency room with “excruciating” right flank pain that was ongoing for “a couple of days.” There was no history of warfarin use, steroid use, trauma, or central venous catheter placement in the interim period between filter placement and the onset of this symptom. The interim ranges of INR values and coagulation profile were as follows during the 3-week period after IVC filter insertion and before the complication occurred: INR, 1.14 –1.31; prothrombin time, 14.8 –18.2 sec; partial thromboplastin time, 25– 40 sec; platelet count, 38 –70 ⫻ 109/L. On the day the patient presented with flank pain, the coagulation profile was as follows: INR, 1.14; prothrombin time, 14.8 sec; partial thromboplastin time, 25.7 sec; and platelet count, 70 ⫻ 109/L. A helical scan of the abdomen showed evidence of retroperitoneal hemorrhage and free intraperitoneal fluid. In addition, there was evidence of significant filter deformity and migration of the filter to a suprarenal position (Fig 2). In view of these findings, the surgical team was consulted. The patient underwent transfusion of 6 U of packed red blood cells and two single platelet donor units and 6 U of fresh frozen plasma. Under general anesthesia, exploratory laparotomy showed migration of the filter into the suprarenal position adjacent to the hepatic vein confluence. There was complete disruption of the IVC wall, and it was clear that the hemorrhage originated from the IVC. There were three filter legs protruding 1–2 mm outside the IVC margin, but the filter was within the IVC and was compressed and deformed. When retrieved from the IVC, the filter sprung back to normal size. No broken supporting legs or deformity were seen. Clots were seen within and proximal to the filter. Thrombectomy was performed and the IVC was closed in two layers. Retroperito-
Figure 2. Axial (a) and coronal reconstruction (b) of CT scan shows suprarenal filter migration with large retroperitoneal hemorrhage 19 days after filter placement. The filter appears to be compressed and deformed.
1104
•
Letters to the Editor
neal clots were evacuated. The patient tolerated the procedure well and the postoperative period was uneventful. The patient again refused further treatment and alternative options of a different type of filter and requested discharge against medical advice. The patient was prescribed 5 mg warfarin as anticoagulation therapy to protect against recurrent pulmonary embolism. Incidental reports of filter complications are particularly important in patients being considered for prophylactic IVC filter insertion. Retroperitoneal hemorrhage from migration of an IVC filter and fatal rupture of the IVC are extremely rare. The incidence of IVC filter migration ranges from 0.3% to 6%, with rare migration of the filter to the heart or lung (0.1%– 1.25%) (1). Fatal retroperitoneal hemorrhage resulting from IVC perforation is one of the most serious complications noted after TrapEase IVC filter placement in the setting of anticoagulation and thrombolytic therapy for treatment of pulmonary embolism (2). Other filter-related complications are filter migration, insertion site thrombosis, filter fracture, vessel wall perforation, strut erosion through the IVC wall, recurrent pulmonary embolism, IVC obstruction, and lower-extremity venous insufficiency (3). Filter occlusion may be caused by trapping of a clot from deep vein thrombosis or formation of clot as a result of the presence of the filter itself, and it is very difficult to determine the exact cause. However, its reported incidence varies widely from 0% to 28% (4). Filter migration is associated with potentially fatal consequences. The risks include migration to locations such as the heart or pulmonary artery. IVC rupture and retroperitoneal hemorrhage caused by IVC filter migration may occur, and further investigation is needed to determine predisposing causes to this complication.
August 2009
JVIR
eter dysfunction, preventing effective dialysis. Pulmonary embolism is a rare but most serious reported complication (1). The incidences of fibrin sheath formation have been reported to be as high as 76% in clinical practice during “pull-back” venography and 100% in experimental studies (2,3). Experimental studies have shown that fibrin sheath formation can start as early as within 24 hours, encases the catheter within 5–7 days, and attaches to the vein wall at the entry site (1,4). In many institutions, large numbers of hemodialysis catheters are removed as bedside procedures. On these occasions, no pull-back venography or fibrin sheath disruption is performed and any fibrin sheaths present are left intact as retained within the central veins. The incidence of retained fibrin sheaths under such circumstances consequently are unknown, but can be assumed to be no less those described in venographic series. It is very likely that many cases of retained fibrin sheaths remained unrecognized or possibly misinterpreted when present on routine imaging. This would not be surprising, given the paucity of imaging literature (4) coupled with limited knowledge among the imaging community on the appearance of retained fibrin sheaths outside of pull-back venography. Only recently has the transesophageal echocardiographic appearance of retained fibrin sheath been described (4). The present communication illustrates the computed tomographic (CT) appearance of a retained fibrin sheath. The author’s institution does not require institutional review board approval for retrospective case reports such as this.
References 1. Haddadian B, Shaikh F, Djelmami HM, et al. Sudden cardiac death caused by migration of a TrapEase inferior vena cava filter: case report and review of the literature. Clin Cardiol 2008; 31: 84 – 87. 2. Inuzuka K, Unno N, Yamamoto N, et al. Hemorrhagic shock with delayed retroperitoneal hemorrhage after deployment of an inferior vena cava filter: report of a case. Surg Today 2007; 37:618 – 621. 3. Tardy B, Mismetti P, Page Y, et al. Symptomatic inferior vena cava filter thrombosis: clinical study of 30 consecutive cases. Eur Respir J 1996; 9:2012–2016. 4. Streiff MB. Vena caval filters: a comprehensive review. Blood 2000; 95:3669 –3677.
Multidetector CT Appearance of Retained Fibrin Sheath From: Uei Pua, MBBS, MMed, FRCR, FAMS Department of Diagnostic Radiology Tan Tock Seng Hospital 11 Jalan Tan Tock Seng Singapore 308433 Editor: Fibrin sheath formation is the Achilles heel of hemodialysis catheters and gained its notoriety through causing cath-
The author has not identified a conflict of interest. DOI: 10.1016/j.jvir.2009.05.002
Figure 1. Coronal contrast-enhanced CT image of patient A shows a hypodense retained fibrin sheath extending from an attachment site in the wall of the right IJV down to the right atrium, forming a ghost image of the removed catheter (white arrows). The irregular appearance of the fibrin sheath (white arrows) may be a result of perisheath thrombus formation. The fibrin sheath is seen to attach eccentrically on the wall of the right IJV (not shown), consistent with the site of previous vascular access.