Inferior Vena Cava Filters

Objectives: Inferior vena cava (IVC) filters have been retrieved after prolonged dwell times; however, the rate of success decreases over time. Embedded or perforated filter components increase the risk of vascular injury and are common reasons for failed retrieval. Advanced techniques, including the use of endobronchial forceps, can be employed to remove tip-embedded filters and filters with prolonged dwell times; however, these removals are riskier than standard filter retrievals. IVC pseudoaneurysm is a form of vascular injury which has been rarely reported after IVC filter retrieval. This report describes the management of an IVC pseudoaneurysm following the endobronchial forceps retrieval of a 28-year-old Greenfield filter. Methods: A 71-year-old male with a history of traumatic brain injury and prophylactically placed titanium Greenfield IVC filter in 1990 presented for the consideration of IVC filter retrieval. A computed tomography (CT) scan revealed moderate caval stenosis, 40° of apical tilt, likely apex embedment, and perforation of two medial struts through the caval wall, abutting the aorta and lumbar artery. The patient complained of focal abdominal pain corresponding to the area of the filter, strongly desired filter retrieval, and had no ongoing indications for filtration. After a detailed discussion with the patient regarding the risk of retrieval, the decision was made to attempt filter retrieval to improve the patient's symptoms and decrease the risks of arterial injury from strut perforation and further caval stenosis or thrombosis. Results: Due to jugular vein occlusion, femoral access was initially obtained to provide a target for fluoroscopic access into a retroclavicular collateral from above, facilitating large sheath insertion and endobronchial forceps retrieval of the filter, which required surprisingly little force. Following retrieval, contained extravasation was observed at the previous site of the filter struts. Despite balloon-tamponade and an attempt at flow diversion using a bare-metal stent, the pseudoaneurysm continued to fill. A catheter was advanced through the stent interstices into the pseudoaneurysm, which was treated with balloon-controlled thrombin administration. After 5 min, repeat Intra vascular Ultrasound (IVUS) showed pseudoaneurysm thrombosis. The final venogram revealed no further contrast extravasation and a patent IVC. The patient was discharged on postoperative day 2. At the 5-month postoperative follow-up visit, the patient reported resolution of previous abdominal pain and CT scan re-demonstrated patent IVC. Conclusion: Extended dwell times and penetrating IVC filters increase the risk of retrieval complications. While conservative treatment options should be considered first, physicians performing high-risk retrievals should understand and be prepared for rare complications.

Publication History

Article published online:
26 April 2021