A Complication of Ultrasound-Guided Inferior Vena Cava Filter Placement

A 45-year-old woman with acquired immunodeficiency syndrome (AIDS) presented to the emergency department with altered mental status and tachycardia. Initial computed tomography (CT) of the head revealed hydrocephalus; an external ventricular drain was placed after the patient's condition continued to decline. She subsequently developed tachycardia, after which a pulmonary embolism protocol chest CT was positive for multiple subsegmental pulmonary emboli. Considering the patient's poor cardiopulmonary reserve and history of recent surgery, interventional radiology (IR) fellow was consulted for emergent after-hours inferior vena cava filter (IVCF) placement.

Due to the patient's hemodynamic instability, a bedside IVCF placement was performed under transabdominal ultrasound (US) guidance in lieu of standard venographic IVCF placement. An IR fellow performed the procedure at bedside under the direct supervision of an IR attending. The fellow performing the procedure had no experience placing a bedside IVCF, and the supervising attending had not performed the procedure in several years.

Preprocedural US revealed what appeared to be a retroaortic left renal vein ([Fig. 1a]). The right common femoral vein was accessed with a 21-gauge needle. Using standard technique, the filter delivery sheath was advanced to the level thought to represent the retroaortic left renal vein. A Gunther Tulip IVCF (Cook Medical Inc., Bloomington, IL) was deployed under direct sonographic guidance ([Fig. 1b]), and appeared to be in normal position on postprocedural US.

Fig. 1 (a) Transabdominal ultrasound in the axial plane demonstrating a presumed retroaortic left renal vein (arrows). (b) Ultrasound-guided delivery of the inferior vena cava (IVC) filter in the expected location of the infrarenal IVC. (c) Inferior vena cavagram demonstrating the filter in the proximal right common iliac vein. (d) Placement of a new IVC filter in the infrarenal IVC under direct fluoroscopy.

A follow-up abdominal radiograph revealed the filter to be in abnormal position in the projection of the right common iliac vein. The patient was subsequently transported to the IR suite the following morning for filter repositioning. Initial venography confirmed the filter to be in the proximal right common iliac vein ([Fig. 1c]). The malpositioned filter was removed under fluoroscopic guidance following a jugular vein approach with a loop snare device. A venogram following filter retrieval revealed no evidence of vascular injury. A new Gunther Tulip IVCF was placed in standard infrarenal IVC position under direct fluoroscopy ([Fig. 1d]).

No further complications of filter placement were noted during the patient's hospital stay. Magnetic resonance imaging demonstrated multiple ring-enhancing brain lesions, and further workup revealed a severely decreased CD4 count with cerebral spinal fluid studies positive for cytomegalovirus and Epstein–Barr virus. Findings were concerning for infection versus central nervous system lymphoma; however, the patient's tenuous clinical status precluded biopsy and given her severely immunocompromised state, chemotherapy could not be safely offered. After palliative care consultation and discussion with her family, the patient was transferred to a hospice facility.

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