Ann Thorac Surg 2008;86:1664-1665. doi:10.1016/j.athoracsur.2008.04.063
© 2008 The Society of Thoracic Surgeons
Case Reports
Inferior Vena Cava Filter Migration to the Heart
Abbas Emaminia, MDa,*,
Lynn M. Fedoruk, MDa,
Klaus D. Hagspiel, MDb,
Ugur Bozlar, MDb,
Irving L. Kron, MDa
a Department of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
b Department of Interventional Radiology, University of Virginia, Charlottesville, Virginia
Accepted for publication April 16, 2008.
* Address correspondence to Dr Emaminia, University of Virginia Health System, Department of Surgery, PO Box 800679, Charlottesville, VA 22908 (Email: emaminia{at}gmail.com).
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Abstract
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Inferior vena cava filters are considered the therapeutic modality for treatment of deep venous thrombosis in patients who are not candidates for anticoagulation therapy. Filter migration to the heart is a rare but serious complication. In this report we present two cases of Inferior vena cava filters that migrated to the heart and how they were managed.
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Introduction
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Deep venous thrombosis can result in pulmonary embolism (PE) with a potentially fatal outcome [1]. Inferior vena cava (IVC) filters are widely used as the standard mechanical method of preventing PE.
Filter complications are variable according to the filter type, and migration of the filter to the heart is rare. In this article, we present two cases in which IVC filters migrated to the heart.
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Patient 1
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A 56-year-old man presented to an outside hospital with sudden onset of dyspnea. Past medical history was significant for PE associated with prostate surgery. Three days previously he had a percutaneous stainless steel Greenfield filter (Boston Scientific, Natick, MA) placed in preparation for additional prostate surgery.
Upon presentation, the patient was hemodynamically stable. Transthoracic echocardiography demonstrated moderate tricuspid regurgitation and a metallic mass between the atrium and ventricle. The patient was immediately taken to the operating room as the transthoracic echocardiography demonstrated a high degree of suspicion for the filter legs being entwined in the tricuspid valve apparatus, making percutaneous retrieval hazardous. The patient was placed on cardiopulmonary bypass, cross clamped, and cardioplegia was used. After opening the right atrium, the IVC filter, which was ensnared in the tricuspid valve chordal apparatus, was carefully removed. No filter was placed. The patient had an unremarkable postoperative course and was discharged home on warfarin sodium.
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Patient 2
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A 77-year-old woman presented with acute onset dyspnea. A computed tomographic pulmonary angiogram revealed PE. She was placed on therapeutic dose heparin, but developed a rectus sheath hematoma the next day. Anticoagulation was stopped and an OptEase filter (Bard Peripheral Vascular, Tempe, AZ) was placed. She was discharged home, but returned with similar symptoms 2 weeks later. A computed tomographic scan showed multiple small PE in both lungs and migration of the filter to the right ventricle. Because of multiple comorbidities, including severe chronic obstructive pulmonary disease, acute on chronic renal failure, recurrent nonrelated congestive heart failure secondary to diastolic dysfunction, and morbid obesity, the patient was deemed a nonoperative candidate, and the decision was made to retrieve the filter percutaneously. Despite using multiple types of devices and catheters, and working from both femoral and jugular approaches, the filter could not be retrieved, because it was firmly attached to the tricuspid valve apparatus (Fig 1). The patient was transferred to the intensive care unit and suffered a ventricular fibrillation arrest a few hours later. An autopsy was not performed.
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Fig 1. An OptEase filter (Bard Peripheral Vascular, Tempe, AZ) is shown trapped in the right ventricle. Attempts with several catheters failed to retrieve it.
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Comment
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Untreated deep venous thrombosis can result in PE with a potentially fatal outcome [1]. Therapeutic anticoagulation is the mainstay of treatment, although it does not dissolve the thrombus [2]. However, some patients are not suitable candidates for anticoagulation because of either contraindications or recurrent PE while anti-coagulated. These patients may benefit from mechanical interruption of the vena cava to prevent recurrent embolism [3].
The IVC filters are widely used as the standard mechanical method of preventing pulmonary embolism in patients with contraindications to (or failed) anti-coagulation, and as prophylactic devices for individuals considered to be temporarily at high risk for PE [4].
Filter migration is defined as a change of more than 1 cm in position in either cranial or caudal direction when compared with the immediate post-placement film [5].
For most patients, the diagnosis of filter migration to the heart is made incidentally through radiologic or echocardiographic studies obtained for other reasons. However, for symptomatic patients, the abdominal and chest roentgenograms are suggested as first-line diagnostic tests. If the misplaced filter is suspected to be in the heart, an echocardiogram is warranted. A computed tomographic scan can also provide invaluable data on the exact location of the filter. The degree of cardiac dysfunction, the anticipated ease of percutaneous removal, and the patient's ability to withstand open removal through a sternotomy are factors used to consider whether either percutaneous or open removal of the migrated filter [6] can be undertaken. Lahey and colleagues [6] have suggested that percutaneous retrieval should be tried for all symptomatic or asymptomatic patients and, if unsuccessful, asymptomatic patients should be followed-up periodically for acute complications and new conduction disturbances. However, cardiac tamponade, valvular dysfunction, and intractable arrhythmia are indications for an emergency surgical approach [6].
The treatment of choice for symptomatic filters that have migrated to the tricuspid valve is surgical. Given the degree of involvement of the tricuspid chordal apparatus, care should be taken not to damage chordae tendineae while retrieving the filter. If the chordae are injured, repair is recommended.
There are a few reports in the literature where migrated filters are left in place, either in the heart chambers or inside pulmonary arteries. Gelbfish and Ascer [7] followed 2 patients with Greenfield filters (Boston Scientific) in the tricuspid valve for 42 months and right pulmonary artery for 60 months without any apparent hemodynamic problems. Castaneda and colleagues [8] decided not to retrieve a Kimray-Greenfield filter (Bard Peripheral Vascular) migrated to the heart because of the high surgical risk. Their patient remained asymptomatic for 18 months. However, filters remaining in the heart or pulmonary arteries carry more than 50% mortality rate. This makes the decision for low-risk surgical cases simple (ie, removal of the filter from the cardiovascular system). The risk of surgery for the high-risk patient (such as the one in this report) is left to the clinical judgment of the surgeon. The patient's age, comorbidities, and risks of complications after a major operation should be weighed against hazards of a foreign body in the heart or pulmonary arteries, and consequential risk of tamponade, arrhythmias, and other lethal complications.
The availability of retrievable IVC filters has significantly increased the number of filters placed in the United States. Therefore, clinicians will likely see increased numbers of filter complications, including migrations. Leaving the filter inside the heart carries the risk of arrhythmias, as well as late perforations. Therefore, we believe that retrieval should always be considered.
Percutaneous techniques should be tried first, and if they fail, surgical removal should be contemplated. In patients with confirmed chordal involvement, percutaneous approaches are less likely to be successful, and surgical intervention should be considered first.
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References
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- Padberg FT. Prevention of venous thromboembolism in the surgical patientIn: Cameron JL, editor. Current surgical therapy. 7th ed.. St. Louis, MO: Mosby; 2001.
- Hayes JD, Stone PA, Flaherty SK, Hass SM, Umstot Jr RK. TrapEase vena cava filter: a case of filter migration and pulmonary embolism after placement Ann Vasc Surg 2006;20:138-144.[Medline]
- Joels CS, Sing RF, Heniford BT. Complications of inferior vena cava filters Am Surg 2003;69:654-659.[Medline]
- Offner PJ, Hawkes A, Madayag R, Seale F, Maines C. The role of temporary inferior vena cava filters in critically ill surgical patients Arch Surg 2003;138:591-594.[Abstract/Free Full Text]
- Mitchel WB, Bonn J. Percutaneous retrieval of a Greenfiled filter after migration to the left pulmonary artery J Vasc Interv Radiol 2005;16:1013-1017.[Medline]
- Lahey SJ, Meyer LP, Karchmer AW. Misplaced caval filter and subsequent pericardial tamponade Ann Thorac Surg 1991;51:299-301.[Abstract]
- Gelbfish GA, Ascer E. Intracardiac and intrapulmonary Greenfield filters: a long-term follow-up J Vasc Surg 1991;14:614-617.[Medline]
- Castaneda F, Herrera M, Cragg AH, et al. Migration of a Kimray-Greenfield filter to the right ventricle Radiology 1983;149:690.[Free Full Text]
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Abstract
Introduction
