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Duodenal perforation from IVC filter strut perforation is a rare complication.
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Patients typically present with abdominal pain and upper gastrointestinal bleeding.
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Both endovascular and open surgical techniques can be used to retrieve a filter
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Endovascular retrieval has the potential for development of peri-operative sepsis.
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Open surgical removal is preferred in patients with significant filter dwell time.
Background
This article describes a rare case of inferior vena cava (IVC) filter perforation into the duodenum in a patient presenting with abdominal pain.
Case report
A 55 year old woman presented with abdominal pain four years after an IVC filter placement. Workup demonstrated an IVC filter strut perforating the duodenum. The filter was removed via laparotomy, the duodenum was closed primarily, and the IVC was repaired. The patient was discharged home on post-operative day five and is doing well.
Conclusions
Most extraluminal perforations of IVC filter struts are asymptomatic. Rare filter associated duodenal perforations may present with non-specific abdominal symptoms. If no other diagnosis can be attributed to the patient's presentation, direct removal of the filter and repair of the duodenum are indicated.
Inferior vena cava (IVC) filters are indicated in patients at high risk of venous thromboembolism (VTE) when anticoagulation is contraindicated or fails. While guidelines are clear on the indications, IVC filters are increasingly used as prophylaxis in patients with fall risk, bariatric and trauma patients, and patients with VTE. Although significant improvements in the last decade in the design of retrievable filters have led to an increased use of filters, the actual removal rate is less than 25%. Overall, filter placement is considered to be a safe procedure; however, there is clear evidence that the insertion of filters may cause complications years after their placement. The most commonly described complications include access site complications, IVC filter migration, strut fracture, and IVC occlusion.
Prevalence of fracture and fragment embolization of Bard retrievable vena cava filters and clinical implications including cardiac perforation and tamponade.
A case of IVC filter strut perforation into the duodenum, causing severe dyspeptic symptoms and abdominal pain, is presented.
Case report
A 55 year old woman with a history of peripheral arterial disease, chronic obstructive pulmonary disease, coronary artery disease, gastroesophageal reflux disease, hepatitis C, rheumatoid arthritis, appendectomy, and aortobi-iliac bypass graft for disabling short distance claudication presented with several weeks’ history of severe intermittent right upper quadrant pain, poor appetite, nausea, and emesis. She had a history of IVC filter placement four years prior to presentation for deep vein thrombosis at another hospital. The patient was on high dose proton pump inhibitor therapy prior to admission. The laboratory workup was unremarkable. Imaging workup demonstrated perforation of the IVC filter strut into the third part of the duodenum (Fig. 1A) and a dilated 9 mm common bile duct with an ampullary stricture. Esophagogastroduodenoscopy (EGD) revealed an IVC filter strut protruding into the third part of the duodenum with mucosal ulceration and thickening (Fig. 1B). Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography with brushings were performed to evaluate the ampullary stricture, followed by sphincterotomy and placement of a biliary stent. EUS was negative for a mass and cytology findings were benign.
Figure 1(A) Perforation of the inferior vena cava (IVC) filter strut anteriorly into the duodenum on an abdominal computed tomography scan (white arrow) (B) Strut protruding into the lumen as seen on esophagogastroduodenoscopy (white arrow) (C) Inferior vena cavagram with the IVC struts outside of the IVC (black arrow).
Despite an extensive workup, the patient remained symptomatic with persistent abdominal pain and poor oral intake with no other identifiable causes, at which point retrieval was planned. A cavagram was performed, which demonstrated a patent IVC with the struts of the filter outside the lumen (Fig. 1C). Open surgical removal of the IVC filter with a duodenal repair was planned owing to the prolonged dwell time. Endovascular removal of the filter was not considered owing to potential complications of IVC rupture and duodenal injury.
The operation was performed through a right transverse incision. A Cattell–Braasch manoeuvre was performed to expose the IVC from the renal vein confluence to the IVC bifurcation. Individual lumbar veins were clipped or controlled with silastic vessel loops. One of the struts was encased in a dense peri-ureteric tissue but was not penetrating the lumen of the right ureter. The strut was cut with wire cutters and pulled out. Next, the duodenocaval fistula (Fig. 2A) was completely exposed. The patient was heparinized and the IVC was occluded with the Rummel tourniquets. The IVC was opened through a longitudinal venotomy and the strut penetrating the duodenum was gently pulled out. The fistula was completely transected, and the duodenum was closed in two layers, and the area copiously irrigated with saline (Fig. 2B). The luminal segments of the filter legs, which were encased in dense fibro-intima, were sharply dissected out and the entire filter removed (Fig. 2C). To avoid narrowing, the IVC was repaired with a greater saphenous vein patch angioplasty (Fig. 2D and E). The patient recovered uneventfully and was discharged home on post-operative day five. She was doing well on her follow up visit six months after surgery, with complete resolution of abdominal pain and dyspepsia.
Figure 2(A) Inferior vena cava (IVC) with duodenocaval fistula. D = duodenum; ROV = right ovarian vein; S = strut (B) Filter as seen through the longitudinal venotomy. F = IVC filter; S = strut (C) Completely removed IVC filter (D) IVC with the filter removed (E) Completed repair with the vein patch angioplasty.
IVC filters have been used increasingly since the early 1970s for the prevention of VTE disease in patients that are unable to undergo systemic anticoagulation. With the introduction of retrievable IVC filters, there has been an increased use of these devices in prophylactic settings, despite lack of evidence and low retrieval rate. Due to lack of randomized data, there is no one filter that provides an improved safety profile over any other. Some of the more commonly reported complications of IVC filters include recurrent pulmonary embolism in 0.5%–6%, filter migration in 0%–11.8%,
and the rates are probably quite conservative due to underreporting, lack of routine surveillance, failure of diagnosis, and most complications being asymptomatic. As such, elective retrieval is indicated when filters are no longer needed. It is common to attempt to retrieve the filters within six months of their placement as attempts after one year often fail due to the fibro-intimal incorporation of the struts and hooks of the filter into the IVC wall.
Duodenal perforation from an IVC filter strut perforation is a rare complication, whose true incidence is unknown. The majority of the patients with symptomatic duodenal perforations present with epigastric and right upper quadrant abdominal pain radiating to the back. As the pain is often non-specific, pain caused by an IVC filter is a diagnosis of exclusion. Pain can also be accompanied by dyspepsia and poor gastrointestinal (GI) tolerance. A high index of suspicion is also recommended for patients with a history of IVC filter placement presenting with a GI bleed.
The initial workup to identify the filter as the source of pain or GI bleed includes radiographs, followed by computed tomography and EGD. An upper GI series and adjunctive imaging studies are useful to rule out gastric outlet, small bowel, or biliary obstruction. A cavagram is often used to identify the patency of the IVC and evaluate for potential clot burden. As there are no formal guidelines on the removal of symptomatic late complications of IVC filters, the decision should consider the severity of the symptoms, risk vs. benefit, and the ability to rule out other potential etiologies of the patient's presentation.
Symptomatic penetrations of IVC filters can be managed with both endovascular techniques and surgical interventions. In the current literature there are a total of 49 case reports and case series describing cases with duodenal perforation (Table 1). Laparotomy, venotomy with extraction of the filter, and direct repair of the duodenum was described in 25 patients. In situations when the IVC was thrombosed, en bloc segmental resection of the IVC with the filter in situ was performed. In 10 patients who had a significant inflammatory reaction around the filter the struts were cut flush with the IVC and the duodenum was repaired, leaving the remaining portion of the filter in the IVC. Complications after an abdominal approach were described in two patients, which included significant bleeding requiring a second operation for haemorrhage control and IVC filter strut removal. One patient developed right renal artery pseudo-aneurysm requiring nephrectomy secondary to the IVC filter strut penetrating the aortic wall. Two patients had delayed return of GI function secondary to post-operative ileus and small bowel obstruction, and one patient died after a prolonged stay in hospital. Several authors
have described endovascular retrieval in symptomatic patients who had duodenal, aortic, or vertebral penetration by an IVC filter. The filter was retrieved in 12 patients, and two patients had a failed attempt. All patients were maintained on broad spectrum antibiotics peri-operatively, to prevent intra-abdominal sepsis. In cases of aortic wall penetration, femoral artery access was maintained intra-operatively for potential haemorrhage control. Table 1 provides a detailed workup list and treatment.
Table 1Clinical presentation, filter characteristics, and treatment outcomes after inferior vena cava (IVC) filter retrieval.
Bird's nest; strut cut flush with the IVC + repair of the duodenum (no cavotomy)
No complications; resolution of symptoms
Formentini et al. (2005)
23, F
Epigastric pain
5 y; AXR + EGD + CT of the abdomen/pelvis
Post-partum DVT + PE
NR; repair of the duodenum extraction of the filter (cavotomy)
No complications; resolution of symptoms
Mansour et al. (2005)
41, M
Haematochezia + abdominal pain
4 y; UGI series + EGD + CT of the abdomen/pelvis
PE + GI bleed
Bird's nest; strut cut flush with the IVC + repair of the duodenum (no cavotomy)
No complications; resolution of symptoms
Durairaj et al. (2006)
83, F
Epigastric discomfort
6 y, abdominal US + CT of the abdomen/pelvis + ERCP
Recurrent DVT + stroke + epistaxis/haematuria
Greenfield; non-operative management, long term antibiotic therapy
NR long term; resolution of symptoms for one mo
Botsios et al. (2006)
77, F
Epigastric pain + GI bleed
9 y, EGD + CT of the abdomen/pelvis
DVT + massive PE
Greenfield; repair of the duodenum extraction of the filter (cavotomy)
No complications; resolution of symptoms
Ibele et al. (2008)
48, F
RUQ pain
14 mo; CT of the abdomen/pelvis
Severe trauma + retroperitoneal bleed
Recovery; endovascular retrieval
No complications; resolution of symptoms
Veroux et al. (2008)
46, F
Diffuse oedema left lower extremity + mural thrombus in the aorta and IVC occlusion
2 y; DUS of the lower extremity + CT of the chest/abdomen/pelvis
Recurrent DVT + PE despite full AC
Recovery; repair of the duodenum + extraction of the filter (cavotomy) + aortic thrombectomy
No complications; residual IVC thrombus
Parkin et al. (2009)
21, M
Lower back pain + discitis
5 y; CT of the abdomen/pelvis
DVT + multiple PE despite AC
Günther tulip; extraction of the filter (cavotomy)
No complications; resolution of symptoms
Franz et al. (2009)
27, M
Abdominal + back pain
10 mo; CT of the abdomen/pelvis
DVT + irregular use of AC
Celect; strut cut flush with the IVC + repair of the duodenum (no cavotomy)
No complications; resolution of symptoms
Obman et al. (2010)
40, F
Upper abdominal pain
15 y; EGD + CT of the abdomen/pelvis
Severe trauma
Greenfield; repair of the duodenum + extraction of the filter (cavotomy)
No complications; resolution of symptoms
Becher et al. (2010)
42, M
Back pain
10 mo; CT of the abdomen/pelvis
Traumatic SAH + multi-organ injury
Celect; repair of the aortic pseudoaneurysm, extraction of the filter (cavotomy)
Right renal artery pseudoaneurysm requiring nephrectomy; resolution of symptoms
Bathla et al. (2011)
76, F
GI bleed
14 mo; EGD + CT of the abdomen/pelvis
Recurrent DVT despite full AC
Celect; repair of the duodenum + extraction of the filter (cavotomy)
No complications; resolution of symptoms
Shang et al. (2011)
58, M
Epigastric pain
10 y; EGD + CT of the abdomen/pelvis + UGI series
DVT + trauma
Bird's nest; repair of the duodenum + extraction of the filter (cavotomy)
No complications; resolution of symptoms
Widmer et al. (2011)
61, F
RUQ abdominal pain
1 y; EGD + CT of the abdomen/pelvis
DVT
NR; NR
NR
Conolly et al. (2012)
49, M; 50–58, F (3 patients)
Abdominal pain
5 mo–3 y, CT of the abdomen/pelvis
DVT + PE, surgical VTE, PE + hypercoagulable state
2 Bard Recovery filters, Bard G2, Celect; repair of the duodenum + extraction of the filter (cavotomy or sheath based open retrieval of the filter)
NR
Malgor et al. (2012)
61, F
Epigastric pain
3 y; EGD + CT of the abdomen/pelvis
DVT + PE
Bard G2; repair of the duodenum + extraction of the filter (cavotomy)
No complications; resolution of symptoms
Bae et al. (2012)
33, F
Epigastric pain + dyspepsia
8 mo; EGD + CT of the abdomen/pelvis
DVT during pregnancy
NR; strut cut flush with the IVC + repair of the duodenum (no cavotomy)
Post-operative ileus; resolution of symptoms
Caldwell et al. (2012)
47, F
Abdominal pain + GI bleed, CT of the abdomen/pelvis
3 y; CT of the abdomen/pelvis
DVT + obesity, pre-operatively before Roux-en-Y
Bard G2; endovascular extraction
No complications; resolution of symptoms
Antonoff et al. (2012)
62, M
Incidental CT scan findings
25 y; CT of the abdomen/pelvis + EGD
Protein C deficiency + prolonged hospitalisation after abdominal surgeries
Miles IVC clip; repair of the duodenum + clip extraction + IVC ligation
No complications; resolution of symptoms
Rondonotti et al. (2013)
57, F
GI bleed
4 y; EGD + capsule endoscopy + CT of the abdomen/pelvis
DVT + factor V mutation + multiple myeloma
NR; repair of the duodenum + extraction of the filter (cavotomy)
No complications; resolution of symptoms
Dat et al. (2014)
60, F
Epigastric pain + GI bleed
1 y; EGD + CT of the abdomen/pelvis
DVT + PE + bleeding
Celect; strut cut flush with the IVC + repair of the duodenum (no cavotomy)
Failed attempt during index surgery due to significant haemorrhage; patient required second surgery; resolution of symptoms
Ishida et al. (2014)
41, M
Routine EGD
18 mo; EGD + CT of the abdomen/pelvis
DVT + PE
ALN filter; strut cut flush with the IVC + repair of the duodenum (no cavotomy)
No complications; resolution of symptoms
Park et al. (2014)
46, M
Abdominal pain
6 y; EGD + CT of the abdomen/pelvis
DVT + paraplegia
NR; conservative management with abdominal pain attributed to urological causes
No complications; resolution of symptoms
Jehangir et al. (2015)
67, F
RUQ abdominal pain
NR; EGD + CT of the abdomen/pelvis
DVT
NR; repair of the duodenum + extraction of the filter (cavotomy)
No complications; resolution of symptoms
Genovese et al. (2015)
29–49, M (3 patients); 17–81 F (6 patients)
Abdominal pain + GI intolerance
2 mo–5 y; EGD + CT of the abdomen pelvis
DVT/PE polytrauma, paraplegia
7 Celect, 2 Recovery; 2 patients had open repair of the duodenum + extraction of the filter (cavotomy); 6 patients had successful endovascular extraction; one patient had a failed endovascular extraction
One patient developed Gram negative bacteraemia after endovascular extraction managed with antibiotics; resolution of symptoms in all patients
Venturini et al. (2015)
45, M
Asymptomatic
5 y; CT of the abdomen/pelvis + cavagram
DVT + PE
ALN filter; endovascular extraction
No complications; resolution of symptoms
Pokharel et al. (2016)
67, F
RUQ abdominal pain + fevers
6 mo; CT of the abdomen/pelvis
PE + groin haematoma
NR; endovascular extraction
No complications; resolution of symptoms
Williams et al. (2016)
32, F
Epigastric abdominal pain
12 mo; CT of the abdomen/pelvis
DVT + contraindication to AC
Celect; endovascular extraction
No complications; resolution of symptoms
Fernandez-Moure et al. (2017)
67, M
Abdominal pain + GI bleed
1 y; EGD + CT of the abdomen/pelvis
DVT + craniotomy for brain tumour
Celect; endovascular extraction
No complications; resolution of symptoms
Kishor Jha et al. (2017)
47, F
Abdominal pain + dyspepsia
20 y; venography + CT of the abdomen/pelvis
DVT + contraindication to AC
NR; repair of the duodenum + extraction of the filter (cavotomy) + ligation of the IVC
MRSA bacteraemia; resolution of symptoms
McKelvie et al. (2017)
39, F
Asymptomatic, found during serial imaging
14 mo; EGD + CT of the abdomen/pelvis
DVT despite AC
Celect; unsuccessful endovascular extraction
NR
Lee et al. (2019)
63, F
Routine EGD
19 mo; EGD + AXR + CT of the abdomen/pelvis
DVT + iliac vein perforation
Celect; repair of the duodenum + extraction of the filter (cavotomy)
No complications; resolution of symptoms
Hongo et al. (2019)
43, M
GI bleed
12 y; EGD + CT of the abdomen/pelvis
DVT + trauma
NR; conservative management
No complications; resolution of GI bleed
Shimizu et al. (2019)
35, M
Epigastric pain
3 y, EGD + CT of the abdomen/pelvis
PE prevention after iatrogenic left iliac vein injury with DVT + malignancy
ALN filter; repair of the duodenum by EGD clipping + extraction of the filter (cavotomy)
No complications; resolution of symptoms
Halim et al. (2021)
28, F 55, M
Abdominal pain
NR; EGD + CT of the abdomen/pelvis
DVT
NR; repair of the duodenum + extraction of the filter (cavotomy)
No complications; resolution of symptoms
Parikh et al. (2021)
33, M
Epigastric abdominal pain
10 y; CT of the abdomen/pelvis
Recurrent DVT + paraplegia
Bird's nest; repair of the duodenum + strut cut flush with the IVC (no cavotomy)
No complications; resolution of symptoms
Khan et al. (2021)
33, F
Epigastric pain
13 y; EGD + CT of the abdomen/pelvis
DVT + paraplegia
Celect; repair of the duodenum + extraction of the filter (cavotomy)
No complications; resolution of symptoms
Tanabe et al. (2022)
26, M
GI bleed
8 y; EGD + CT of the abdomen/pelvis
IVC tumour embolisation
NR; repair of the duodenum + strut cut flush with the IVC + endovascular extraction
No complications; resolution of symptoms
M = male; RUQ = right upper quadrant; AXR = abdominal Xray; PE = pulmonary embolism; NR = not reported; AC = anticoagulation; F = female; EGD = oesophagogastroduodenoscopy; CT = computed tomography; DVT = deep vein thrombosis; CP = chest pain; SOB = shortness of breath; GI = gastrointestinal; CVA = cerebrovascular accident; BE = barium enema; US = ultrasound; SB = small bowel; UGI = upper gastrointestinal; ERCP = endoscopic retrograde cholangiopancreatography; DUS = duplex ultrasound; SAH = subarachnoid haemorrhage; VTE = venous thrombo-embolism; MRSA = methicillin resistant Staphylococcus aureus.
In the current era of minimally invasive surgery there are also several reports of laparoscopic assisted, retroperitoneal laparoscopic, and even robotic assisted retrievals of an IVC filter. These approaches did not demonstrate decreased duration of hospital stay vs. open techniques, and several patients experienced post-operative fever and haematuria.
The conventional endovascular approach to remove an IVC filter revolves around retrieving the filter using a snare with a co-axial sheath. Several adjunctive manoeuvres, such as stiff wire displacement, loop snare realignment, wire loop and snare sling techniques, angioplasty balloon displacement, parallel wire and snare flossing, and dissection with endobronchial forceps, can aid the process. Another alternative is endovascular IVC filter retrieval using an excimer laser sheath, which has been described as safe and effective in extracting embedded filters.
Despite advances in techniques, endovascular attempts at retrieval have their own set of complications. There have been cases of strut bending with non-collapsibility into the jugular sheath, which requires urgent open surgery There is also potential for strut fracture with migration to the right ventricle and pulmonary artery. The complication rate for endovascular retrieval that requires adjuncts beyond standard snare and sheath varies from 5.3% to 20.6% between series.
In conclusion, an IVC filter causing duodenal perforation is a rare complication with non-specific symptoms. Multimodal imaging and diagnostic studies should be used to rule out other morelikely causes of a patient's symptoms. Consultation with gastroenterology should be considered. When all other reasonable causes have been excluded, direct filter removal can be performed safely using established endovascular or open surgical techniques. As the present case demonstrates, safe removal of the filter can be performed in the context of previous abdominal surgery.
Conflicts of interest
None.
Funding
None.
Appendix ASupplementary data
The following are the supplementary data related to this article:
Prevalence of fracture and fragment embolization of Bard retrievable vena cava filters and clinical implications including cardiac perforation and tamponade.
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