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Duodenocaval Fistula from an Inferior Vena Cava Filter Perforation

Open AccessPublished:June 14, 2022DOI:https://doi.org/10.1016/j.ejvsvf.2022.06.001

      Highlights

      • Duodenal perforation from IVC filter strut perforation is a rare complication.
      • Patients typically present with abdominal pain and upper gastrointestinal bleeding.
      • Both endovascular and open surgical techniques can be used to retrieve a filter
      • Endovascular retrieval has the potential for development of peri-operative sepsis.
      • 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.

      Keywords

      Introduction

      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.
      • An T.
      • Moon E.
      • Bullen J.
      • Kapoor B.
      • Wu A.
      • Sands M.
      • et al.
      Prevalence and clinical consequences of fracture and fragment migration of the Bard G2 filter: imaging and clinical follow-up in 684 implantations.
      • Hajduk B.
      • Tomkowski W.Z.
      • Malek G.
      • Davidson B.L.
      Vena cava filter occlusion and venous thromboembolism risk in persistently anticoagulated patients: a prospective, observational cohort study.
      • Nicholson W.
      • Nicholson W.J.
      • Tolerico P.
      • Taylor B.
      • Solomon S.
      • Schryver T.
      • et al.
      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 thumbnail gr1
      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 thumbnail gr2
      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.

      Discussion

      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%,
      • Zhou D.
      • Spain J.
      • Moon E.
      • McLennan G.
      • Sands M.J.
      • Wang W.
      Retrospective review of 120 celect inferior vena cava filter retrievals: experience at a single institution.
      caval thrombosis in 2.7%–13%,
      • Wang S.L.
      • Siddiqui A.
      • Rosenthal E.
      Long-term complications of inferior vena cava filters.
      filter fracture in 23%–40%,
      • Wang S.L.
      • Siddiqui A.
      • Rosenthal E.
      Long-term complications of inferior vena cava filters.
      and IVC perforation in 15%–70%.
      • Wang S.L.
      • Siddiqui A.
      • Rosenthal E.
      Long-term complications of inferior vena cava filters.
      These complications can be seen as early as six months after implantation,
      • Johnson M.S.
      • Nemcek Jr., A.A.
      • Benenati J.F.
      • Baumann D.S.
      • Dolmatch B.L.
      • Kaufman J.A.
      • et al.
      The safety and effectiveness of the retrievable option inferior vena cava filter: a United States prospective multicenter clinical study.
      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.
      • Hoekstra A.
      • Hoogeveen Y.
      • Elstrodt J.M.
      • Tiebosch A.T.
      Vena cava filter behavior and endovascular response: an experimental in vivo study.
      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
      • Genovese E.A.
      • Jeyabalan G.
      • Marone L.K.
      • Avgerinos E.D.
      • Makaroun M.S.
      • Chaer R.A.
      Endovascular management of symptomatic gastrointestinal complications associated with retrievable inferior vena cava filters.
      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.
      Author (year)
      See Supplementary Appendix S1 for the full references.
      Age, sexClinical presentationInterval from placement and diagnostic modalityIndicationsType of IVC filter and treatment modalityComplications and outcomes
      Irvin (1972)48, MFever, RUQ pain + right flank tenderness7 days; AXRRecurrent PE despite ACMobin-Uddin; ligation of the IVC just below renal veinsNo complications; resolution of symptoms
      Appleberg et al. (1990)71, FDiarrhoea + weight loss6 y; AXR + EGD + cavagram + CT of the abdomen/pelvisMassive iliofemoral DVTGreenfield; repair of the duodenum and extraction of the filter (cavotomy)No complications; resolution of symptoms
      Taheri et al. (1992)41, FCP + SOB + RUQ pain7 mo; AXR + cavagramDVT + PE + GI bleedGreenfield (suprarenal); repair of the duodenum and extraction of the filter (cavotomy)No complications; resolution of symptoms
      Tritsch et al. (1993)66, FFever + weight loss + epigastric pain4 y; AXR + EGD + CT of the abdomen/pelvisDVT + PEKimray–Greenfield; strut cut flush with the IVC + repair of the duodenum (no cavotomy)Small bowel obstruction; CVA during hospitalisation and death
      Goldman et al. (1994)58, FRUQ abdominal + flank pain10 y; EGD + BE + colonoscopy + abdominal US + cavagram + CT of the abdomen/pelvisIntracranial bleed + DVTMobin–Uddin; extraction of filter found outside the IVCNo complications; resolution of symptoms
      Al Zaharani et al. (1995)55, MMelaena + haematemesis5 y; EGD + CT of the + abdomen/pelvisRecurrent DVT + PE despite ACBird's nest; strut cut flush with the IVC repair of the duodenum (no cavotomy)Post-operative DVT requiring AC; resolution of symptoms
      Bianchini et al. (1996)29, MHeartburn + haematemesis16 mo; AXR + EGDDVT + PE despite full ACGreenfield; repair of the duodenum + partial extraction of the filter (cavotomy)No complications; resolution of symptoms
      Sarkar et al. (1997)68, FAnaemia + GI bleed11 y; EGDDVT + PE post-operativelyMobin–Uddin; repair of the duodenum + extraction of the filter (cavotomy)No complications; resolution of symptoms
      Dardik et al. (1997)36, MNausea (SB obstruction)2 y; AXR + UGI series +EGD + CTDVT + GI bleedGreenfield; repair of the duodenum + extraction of the filter (cavotomy)No complications; resolution of symptoms
      Guillem et al. (2001)60, FAbdominal + lumbar pain10 y; abdominal US + EGD + CT of the abdomen/pelvisThrombophlebitis + recurrent PENR; repair of the duodenum + extraction of the filter (cavotomy)Post-operative bleeding requiring ligation of a disrupted IVC branch; resolution of symptoms long term
      Feezor et al. (2002)40, MEpigastric/RUQ pain + weight lossNR; plain AXR + abdominal US + CT + EGD + cavogramDVT + strokeBird's nest; strut cut flush with the IVC + repair of the duodenum (no cavotomy)No complications; resolution of symptoms
      Formentini et al. (2005)23, FEpigastric pain5 y; AXR + EGD + CT of the abdomen/pelvisPost-partum DVT + PENR; repair of the duodenum extraction of the filter (cavotomy)No complications; resolution of symptoms
      Mansour et al. (2005)41, MHaematochezia + abdominal pain4 y; UGI series + EGD + CT of the abdomen/pelvisPE + GI bleedBird's nest; strut cut flush with the IVC + repair of the duodenum (no cavotomy)No complications; resolution of symptoms
      Durairaj et al. (2006)83, FEpigastric discomfort6 y, abdominal US + CT of the abdomen/pelvis + ERCPRecurrent DVT + stroke + epistaxis/haematuriaGreenfield; non-operative management, long term antibiotic therapyNR long term; resolution of symptoms for one mo
      Botsios et al. (2006)77, FEpigastric pain + GI bleed9 y, EGD + CT of the abdomen/pelvisDVT + massive PEGreenfield; repair of the duodenum extraction of the filter (cavotomy)No complications; resolution of symptoms
      Ibele et al. (2008)48, FRUQ pain14 mo; CT of the abdomen/pelvisSevere trauma + retroperitoneal bleedRecovery; endovascular retrievalNo complications; resolution of symptoms
      Veroux et al. (2008)46, FDiffuse oedema left lower extremity + mural thrombus in the aorta and IVC occlusion2 y; DUS of the lower extremity + CT of the chest/abdomen/pelvisRecurrent DVT + PE despite full ACRecovery; repair of the duodenum + extraction of the filter (cavotomy) + aortic thrombectomyNo complications; residual IVC thrombus
      Parkin et al. (2009)21, MLower back pain + discitis5 y; CT of the abdomen/pelvisDVT + multiple PE despite ACGünther tulip; extraction of the filter (cavotomy)No complications; resolution of symptoms
      Franz et al. (2009)27, MAbdominal + back pain10 mo; CT of the abdomen/pelvisDVT + irregular use of ACCelect; strut cut flush with the IVC + repair of the duodenum (no cavotomy)No complications; resolution of symptoms
      Obman et al. (2010)40, FUpper abdominal pain15 y; EGD + CT of the abdomen/pelvisSevere traumaGreenfield; repair of the duodenum + extraction of the filter (cavotomy)No complications; resolution of symptoms
      Becher et al. (2010)42, MBack pain10 mo; CT of the abdomen/pelvisTraumatic SAH + multi-organ injuryCelect; repair of the aortic pseudoaneurysm, extraction of the filter (cavotomy)Right renal artery pseudoaneurysm requiring nephrectomy; resolution of symptoms
      Bathla et al. (2011)76, FGI bleed14 mo; EGD + CT of the abdomen/pelvisRecurrent DVT despite full ACCelect; repair of the duodenum + extraction of the filter (cavotomy)No complications; resolution of symptoms
      Shang et al. (2011)58, MEpigastric pain10 y; EGD + CT of the abdomen/pelvis + UGI seriesDVT + traumaBird's nest; repair of the duodenum + extraction of the filter (cavotomy)No complications; resolution of symptoms
      Widmer et al. (2011)61, FRUQ abdominal pain1 y; EGD + CT of the abdomen/pelvisDVTNR; NRNR
      Conolly et al. (2012)49, M;

      50–58, F (3 patients)
      Abdominal pain5 mo–3 y, CT of the abdomen/pelvisDVT + PE, surgical VTE, PE + hypercoagulable state2 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, FEpigastric pain3 y; EGD + CT of the abdomen/pelvisDVT + PEBard G2; repair of the duodenum + extraction of the filter (cavotomy)No complications; resolution of symptoms
      Bae et al. (2012)33, FEpigastric pain + dyspepsia8 mo; EGD + CT of the abdomen/pelvisDVT during pregnancyNR; strut cut flush with the IVC + repair of the duodenum (no cavotomy)Post-operative ileus; resolution of symptoms
      Caldwell et al. (2012)47, FAbdominal pain + GI bleed, CT of the abdomen/pelvis3 y; CT of the abdomen/pelvisDVT + obesity, pre-operatively before Roux-en-YBard G2; endovascular extractionNo complications; resolution of symptoms
      Antonoff et al. (2012)62, MIncidental CT scan findings25 y; CT of the abdomen/pelvis + EGDProtein C deficiency + prolonged hospitalisation after abdominal surgeriesMiles IVC clip; repair of the duodenum + clip extraction + IVC ligationNo complications; resolution of symptoms
      Rondonotti et al. (2013)57, FGI bleed4 y; EGD + capsule endoscopy + CT of the abdomen/pelvisDVT + factor V mutation + multiple myelomaNR; repair of the duodenum + extraction of the filter (cavotomy)No complications; resolution of symptoms
      Dat et al. (2014)60, FEpigastric pain + GI bleed1 y; EGD + CT of the abdomen/pelvisDVT + PE + bleedingCelect; 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, MRoutine EGD18 mo; EGD + CT of the abdomen/pelvisDVT + PEALN filter; strut cut flush with the IVC + repair of the duodenum (no cavotomy)No complications; resolution of symptoms
      Park et al. (2014)46, MAbdominal pain6 y; EGD + CT of the abdomen/pelvisDVT + paraplegiaNR; conservative management with abdominal pain attributed to urological causesNo complications; resolution of symptoms
      Jehangir et al. (2015)67, FRUQ abdominal painNR; EGD + CT of the abdomen/pelvisDVTNR; 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 intolerance2 mo–5 y; EGD + CT of the abdomen pelvisDVT/PE polytrauma, paraplegia7 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 extractionOne patient developed Gram negative bacteraemia after endovascular extraction managed with antibiotics; resolution of symptoms in all patients
      Venturini et al. (2015)45, MAsymptomatic5 y; CT of the abdomen/pelvis + cavagramDVT + PEALN filter; endovascular extractionNo complications; resolution of symptoms
      Pokharel et al. (2016)67, FRUQ abdominal pain + fevers6 mo; CT of the abdomen/pelvisPE + groin haematomaNR; endovascular extractionNo complications; resolution of symptoms
      Williams et al. (2016)32, FEpigastric abdominal pain12 mo; CT of the abdomen/pelvisDVT + contraindication to ACCelect; endovascular extractionNo complications; resolution of symptoms
      Fernandez-Moure et al. (2017)67, MAbdominal pain + GI bleed1 y; EGD + CT of the abdomen/pelvisDVT + craniotomy for brain tumourCelect; endovascular extractionNo complications; resolution of symptoms
      Kishor Jha et al. (2017)47, FAbdominal pain + dyspepsia20 y; venography + CT of the abdomen/pelvisDVT + contraindication to ACNR; repair of the duodenum + extraction of the filter (cavotomy) + ligation of the IVCMRSA bacteraemia; resolution of symptoms
      McKelvie et al. (2017)39, FAsymptomatic, found during serial imaging14 mo; EGD + CT of the abdomen/pelvisDVT despite ACCelect; unsuccessful endovascular extractionNR
      Lee et al. (2019)63, FRoutine EGD19 mo; EGD + AXR + CT of the abdomen/pelvisDVT + iliac vein perforationCelect; repair of the duodenum + extraction of the filter (cavotomy)No complications; resolution of symptoms
      Hongo et al. (2019)43, MGI bleed12 y; EGD + CT of the abdomen/pelvisDVT + traumaNR; conservative managementNo complications; resolution of GI bleed
      Shimizu et al. (2019)35, MEpigastric pain3 y, EGD + CT of the abdomen/pelvisPE prevention after iatrogenic left iliac vein injury with DVT + malignancyALN 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 painNR; EGD + CT of the abdomen/pelvisDVTNR; repair of the duodenum + extraction of the filter (cavotomy)No complications; resolution of symptoms
      Parikh et al. (2021)33, MEpigastric abdominal pain10 y; CT of the abdomen/pelvisRecurrent DVT + paraplegiaBird's nest; repair of the duodenum + strut cut flush with the IVC (no cavotomy)No complications; resolution of symptoms
      Khan et al. (2021)33, FEpigastric pain13 y; EGD + CT of the abdomen/pelvisDVT + paraplegiaCelect; repair of the duodenum + extraction of the filter (cavotomy)No complications; resolution of symptoms
      Tanabe et al. (2022)26, MGI bleed8 y; EGD + CT of the abdomen/pelvisIVC tumour embolisationNR; repair of the duodenum + strut cut flush with the IVC + endovascular extractionNo 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.
      See Supplementary Appendix S1 for the full references.
      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.
      • Kuo W.T.
      • Odegaard J.I.
      • Rosenberg J.K.
      • Hofmann L.V.
      Laser-assisted removal of embedded vena cava filters: a 5-year first-in-human study.
      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.
      • Brahmandam A.
      • Skrip L.
      • Mojibian H.
      • Aruny J.
      • Sumpio B.
      • Dardik A.
      • et al.
      Costs and complications of endovascular inferior vena cava filter retrieval.
      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:

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