Complex Semipermanent Inferior Vena Cava Filter Removal Requiring Surgical Intervention for Aortic Injury

M. Markovitz, A. Alayli, J. Vogler, C. Raymond, L. S. Grundy, K. Massis, J. Shaikh, G. Hoots

Purpose: To discuss a unique case of complex semipermanent inferior vena cava (IVC) filter removal complicated by aortic injury requiring surgical intervention. We explore strategies for removing semipermanent and permanent filters and then review potential complications and their associated management.

Materials and Methods: All protected health information was managed according to the Health Insurance Portability and Accountability Act protocols at our institution. Patient history and imaging were reviewed in a standard electronic medical record and picture archiving and communication system workstation. The procedures described were performed using standard angiography technique. The patient was followed throughout his hospital course until discharge.

Results: A 49-year-old man with recurrent deep vein thrombosis and pulmonary embolism secondary to protein C deficiency had an OptEase IVC filter placed in 2006. He presented with acute on chronic bilateral nonocclusive lower extremity thrombus and a tilted infrarenal filter with multiple fracture fragments. Venography and thrombolysis of the lower extremities was performed with IVC filter removal the following day. Two filter fragments embedded in the caval wall were unable to be safely removed. He developed a tear in the IVC requiring temporary balloon occlusion and IVC stent placement without residual extravasation. Overnight he had continued pain and bleeding concerning for retroperitoneal bleed. He was taken for arteriography which demonstrated active bleeding from the right gonadal and L2 and L3 lumbar arteries, which were embolized with coils. He continued to have worsening symptoms requiring large-volume blood products, prompting repeat angiography, which concerning for a small aortic perforation at the right L3 level. Vascular and trauma surgery took the patient for endovascular aortic endograft placement and exploratory laparotomy for retroperitoneal hematoma evacuation. His hemoglobin normalized during the remainder of his hospital stay, and he was discharged without further significant event.

Conclusions: Removal of nearly every permanent and semipermanent filter has been described, be it intact or in piecemeal fashion. This case emphasizes the challenges and unique risks of removing these filters, especially when multiple fracture fragments are present and the struts make long segments of wall contact, such as the OptEase and TrapEase filters. Although uncommon, arterial injury is a dreaded complication of filter removal that should be anticipated and may occasionally require surgical intervention.