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IVC Filter Thrombosis: Beware of Lawsuits
By Sohail Khan, MD, FACC, FSCAI; Hamid Salam, MD, FACC; David Toups, MD
Although inferior vena cava (IVC) filters might decrease the incidence of pulmonary embolism (PE), the risk of deep venous thrombosis (DVT) is increased. Reported caval thrombosis rate associated with filter implantation varies, likely increasing with time of implantation and conditions predisposing the patient to thromboembolism. Caval thrombosis can cause significant morbidity such as lower extremity edema and phlegmasia cerulea dolens. In patients with retrievable filters, caval thrombosis can preclude removal.
Case Presentation
A 78-year-old male presented to our facility with previous history of right lower extremity deep venous thrombosis and pulmonary embolism 10 years ago. The patient had a negative work up for hypercoagulable condition at that time and was treated with Coumadin for six months. The patient had another episode of right lower extremity in 2010 while travelling. At that time, he had a VenaTech LP permanent vena caval filter placement (B. Braun Interventional Systems Inc.) to prevent pulmonary embolism and was started on anticoagulation again (Figure 1).
He presented to us with acute onset of lower abdominal pain and severe pain, swelling, cyanosis, and edema of bilateral lower extremities consistent with phlegmasia cerulea dolens. The patient had returned from a 10-hour flight from Alaska a day earlier. The patient had not been on anticoagulation for several months. The initial venous ultrasound showed extensive DVT in bilateral lower extremities.
The patient was taken to the cardiac catheterization lab. Two accesses were obtained in the bilateral posterior tibial veins using 5 Fr Terumo Radial Glidesheath Slender Introducer Sheaths. The initial venogram showed extensive DVT in bilateral lower extremities (Video 1, 2). The Glidewire was crossed easily into the IVC from the left posterior tibial vein however it was difficult from the right posterior tibial (PT) vein due to extensive scarring of the right below-the-knee veins from the previous DVTs. The third access was then obtained in the right common femoral vein. The venogram showed complete occlusion of the IVC filter with the clot extending into the renal veins (Videos 3, 4) (Figure 2).
Next, 2 EKOS catheters (EndoWave Infusion Catheter System) were deployed through the left PT vein and the right common femoral vein respectively (Video 5, Figure 3). Catheter directed thrombolysis was performed using tPA for 16 hours. The final venogram showed complete resolution of the IVC clot and complete resolution of the symptoms (Videos 6, 7). The patient was discharged home on lifelong anticoagulation.
Questions for the readers:
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Should IVC filter be jailed against the IVC wall with a stent?
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Should permanent IVC filters be surgically removed if necessary?
We welcome any suggestions.
Figure 1. VenaTech IVC filter.
Figure 2. IVC thrombosis extending beyond filter.
Figure 3. Two EKOS catheters in the IVC.
