DOI:10.2214/AJR.06.1037
AJR 2007; 189:S24-S25
© American Roentgen Ray Society
AJR Teaching File: Chest Pain in a Woman with an Inferior Vena Cava Filter
Benjamin Thonar1,
Nilesh H. Patel2,3,
Hector Ferral3 and
George Behrens1
1 Rush University Medical Center, Chicago, IL.
2 Vascular and Interventional Program, Central DuPage Hospital, 25 N. Winfield
Rd., Winfield, IL 60190.
3 Department of Diagnostic Radiology and Nuclear Medicine, Rush University
Medical Center, Chicago, IL.
Received August 4, 2006;
accepted after revision October 4, 2006.
Address correspondence to N. H. Patel
(nilesho326{at}aol.com).
Keywords: deep vein thrombosis • metallic artifacts • retrievable IVC filter
Case History
An ambulatory 37-year-old woman with end-stage renal disease, left lower
extremity deep vein thrombosis (DVT), and renal and pancreatic transplants
presents to the emergency department with chest pain.
Radiologic Description
Magnified view of lateral chest radiograph shows an inferior vena cava
(IVC) filter in the right atrium (Fig.
1A). Unenhanced chest CT image shows the IVC filter in the right
atrium and no pericardial fluid (Fig.
1B). Further history disclosed that a Günther Tulip
retrievable vena cava filter (Cook, Inc.) was placed in the infrarenal vena
cava 4 months prior because of acute gastrointestinal bleeding while the
patient was receiving systemic anticoagulation for left lower extremity
DVT.
Differential Diagnosis
Metallic artifacts in the right atrium can be caused by pacemaker leads, a
metallic foreign body such as a lost intravascular guidewire, prolapsed wires
of Bird's nest IVC filter, or complete migration of an implanted device such
as an IVC filter or stent [1].
The patient can be asymptomatic or present with symptoms of chest pain,
palpitation, arrhythmia, and cardiac tamponade due to right heart perforation
from the migrated vena caval filter.
Diagnosis
The diagnosis in this case is migrated Günther Tulip retrievable IVC
filter (Cook, Inc.).
Commentary
IVC filters are widely used in patients with DVT to prevent pulmonary
embolism by trapping and retaining large venous thrombi. IVC filters are
indicated for patients with thromboembolic disease in whom anticoagulation is
contraindicated, complication occurs while on anticoagulation, or
thromboembolic disease recurs despite therapeutic anticoagulation. They are
also indicated for patients with poor cardiac or pulmonary reserve, patients
with free-floating iliocaval thrombus, or high-risk patients as prophylaxis
for pulmonary embolism. Retrievable IVC filters are ideally suited for
patients who are young and active, patients requiring perioperative
prophylaxis for pulmonary embolism, and in women who are of child-bearing age
or pregnant [2]. In this
patient, review of the vena cavogram obtained before filter placement shows an
IVC diameter of 18 mm and no clot. Venogram after filter deployment showed
good positioning of the filter with proper orientation of its legs.
Adverse outcomes associated with IVC filters may arise during filter
insertion, as delayed complications after insertion, or during filter
retrieval. The most frequently encountered delayed complications of IVC filter
are recurrent pulmonary embolism and filter migration. Recurrent pulmonary
embolism may be due to de novo thrombus formation related to the filter,
trapped embolized thrombus within the filter, cephalad propagation of thrombus
through the filter, incompletely expanded IVC filter, or migrated filter
[3]. Kinney
[3] foundthat IVC filters do
reduce long-term pulmonary embolus; however, they may lead to an increased
incidence of IVC thrombosis and recurrent lower-extremity DVT than treatment
with anticoagulation alone.
Because of long-term complications associated with permanent IVC filters,
retrievable filters are increasingly being used for patients' short-term
protection from pulmonary embolism. The reported complication rates for
retrievable filters are lower than for permanent filters
[4,
5].
In the present case there is a delayed migration of a retrievable
Günther Tulip IVC filter to the patient's right atrium from its original
infrarenal inferior vena cava location (Figs.
1C and
1D). Filter migration may be
caused by a defective device or due to clot formation within the sheath
preventing all legs of the filter from deploying
[2]. It also may occur as a
result of miscalculating the caval diameter, guidewire entrapment in the
filter during central venous catheter placement, or a large thrombus
dislodging the filter. A migrated Günther Tulip IVC filter may be
retrieved using a loop-snare catheter, as in this case. Surgical removal is
required if there is associated perforation of the heart with blood in the
pericardial sac.
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Fig. 1C —37-year-old woman with history of deep venous thrombosis
presents with chest pain. Scout film from CT scan shows original location of
Günther Tulip filter (Cook, Inc.) in infrarenal IVC.
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Fig. 1D —37-year-old woman with history of deep venous thrombosis
presents with chest pain. Unenhanced abdominal CT acquired 2 months before
emergency admission shows Günther Tulip filter in acceptable position,
unchanged from its original placement site and with no thrombus.
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Fig. 1B —37-year-old woman with history of deep venous thrombosis
presents with chest pain. Unenhanced chest CT shows IVC filter migration to
right heart across tricuspid valve with its legs in right ventricle. No
pericardial hematoma is seen.
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Objective
The educational objective of this article is to make the reader cognizant
of delayed complications associated with IVC filters.
Conclusion
The purpose of vena cava filters is to prevent pulmonary thromboembolism.
However, there are risks associated with IVC filters, including IVC
thrombosis, filter migration, and recurrent pulmonary embolus.
References
- Roehm JO Jr. Bird's nest filter migration to the right atrium.
AJR 2005; 185:555
–556[Free Full Text]
- Bochenek KM, Aruny JE, Tal MG. Right atrial migration and
percutaneous retrieval of a Günther Tulip inferior vena cava filter.
J Vasc Interv Radiol 2003;14
:1207
–1209[Medline]
- Kinney TB. Update on inferior vena cava filters. J Vasc
Interv Radiol 2003; 14:425
–440[Medline]
- Linsenmaier U, Rieger J, Schenk F, Rock C, Mangel E, Pfeifer KJ.
Indications, management, and complications of temporary inferior vena cava
filters. Cardiovasc Intervent Radiol1998; 21:464
–469[CrossRef][Medline]
- Stein PD, Alnas M, Skaf E, et al. Outcome and complications of
retrievable inferior vena cava filters. Am J Cardiol2004; 94:1090
–1093[CrossRef][Medline]
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Case History
Radiologic Description
