Unstructured abstract
A 42-year old man with thrombophilia (prothrombin gene mutation)
required the insertion of an inferior vena cava filter because of
recurrent gastrointestinal bleeding associated with oral
anticoagulation. However, it penetrated through the retro-hepatic vena
cava into the liver, being manifested by constant, blunt abdominal pain.
Endovascular retrieval was considered of extreme risk, though a surgical
approach was performed under cardiopulmonary bypass with deep
hypothermic circulatory arrest. The patient has recovered uneventfully
with complete symptom relief.
Indications of vena cava filters are presence of venous thromboembolic
events with contraindication or failure of anticoagulation. Although
indications are usually an exception rather than the rule, inferior vena
cava (IVC) filters are placed frequently in patients with weak or no
guideline-supported indications for filter placement. Wassef and
colleagues1 found that no contraindication to
anticoagulation was present in only 20.7% of insertions. Moreover,
there is a high variation between hospitals2 in vena
cava filter use for venous thromboembolism, indicating that indications
do not follow a strict criteria.
Complications of inferior vena cava filters are relatively common, and
they vary according to different filter types and designs. Possible
complications are caval penetration, filter migration (including the
lungs), thrombosis, and filter fracture. Strut penetration of the vena
cava wall into an adjacent organ can lead to acute abdominal syndrome,
pain and hemorrhage3,4. Unintended vena cava
penetration is frequently underrecognized, since only nearly 10% of all
penetrations are symptomatic, being pain the most predominant clinical
manifestation5.
An inferior vena cava filter penetrated into the liver parenchyma
(Figure 1 – panels A and B) causing relentless, constant right upper
quadrant pain in a 42-year old man with thrombophilia (prothrombin gene
mutation) that presented bleeding complications with oral
anticoagulation. The Figure 1 shows that the filter had fractured and
most of the struts perforated the vena cava wall into the liver.
Endovascular filter retrieval was initially considered since it is the
treatment of choice in symptomatic patients. However, two endovascular
surgeons turned down the case, because they judged to be of extreme risk
of leaving fractured struts outside the IVC and causing vein laceration.
The patient was submitted to open surgical approach (Figure 1 – C) with
the aid of cardiopulmonary bypass with deep hypothermic circulatory
arrest. The retro-hepatic IVC was longitudinally opened and the filter
was easily removed. The patient has recovered uneventfully with complete
symptom relief.
In symptomatic penetrated vena cava filters in which endovascular
retrieval is not feasible, a surgical approach with appropriate planning
is a safe and effective treatment.
Recommendation: Fernando A. Atik (performed the surgical procedure,
concept/design, drafting article); Claudio Ribeiro da Cunha (part of
surgical team, concept/design, drafting article), Murilo T. Macedo (part
of the surgical team, Figures); Guilherme U. Monte (cardiologist,
drafting article, concept/design).