Late Erosion of a Prophylactic IVC Filter into the Aorta, Right Renal Artery, and Duodenal Wall

BACKGROUND: Prophylactic insertion of inferior vena cava (IVC) filters accounts for more than half of all IVC filters placed into multisystem trauma patients with contraindications to anticoagulation. There has been an increase in the use of prophylactic IVC filters associated with the introduction of retrievable IVC filters (R-IVCF), the majority of which are not removed. In this case we describe a patient with R-IVCF-related pseudoaneurysms of the infrarenal aorta and right renal artery who presented 10 months following multi-organ trauma and prophylactic R-IVCF placement. Management required autogenous aortic reconstruction, caval repair, and subsequent right nephrectomy.
METHODS: A 42-year-old gentleman presented with left upper extremity edema and was diagnosed with left arm thrombophlebitis. During inpatient hospitalization, the patient underwent a computed tomography (CT) scan of the abdomen and pelvis as part of an evaluation of back pain. The CT demonstrated an IVC filter with struts protruding outside the vena cava lumen associated with fluid collections, an infrarenal aortic pseudoaneurysm, and penetration into the duodenal wall (Figures 1 and 2). A follow-up CT scan three days later demonstrated increased peri-caval fluid collections and new septic emboli to the lungs. The patient’s Celect R-IVCF (Cook Medical, Bloomington, IN) had been placed 10 months prior for pulmonary embolus prophylaxis in the absence of documented deep vein thrombosis following a motor vehicle accident associated with multi-organ injuries. At the completion of his trauma hospitalization, an unsuccessful attempt was made to retrieve the filter and it was left in place. After a second unsuccessful attempt to remove the filter percutaneously, we proceeded with open removal of the R-IVCF requiring retro-hepatic caval control, bilateral renal vein control, and infrarenal caval control. One filter strut was imbedded in the duodenal wall but did not enter the lumen. The aortic pseudoaneurysm was repaired using a femoral-popliteal vein interposition graft. The patient was discharged home on postoperative day 20. Follow-up contrast CT obtained after discharge demonstrated a right renal artery pseudoaneurysm (Figure 3) which was not present on the pre-operative CT. Arteriography demonstrated a pseudoaneurysm arising from the right main renal artery bifurcation at the previous location of one of the filter struts. The patient was not considered a reasonable candidate for renal salvage and was managed with embolization followed by right nephrectomy.
RESULTS: The patient is doing well at three month follow-up with normal renal function. He is asymptomatic with evidence of patency of his inferior vena cava and aortic repair.
CONCLUSIONS: The use of prophylactic R-IVCFs after multisystem trauma is increasing; a majority are not removed. This case report demonstrates that R-IVCFs may be associated with significant risks. We urge caution in the prophylactic use of R-IVCFs until there are data demonstrating benefit of such a management strategy.