Case report on the non-operative management of a retrievable inferior vena cava filter perforating the duodenum

Abstract

Introduction: Deep vein thrombosis (DVT) continues to be a significant source of morbidity for surgical patients. Placement of a retrievable inferior vena cava (IVC) filter is used when patients have contraindications to anticoagulation or recurrent pulmonary embolism despite therapeutic anticoagulation. Although retrievable IVC filters are often used, they carry a unique set of risks.

Presentation of case: A 67-year-old man presents to the Emergency Room (ER) following large volume melena and complaining of syncope. One year prior, the patient had been diagnosed with Glioblastoma multiforme, for which he underwent a craniotomy with near-total resection of the mass. He subsequently developed a deep vein thrombosis and underwent placement of a retrievable inferior vena cava (IVC) filter. Computerized tomography (CT) and esophagogastroduodenoscopy showed duodenal perforation by the retrievable IVC filter. The filter was successfully retrieved through an endovascular approach.

Discussion: Retrievable IVC filter placement is the preferred method of pulmonary embolism prevention in patients with significant risk for bleeding. Duodenal perforation by a retrievable IVC filter is a rare and serious complication. It is usually managed surgically, but can also be managed non-operatively.

Conclusion: For patients with significant comorbidities or patients who are poor surgical candidates, non-operative management with close monitoring can serve as an initial approach to the patient with a caval enteric perforation secondary to a retrievable IVC filter.

Keywords: Duodenum; Filter; Inferior vena cava; Melena; Perforation.

Fig. 1

Angiogram of retrievable IVC filter placement in inferior vena cava.

Fig. 2

(A and B) Axial and coronal CT views of abdomen and pelvis demonstrating the perforation of retrievable IVC filter tines through IVC into duodenum (yellow arrows). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 3

Esophagogastroduodenoscopy (EGD) (multiple views A–C) revealing retrievable IVC filter tines perforating the second portion of duodenum without evidence of bleeding.

Fig. 4

Angiogram of retrievable IVC filter being removed. Initially scout film demonstrating the tines extending into the gas filled duodenum (A). The initially contrast study showing no active extravasation from the IVC (B). Completion angiogram after removal of the filter shows no extravasation (C).