Bird's Nest Inferior Vena Caval Filter Migration into the Duodenum: A Rare Cause of Upper Gastrointestinal Bleeding

Abstract

Purpose: To report the first case of a potentially catastrophic complication of vena caval interruption with a bird's nest filter. Methods and Results: A 55-year-old Saudi patient presented with hypovolemic shock from massive upper gastrointestinal hemorrhage. Endoscopy identified a metallic object penetrating the duodenum. Five years earlier, the patient had a bird's nest vena caval filter inserted for recurrent pulmonary embolism. During emergent laparotomy, a broken filter wire was found projecting into the duodenum, where it had induced three profusely bleeding ulcers. The wire was transected and the ulcers oversewn. A hook projecting from the inferior vena cava (IVC) was also cut flush with the vessel wall, but the IVC was not opened nor the filter replaced. The patient's postoperative course was complicated by deep venous thrombosis, but he recovered and is asymptomatic on warfarin anticoagulation after 1 year. Computed tomography (CT) at 1-year follow-up confirmed no further migration of the filter. Conclusion: This event reinforces the need to monitor patients with IVC filters over the long term, preferably using CT scanning, and to consider filter migration as a possible cause of upper gastrointestinal bleeding.

Symptomatic duodenal perforation by a Bird's Nest vena cava filter

“…13 Therefore, several studies with perforation have left the Bird's Nest filter in place and instead trimmed the protruding struts flush with the caval wall such as in our case. [14][15][16] Of those with IVC filter perforation from any type of filter who present with symptoms, nearly 80% demonstrate radiographic evidence of surrounding organ penetration. 7 Specifically for Bird's Nest filters, several reports exist in the literature for visceral perforation including renal, duodenum, and hepatic.…”

“…7 Specifically for Bird's Nest filters, several reports exist in the literature for visceral perforation including renal, duodenum, and hepatic. [11][12][14][15][16][17] Several cases of duodenal perforation resulted in gastrointestinal bleeding and were subsequently treated by trimming protruding struts in addition to duodenal repair and omental patch. 14,15 We did not consider an omental patch in our case because duodenal repair was not needed and there was no evidence of bile staining or spillage of contents.…”

“…[11][12][14][15][16][17] Several cases of duodenal perforation resulted in gastrointestinal bleeding and were subsequently treated by trimming protruding struts in addition to duodenal repair and omental patch. 14,15 We did not consider an omental patch in our case because duodenal repair was not needed and there was no evidence of bile staining or spillage of contents. A more potentially serious complication is the migration of the filter into the adjacent aorta and right atrium, which has been documented as well, resulting in pseudoaneurysm and death, respectively.…”

Symptomatic duodenal perforation by inferior vena cava filter

“…There were 33 cases that met the inclusion criteria in 30 case reports or case series studies 7–36 The median age of the patients was 50 years (range 21–84 years) and 66% were female. Twenty-three patients (69%) presented with upper abdominal pain, most often in the epigastrium or in the right upper quadrant.…”

“…5 We believe that IVCF penetration ratio may increase over time. 5 Patients with fistulas between the digestive tract and the vascular tree may have symptoms such as digestive bleeding and sepsis, [14][15][16][17] but according to our analysis no one presented with both manifestations. Signs of duodenum-cava fistula ranged from fever and chills to melanotic stools and hematochezia.…”