Double Whammy

Abstract

A 72-year-old man was referred for computed tomography angiogram of his abdominal aorta for investigation of gradually worsening, now severe, intermittent claudication incurred at Ϸ10 yards. Risk factors for peripheral vascular disease included being a former smoker and hypertensive. His medical history included transurethral resection of his prostate 7 years previously, complicated by postoperative pulmonary emboli and delayed bleeding from the prostatectomy resection site. Given the latter, a Gunther-Tulip inferior vena cava (IVC) filter (Cook, Bloomington, IN) was inserted as protection against further pulmonary embolism while his anticoagulation was temporarily withheld.Contrast-enhanced computed tomography angiogram demonstrated mild fusiform aneurysmal dilatation of the infrarenal aorta with a maximum measurement of 4.2 cm, with thrombotic occlusion of the aorta immediately below the origin of his renal arteries. Within the area of aneurysmal dilatation, a metal strut of the previously placed filter was clearly visible within the aortic wall; this strut had perforated the IVC and eroded into the adjacent aorta (Figure 1). The IVC was itself thrombosed and atretic caudal of the point of perforation (Figure 2). The patient was asymptomatic in terms of his IVC thrombosis; he was subsequently referred for an axillary bifemoral bypass operation as treatment for his claudication.Practically all IVC filters currently in use have tethering hooks for device anchoring and prevention of migration. Although these hooks will embed in the vessel wall, actual transmural penetration and entry to the pericaval space are uncommon (0.3%), 1 and secondary perforation of the aorta is exceedingly rare. 2,3 Filter-related IVC thrombosis is more frequent, estimated to occur in 2% to 10% of filter recipients. 4 Increased use of retrievable filters for temporary indications will likely reduce the incidence of delayed complications associated with permanent IVC interruption. Thick-slab coronal maximum-intensity projection reformatted from the same study. Note the thin atretic thrombosed IVC caudal to the point of perforation (curved arrow). The entire infrarenal aorta is occluded from below the renal artery origins (straight arrow).

Implications and limitations of the PREPIC2 study—the interventionist’s perspective

“…For example in a post trauma patient if the immobilization is limited to several weeks to a few months, this patient can benefit from retrievable IVC filters. Permanent IVC filters are associated with certain complications, such as post-thrombotic syndrome, recurrent deep venous thrombosis and even IVC occlusion (14,15).…”