Failed Retrieval of an Inferior Vena Cava Filter During Pregnancy Because of Filter Tilt: Report of Two Cases

Abstract

Thromboembolic disease during pregnancy is an important cause of obstetric morbidity and mortality. Pregnant patients with venous thromboembolism are usually managed by conventional anticoagulation. However, this must be discontinued during vaginal or caesarian delivery to avoid haemorrhage and to reduce the risk of possible epidural haematoma. Retrievable inferior vena cava filters (IVCFs) offer protection against pulmonary embolism during this high-risk period, when anticoagulation is discontinued, while avoiding potential long-term sequelae of a permanent IVCF. Here we report two patients who presented in the third trimester of pregnancy with floating ileofemoral deep vein thrombosis. Both patients were initially treated with standard anticoagulation; however, shortly before delivery both patients had a retrievable IVCF placed in a suprarenal position. In both patients, retrieval failed at 28 days after insertion because of filter tilt. The timing and mechanism of filter tilt remains uncertain. We believe that a number of factors could have been involved, including change in the anatomic configuration with lateral displacement of the IVCF as a result of the gravid uterus as well as forceful uterine contractions during labour, which modified the shape and diameter of the IVC. We showed that failure to retrieve the IVCF has had considerable implications for the two young patients regarding long-term anticoagulation and have highlighted the need for further clinical trials regarding the safe use of retrievable IVCFs during pregnancy.

How I treat pregnancy-related venous thromboembolism

“…Still, experience with these devices during pregnancy is limited, and filter migration and inferior caval vein perforation have been described in pregnant patients. 52,53 Even in a large hospital like ours, with highly experienced interventional radiologists, their experience with filters in this population, and through the jugular route, is virtually absent.…”

New technique to prevent tilt during inferior vena cava filter placement

“…However, our findings are still in line with the reported literature. 10 Shelgikar et al 8 found that Cook Celect filters were more likely to self-center by the time of filter retrieval compared with the standard Gunther Tulip filter, but that this did not translate into a difference in filter retrieval rates. Failed attempts at retrieval impart unnecessary risks of venous access and accessing the central venous system.…”

“…9 In our institution, we use the Cook Celect filter (Cook Medical, Bloomington, Ind), which has been shown to have tilt rates of 9.2% to 40%. 5, 10 We have instituted a new technique that we believe prevents the complication of tilted filter placement.…”

Treatment of pregnancy-associated venous thromboembolism - position paper from the Working Group in Women’s Health of the Society of Thrombosis and Haemostasis (GTH)

“…A retrievable inferior vena cava fi lter may also be inserted and then removed postpartum to prevent PE during delivery. However, experience with these devices is very limited, and in consideration of the potential complications, it may be best to restrict IVC fi lter insertion to women in whom anticoagulation is contraindicated or in women with proven DVT who have recurrent PE despite adequate anticoagulation [8,9,55,56]. Outside pregnancy, the use of IVC fi lters has failed to provide any protection against PE, and they have been associated with serious complications [57].…”