Successful endovascular explantation of an IVC filter from the heart chamber of a patient with PE

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Introduction

Venous thromboembolism is a complex disease combining deep vein thrombosis (DVT) and one of its most dangerous complications, pulmonary embolism (PE), which affects millions of people worldwide [1]. Scientists have proven that COVID-19 is currently one of the causes leading to the development of coagulopathy [2].

Treatment of venous thromboembolism requires immediate anticoagulant therapy [3]. However, in some patients, drug therapy is associated with the development of a number of complications [4]. These include, for example, patients with floating thrombi in the veins of the lower extremities, patients with contraindications to anticoagulant therapy, and patients with pulmonary hypertension* [6].

Endovascular implantation of an IVC filter (IVC) is indicated for such patient groups [7]. In addition, foreign clinicians widely implant IVC filters in patients at high risk of developing venous thromboembolic events (VTE) for prophylactic purposes [8; 9].

However, like any surgical procedure, IVC filter implantation is associated with a number of complications that are directly related to technical errors in IVC filter implantation. According to a number of authors, such complications are recorded in 3.5–15 % of cases, including, for example, puncture of an adjacent artery, bleeding, hematoma in the vascular access area, and pneumothorax [10–15].

In addition to these outcomes, IVC filter implantation has a rare but fatal complication, such as migration of the IVC filter into the heart chamber. The causes of filter dislocation are incomplete opening, large diameter of the inferior vena cava (IVC), multiple thromboembolism in the IVC filter, and destruction of the IVC filter [17–19].

To this end, we present our clinical case of IVC filter dislocation into the right chambers of the heart.

Clinical Case

Patient V. was admitted to the clinic in March 2023 with complaints of pain in the lower limbs and groin area, a feeling of fullness and heaviness in the lower limbs, severe shortness of breath and palpitations at rest, and general weakness. The patient's medical history indicates that in April 2018, she suffered a subarachnoid hemorrhage with rupture into the ventricular system. In August of the same year, the patient was admitted to the cardiovascular surgery department on an emergency basis with clinical signs of respiratory and heart failure. An ultrasound examination of the veins of the lower extremities revealed thrombosis of the common femoral vein, superficial femoral vein, and veins of the lower leg, as well as thrombosis of the inferior vena cava. Since the patient had contraindications to anticoagulant therapy, an IVC filter was installed to prevent possible complications, such as pulmonary thromboembolism (PTE).

A complete examination was performed at the clinic. According to transthoracic echocardiography, there was a foreign body in the right atrium (Fig. 1). During follow-up angiography, dislocation of the IVC filter into the heart chamber was observed (Fig. 2). Pulmonary angiography with contrast of the heart chamber reveals a foreign body in the position of the tricuspid valve: 2/3 of the IVC filter is fixed to the right ventricle, 1/3 to the right atrium. The consultation decided to attempt endovascular removal of the IVC filter, as open surgery is associated with high risks.

 

Fig. 1. Echocardiography. Foreign body in the heart chamber

 

Fig. 2. Dislocation of IVC filter into the heart cavity

 

Technique for performing the operation. A puncture was made in the left subclavian vein, an introducer was inserted and advanced to the level of the right atrium. Next, an ablation electrode was passed through the introducerto hook the IVC filter and pull it back into the right atrium, but multiple attempts were unsuccessful because the filter was fixed in the right ventricle. It was decided to insert a ten-pole steerable catheter into the right ventricle and trap, after which the IVC filter was fixed (Fig. 3) and its traction was performed. During this procedure, traction resistance and ventricular arrhythmias were observed, which were relieved with medication. As a result, it was possible to move the IVC filter into the right atrium cavity using careful circular movements, and the IVC filter was fixed in this position. Next, a puncture was made in the right subclavian vein, through which an introducer was advanced to the right atrium for the right coronary catheter and trap. The trap captured the tip of the cava filter and carefully removed it through the right subclavian vein together with the introducer (Fig. 4).

 

Fig. 3. Angiography. IVC filter in the cavity of the right atrium and ventricle

 

Fig. 4. Explanted IVC filter

 

The patient was discharged on the ninth day in satisfactory condition. Medium-term follow-up was conducted remotely. The patient has no active complaints, has fully resumed her daily activities, and her quality of life has not been impaired. An IVC filter was installed in a scheduled procedure.

Results and Discussion

Due to the rarity of this complication, there are only a few reports in the world literature describing IVC filter migration into the heart cavity. B. Haddadian et al. describe a case study: a 43-year-old female patient was admitted to the clinic with chest pain and sudden shortness of breath. Examination revealed PTE pulmonary thromboembolism. The patient had an IVC filter implanted. On the fifth day, abdominal pain appeared, but no signs of migration were found on the IVC filter. On the sixth day, cardiac arrest was recorded, and resuscitation measures were ineffective. During the autopsy, the IVC filter was found in the tricuspid valve area [20]. An identical case, but with a favorable outcome, was described by M. Porcellini et al.: a 52-year-old patient underwent surgery for a fracture of the left femur and was diagnosed with bilateral pulmonary thromboembolism one month after the operation [17]. The patient had an IVC filter implanted. Seven days after implantation, the patient was urgently admitted to the hospital with respiratory failure and hemodynamic collapse. The IVC filter was surgically removed, and the patient was discharged on oral anticoagulant therapy [19]. According to M.V. Boyarkov et al., migration of an IVC filter into the right atrium is a fairly rare complication, occurring in only 1.3% of cases [19; 21].

There are reports of IVC filter displacement into the right ventricular cavity with subsequent development of ventricular arrhythmias and fatal outcome [22]: a 52-year-old patient was urgently admitted to the clinic with sudden onset of respiratory and renal failure and syncopal episodes.

The patient's medical history included the placement of an IVC filter eight months earlier. A thorough examination of the patient revealed dislocation of the IVC filter into the right chambers of the heart. An attempt at endovascular explantation of the IVC filter was unsuccessful, requiring surgical intervention to extract the IVC filter and repair the tricuspid valve [23].

M.N. Peters et al. describe the following case: a 69-year-old patient with a history of hemorrhagic stroke underwent IVC filter implantation for confirmed pulmonary thromboembolism (PTE). On the 7th day, paroxysms of ventricular tachycardia appeared that did not respond to drug therapy. Examination revealed a migrated IVC filter in the right ventricle. After attempts to remove the IVC filter endovascularly, the authors decided to remove it surgically. In the early postoperative period, the heart rhythm was restored. The authors emphasize that non-sustained ventricular tachycardia in patients with an implanted IVC filter requires exclusion of IVC filter dislocation and thorough diagnosis [22; 24].

Z. Sako et al. demonstrated an interesting case of IVC filter migration into the right ventricular cavity in a young 32-year-old patient. The patient complained of chest pain. A CT scan of the chest revealed a foreign body in the right ventricular cavity, adjacent to the posterior wall. The patient underwent successful endovascular explantation of the foreign body [25].

According to some authors, embolization of the IVC filter can reach 11.8 % [26], but migration of the IVC filter into the heart chamber is a rare complication that requires increased attention, because timely verification of this complication is of particular practical importance in view of the development of fatal complications [27]. It should be remembered that the clinical picture of IVC filter migration in the heart chamber has blurred symptoms and includes chest pain, signs of respiratory failure, syncopal phenomena, various heart rhythm disturbances, and hemodynamic collapse [28]. However, there are reports in the literature of asymptomatic migration of IVC filters [2; 30]. For example, a 53-year-old female patient presented with complaints of lower back pain after a fall. The patient had a history of an IVC filter implanted nine years earlier. During examination, a dislocation of the broken IVC filter into the right ventricle was randomly detected, but since the patient had a high surgical risk, the consultation decided not to explant the IVC filter. During the observation period, the patient remained hemodynamically stable and asymptomatic [31].

PTE pulmonary thromboembolism is a life-threatening condition [32] that requires IVC filter implantation if contraindications are present. However, as the experience of our colleagues shows, the issue of IVC filter implantation remains open [33]. Our clinical case shows that any interventional procedure on the heart carries a risk of various complications. Therefore, in the preoperative period, the doctor must take an individual approach to patient management and consider the risks of a particular type of intervention. Interventional procedures for the prevention of pulmonary thromboembolism (PTE) are helpful in both the early and late stages, avoiding more invasive procedures. However, as demonstrated by this clinical case and the experience of colleagues, IVC filter implantation carries a small risk of migration into the heart chambers, which can lead to further fatal complications [34]. In the literature, some authors believe that approaches to treating IVC filter migration in the heart cavity vary and depend on the severity of the patient's condition [37]. To sum up, the readiness of a team of doctors consisting of a cardiologist, functional diagnostics doctors, a radiologist, an endovascular surgeon, and a cardiovascular surgeon for complex intervention will help to detect and correct the problem in a timely manner, preventing further consequences.

 

* American College of Radiology. ACR–SIR–SPR Practice Parameter for the Performance of Inferior Vena Cava (IVC) Filter Placement for the Prevention of Pulmonary Embolism. 2016; 1–18. Accessed May 10, 2018 available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/ ivc-fliterplacement.pdf?la=en

About the authors

Bakytbek K. Kadyraliev

FCCS named after S.G. Sukhanov; MC Cardio Asia Plus

Email: kadyraliev.bakitbek@yandex.ru
ORCID iD: 0000-0002-4007-7665

DSc (Medicine), Cardiovascular Surgeon

Russian Federation, Perm; Osh

K. A. Kalysov

MC Cardio Asia Plus

Email: nurslu.kdralieva@mail.ru
ORCID iD: 0000-0001-7223-551X

PhD (Medicine), Head of the Interventional Arrhythmia Treatment Group

Russian Federation, Osh

T. K. Eraliev

Kyrgyz-Russian medical center

Email: nurslu.kdralieva@mail.ru
ORCID iD: 0000-0003-4882-4191

PhD (Medicine), Physician of Radiological Endovascular Diagnostics and Treatment, Head of the Medical Center

Russian Federation, Osh

F. Kh. Norov

Istiklol Medical Clinic

Email: nurslu.kdralieva@mail.ru

PhD (Medicine), Endovascular and Interventional Radiologist

Tajikistan, Dushanbe

A. S. Zhanbayev

Osh Interregional Clinical Hospital

Email: nurslu.kdralieva@mail.ru

Cardiovascular Surgeon

Kyrgyzstan, Osh

Zh. Abdimitalip

Osh Interregional Clinical Hospital

Email: nurslu.kdralieva@mail.ru

Cardiovascular Surgeon

Kyrgyzstan, Osh

А. T. Satybaldiev

MC Cardio Asia Plus

Email: nurslu.kdralieva@mail.ru
ORCID iD: 0009-0008-1725-9429

Cardiovascular Surgeon

Kyrgyzstan, Osh

Nurslu V. Kdralieva

FCCS named after S.G. Sukhanov

Author for correspondence.
Email: nurslu.kdralieva@mail.ru
ORCID iD: 0009-0005-7617-2305

Cardiovascular Surgeon

Russian Federation, Perm

References

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