Inferior Vena Cava Filter Thrombosis Causing Transient Apical Ballooning

Article Outline

• References
• Copyright

To the Editor:

A 78-year-old woman presented to the emergency department with increasing bilateral leg pain and swelling, generalized weakness, and 1 episode of syncope. On admission, the patient was found to be severely hypotensive. Physical examination was significant for bilateral lower extremity edema up to her thighs. Intravenous fluids and phenylephrine were administered. Electrocardiogram revealed significant ST-segment elevation of 4 mm in the anterior myocardial leads associated with a slight elevation of cardiac enzymes. Urgent echocardiogram performed at the bedside revealed a severely decreased ejection fraction of less than 25% and akinesis of all but basal segments with apical ballooning associated with significant systolic anterior motion of mitral valve leaflet with left ventricular outflow tract obstruction (Figure 1). Emergency cardiac catheterization revealed hemodynamically insignificant coronary artery disease. The patient continued to be hypotensive with increasing requirement for fluids and phenylephrine. Despite aggressive fluid administration, the patient did not show any evidence of volume overload or pulmonary congestion. These clinical findings raised the suspicion of possible venous obstruction from deep venous thrombosis of the inferior vena cava (IVC) or leg veins. This suspicion was further augmented because the patient had a previous deep vein thrombosis and a Greenfield filter inserted into the IVC. Subsequent evaluation with venous Doppler and computed tomography scan confirmed extensive thrombosis in the IVC both below and above the IVC filter (Figure 2); thrombus in the femoral, popliteal, and calf muscle veins; and filling defects in the pulmonary veins suggestive of pulmonary embolism. At this point, acute renal failure secondary to acute tubular necrosis from severe hypotension developed, and dialysis was initiated.

• 
  • View Large Image
  • Download to PowerPoint

• Figure 1. 

  Echocardiogram showing left ventricular apical ballooning.

• 
  • View Large Image
  • Download to PowerPoint

• Figure 2. 

  Computed tomography scan showing thrombosis in the IVC above the Greenfield filter.

The patient was then evaluated by a vascular surgeon, and she underwent 4 surgical procedures, including thrombectomy and clot retrieval from the IVC. This was followed by immediate correction of hypotension with significant improvement in renal and cardiac function. Repeat echocardiograms obtained at this time showed significant improvement in cardiac function with return of ejection fraction back to the baseline of 45%. After several weeks of recovery, the patient was weaned from dialysis and discharged with outpatient follow-up.

IVC filter placement is a common procedure for prevention of pulmonary embolism in situations when anticoagulation is contraindicated.¹, ² IVC filter thrombosis is a well-known complication, and presentation with hypotension and shock³ is not uncommon. Presentation with ST elevations and takotsubo phenomenon has not been described in the literature. Transient apical ballooning is a relatively newly recognized phenomenon seen in emotionally stressful situations and has been associated with several conditions (eg, subarachnoid hemorrhage⁴ and pulmonary embolism) but has rarely been seen in the situation of a filter thrombus. Adrenergic surge is postulated to be responsible for the transient apical ballooning and may be a possible explanation in our patient because of the hypotension caused by IVC thrombosis, entrapment of fluids in lower extremities, and relative hypovolemia. The patient's dramatic improvement after thrombectomy and the reversal of cardiac function suggest that the IVC filter thrombus and resultant hypovolemia may have been responsible for the apical ballooning observed in this patient. Figure 1, Figure 2.

Back to Article Outline

References 

1. Stein PD, Kayali F, Olson RE, et al. Twenty-one-year trends in the use of inferior vena cava filters. Arch Intern Med. 2004;164:1541–1545
   • View In Article
   • MEDLINE
   • CrossRef
2. Hyers TM, Agnelli G, Hull RD, et al. Antithrombotic therapy for venous thromboembolic disease. Chest. 2001;119:176–193
   • View In Article
   • MEDLINE
   • CrossRef
3. Tardy B, et al. Symptomatic vena cava thrombosis in a study of 30 patients. Eur Respire J. 1996;9:2012–2016
   • View In Article
4. Otomo S, Sugita M, Shimoda O, et al. Two cases of transient left ventricular apical ballooning syndrome associated with subarachnoid hemorrhage. Anesth Analg. 2006;103:583–586
   • View In Article