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Chronic Abdominal Pain from Inferior Vena Cava Filter Strut Perforation: A Case Report

Published:December 08, 2015DOI:https://doi.org/10.1016/j.amjmed.2015.10.038

      Presentation

      A 49-year-old woman presented to our hospital with a 1-month history of progressive epigastric and right upper quadrant abdominal pain, nausea, anorexia, non-bloody vomiting, and loose stools. The pain was sharp, worsening over the week before presentation, and not improving with over-the-counter pain medications.
      Medical history was significant for pancreatitis, diabetes type 2 treated with insulin, antiphospholipid antibody syndrome, abdominal vein thrombosis, and stroke with no residual defects. Her prior stroke was associated with concomitant deep vein thrombosis, and workup revealed lupus anticoagulant syndrome. A caval filter was placed, and she was initiated on warfarin therapy. Her family history was significant for diabetes and coronary artery disease. She denied cigarette smoking and alcohol use.
      The physical examination was significant for moderate abdominal tenderness in the mid-epigastric and right hypochondriac region. Laboratory results were unremarkable at admission, with a random blood glucose of 116 mg/dL.
      The patient had been hospitalized for back pain in another center, 3 months before current admission, and had a computed tomography scan that showed one of the filter struts extending into the L3 vertebral body. She was hospitalized again 1 month later for abdominal pain of a similar character, was worked up for pancreatitis with negative results, and was discharged after pain control.

      Assessment

      Computed tomography (CT) of the abdomen and pelvis was performed, which showed mild hepatomegaly and a dilated common bile duct of 8 mm, likely due to previous cholecystectomy. It also revealed the caval filter to be in the infrarenal inferior vena cava, with the medial-most strut of the filter extending into the aorta at the level of the bifurcation and the posterior-most strut extending into the L3 vertebral body; the anterior and lateral struts appeared to extend outside the inferior vena cava into the mesentery and right psoas muscles, respectively (Figures 1A-C and 2). The patient was hospitalized 2 months before admission with similar abdominal pain. During that admission, a CT scan demonstrated findings similar to the present CT results showing migration of all four struts.
      Figure thumbnail gr1
      Figure 1Computed tomography of the abdomen and pelvis with contrast. (A) Axial section showing inferior vena cava filter in the infrarenal vena cava, with the medial strut eroding into the aorta (red arrow), the posterior strut eroding into the L3 vertebral body (black arrowhead), and the anterior and lateral struts eroding into the mesentery (yellow arrow) and right psoas muscles (white arrow). (B) Coronal section showing inferior vena cava filter in the infrarenal vena cava (blue arrow), with the medial strut eroding into the aorta (red arrow). (C) Sagittal section showing inferior vena cava filter strut penetrating the L3 vertebral body (red arrow).
      Figure thumbnail gr2
      Figure 2Scout image showing the overall shape and appearance of the vena cava filter (black arrow).

      Diagnosis

      Filter placements are typically low-risk procedures with very low major complication rates (0.5%).
      • Uberoi R.
      • Tapping C.R.
      • Chalmers N.
      • Allgar V.
      British Society of Interventional Radiology (BSIR) Inferior Vena Cava (IVC) filter registry.
      Perforation and migration are the most commonly reported complications (constituting 22% and 20% of the complications, respectively).
      • Angel L.F.
      • Tapson V.
      • Galgon R.E.
      • Restrepo M.I.
      • Kaufman J.
      Systematic review of the use of retrievable inferior vena cava filters.
      Most of these perforations are without symptoms but have the potential for clinically significant sequelae in the event of penetration into nearby organs and vasculature.
      • Durack J.C.
      • Westphalen A.C.
      • Kekulawela S.
      • et al.
      Perforation of the IVC: rule rather than exception after longer indwelling times for the Günther Tulip and Celect retrievable filters.
      Case reports of retroperitoneal hematomas, sepsis, aortacaval fistula, aortic pseudoaneurysms, and duodenocaval fistulas have been described as possible complications of filter penetrations into the adjacent organs.
      • Shang E.K.
      • Nathan D.P.
      • Carpenter J.P.
      • Fairman R.M.
      • Jackson B.M.
      Delayed complications of inferior vena cava filters: case report and literature review.
      • Feezor R.J.
      • Huber T.S.
      • Welborn 3rd, M.B.
      • Schell S.R.
      Duodenal perforation with an inferior vena cava filter: an unusual cause of abdominal pain.
      • Kendirli M.T.
      • Sildiroglu O.
      • Cage D.L.
      • Turba U.C.
      Inferior vena cava filter presenting as chronic low back pain.
      • Franz R.W.
      • Johnson J.D.
      • Shah K.J.
      Symptomatic inferior vena cava perforation by a retrievable filter: report of two cases and a literature review.
      Abdominal pain secondary to caval wall penetration may be due to injury of the duodenum, aorta, vertebrae, and ureters by the filter struts. After reviewing the literature, we found cases of abdominal pain due to duodenal perforation, strut fracture and implantation into a lumbar vertebra, or mesenteric inflammation.
      • Feezor R.J.
      • Huber T.S.
      • Welborn 3rd, M.B.
      • Schell S.R.
      Duodenal perforation with an inferior vena cava filter: an unusual cause of abdominal pain.
      • Kendirli M.T.
      • Sildiroglu O.
      • Cage D.L.
      • Turba U.C.
      Inferior vena cava filter presenting as chronic low back pain.
      • Franz R.W.
      • Johnson J.D.
      • Shah K.J.
      Symptomatic inferior vena cava perforation by a retrievable filter: report of two cases and a literature review.
      Our patient had multiple struts penetrating into the aorta, vertebral body, psoas muscle, and mesentery. She had an extensive diagnostic workup and imaging to rule out the more common causes of abdominal pain before the filter penetration was deemed responsible for the abdominal pain.

      Management

      The patient was started on pantoprazole and morphine for pain control. Vascular surgery was consulted. It was determined that her inferior vena cava filter needed to be removed. An open surgical repair was performed involving exposure of the inferior vena cava and bilateral renal veins, with explantation of the eroding filter from the inferior vena cava. The vena cava had a fistulous connection with the aorta at the level of the entrance of the strut, which was repaired. The patient had an uneventful postoperative hospital recovery and was discharged on postoperative day 4. Our case illustrates that inferior vena cava filter penetration can cause clinical sequelae and should be entertained as a cause for abdominal pain, especially when there is no other reasonable explanation for the patient's symptoms. This is the only case report of filter strut perforation involving 4 adjacent structures simultaneously and presenting as chronic abdominal pain.

      Acknowledgment

      The authors thank Parinda Shah, MD, Advocate Illinois Masonic Center, Department of Radiology, for providing images for this case report.

      References

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        • Tapson V.
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        Systematic review of the use of retrievable inferior vena cava filters.
        J Vasc Interv Radiol. 2011; 22: 1522-1530
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        • Westphalen A.C.
        • Kekulawela S.
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        Perforation of the IVC: rule rather than exception after longer indwelling times for the Günther Tulip and Celect retrievable filters.
        Cardiovasc Intervent Radiol. 2012; 35: 299-308
        • Shang E.K.
        • Nathan D.P.
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        Delayed complications of inferior vena cava filters: case report and literature review.
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