Catheter-Directed Fibrinolysis of Submassive Pulmonary Embolism After IVC Filter Migration to Renal Veins

Abstract: A 76-year-old male presented with a submassive pulmonary embolism despite having an inferior vena cava (IVC) filter. Imaging demonstrated pulmonary artery emboli and a deep vein thrombosis in the left common femoral vein. Venography revealed the IVC filter with struts extending into the left and right renal veins. A new IVC filter was deployed below the prior filter.This case demonstrates IVC filter migration complicated by a submassive pulmonary embolism.

J INVASIVE CARDIOL 2017;29(1):E8-E9.

Key words: submassive pulmonary embolism, inferior vena cava filter, migration, complications

A 76-year-old male presented with a submassive pulmonary embolism (PE) despite having an inferior vena cava (IVC) filter. Contrast-enhanced computed tomographic scan revealed left and right main pulmonary artery emboli (Figure 1). Transthoracic echocardiography revealed moderate right ventricular dysfunction and dilation, and N-terminal proBNP was 3970 pg/mL (reference range, <450 pg/mL). An acute deep vein thrombosis in the left common femoral vein was found by venous duplex ultrasound (Figure 2). Venography showed the IVC filter with struts extending into both the left and right renal veins (Figure 3). Because of the mobile nature of the thrombus and potential for embolization, a new infrarenal IVC filter was deployed below the level of the prior filter. Pulmonary angiography confirmed the finding of bilateral pulmonary emboli (Figure 4). EkoSonic Endovascular System (EKOS Corporation) catheter-directed, low-dose fibrinolysis (total dose, 24 mg) was initiated via bilateral catheters (Figure 5) along with intravenous heparin. Repeat pulmonary angiogram the following day revealed significant improvement of the filling defects bilaterally (Figure 6). The patient was asymptomatic after 12 hours of therapy, and was discharged from the hospital on warfarin.

This case demonstrates IVC filter migration complicated by a submassive pulmonary embolism. At least two of the filter struts were within the renal veins, creating large gaps through which femoral venous thrombus likely embolized. Migration of IVC filters and/or struts has been frequently reported, but there are limited descriptions of filter migration to the renal veins.^1-3 In addition to ineffective prevention of pulmonary embolism, this particular complication may lead to renal vein thrombosis and acute renal failure. In patients with IVC filters and pulmonary emboli, careful investigation of the filter by computed tomography or venography should be considered.

References

1.     Taheri SA, Kulaylat MN, Johnson E, Hoover E. A complication of the Greenfield filter: fracture and distal migration of two struts — a case report. J Vasc Surg. 1992;16:96-99.

2.    Janvier AL, Hamdan H, Malas M. Bilateral renal vein thrombosis and subsequent acute renal failure due to IVC filter migration and thrombosis. Clin Nephrol. 2010;73:408-412.

3.    Bélénotti P, Sarlon-Bartoli G, Bartoli MA, et al. Vena cava filter migration: an unappreciated complication. About four cases and review of the literature. Ann Vasc Surg. 2011;25:1141.e9-e14.

From the University of Chicago, ¹Department of Internal Medicine; ²Department of Radiology, Vascular & Interventional Radiology; and ³Department of Internal Medicine, Section of Cardiology, Chicago, Illinois.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflict of interest regarding the content herein.

Manuscript submitted June 17, 2016, provisional acceptance given June 24, 2016, final version accepted July 1, 2016.

Address for correspondence: Jonathan D. Paul, MD, The University of Chicago Medicine, 5841 S. Maryland Avenue, MC 6080, Chicago, IL 60637. Email: jpaul@medicine.bsd.uchicago.edu