1859 Paperclip or Inferior Vena Cava Filter Probe? The Case of an Unusual Foreign Body

Abstract

INTRODUCTION: Inferior vena cava (IVC) filters are mechanical devices used to prevent pulmonary embolism, often used in patients with recurrent venous thromboembolism while on anticoagulation, or who have a contraindication to anticoagulation. Despite its increasing popularity over the last two decades, they do not come without complications such as migration of the filter or its parts, perforation or protrusion into surrounding structures such as the small or large bowel, vasculature, diaphragm, or the retroperitoneal space. We herein present a case of duodenal perforation caused by a migrating IVC filter, of which there have only been a few reported cases. CASE DESCRIPTION/METHODS: The patient is a 61-year-old female with HTN, GERD, iron-deficiency anemia, and a history of DVT while on anticoagulation (s/p IVC filter placement in October 2011) who initially presented with complaints of dizziness. Her workup revealed a new anemia with no overt GI bleeding for which she underwent endoscopic evaluation. She was found to have a thin piece of metal in the second portion of her duodenum, thought to be a swallowed foreign body, possibly a paperclip, which was later denied by the patient. Several attempts at retrieval were unsuccessful. One week later, she developed sudden-onset, severe, epigastric pain with guarding. She presented to our emergency department where a CT abdomen/pelvis with contrast revealed an infrarenal IVC filter with protrusion of a prong through the lateral wall of the IVC into the duodenum, as well as protrusion of a prong through the posterior wall of the IVC into the superior aspect of the right iliopsoas muscle. Given the pain, she was ultimately taken for successful percutaneous removal via the right internal jugular vein by Vascular Surgery with endoscopic assistance by Gastroenterology. There was no involvement of the ampulla and the duodenum maintained insufflation following removal. DISCUSSION: With the advent of contemporary IVC filters, the migration rates are less than 1%. However, because of new prong hooks to prevent migration, they can lead to perforation of surrounding structures. Retrievable filters have been found to have higher rates of perforation than the permanent form, particularly when the retrievable filters are left in place longer than anticipated. As seen in this case, the importance of IVC filters are paramount to prevent pulmonary embolism, but in a patient with sudden onset abdominal pain, one must rule out IVC filter perforation into surrounding structures.