“A Needle in the Duodenum”: A Complication of Inferior Vena Cava Filter

Abstract

Introduction: With the advent of retrievable filters, the use of inferior vena cava filter (IVC) has increased over the past decade. The reported incidence of complications of IVC filter is 0-1%. We report a case of duodenal penetration of Celect IVC filter that was initially misdiagnosed as a “needle” in the duodenum. An 88-year-old female with multiple medical problems was initially admitted to an outside hospital for bright red blood per rectum. She received 1 unit of packed red blood cells. An upper gastrointestinal (UGI) endoscopy showed a “needle” in the duodenum that could not be retrieved with multiple attempts. She was transferred to our hospital for further management. She denied abdominal pain, nausea, vomiting, and intentional or accidental ingestion of needle or foreign body. Physical examination revealed a cachectic female with soft and non-tender abdomen. Laboratory data showed hemoglobin 10.7 g/dl, otherwise normal. A repeat UGI endoscopy revealed no active bleeding but a metallic device in the second portion of duodenum that was highly suggestive of a prong of an IVC filter (Figure 1). A computed tomography of the abdomen showed migration of the anterior right leg of IVC filter into the descending duodenum. The standard endovascular technique using a 15mm snare through a 7Fr, 55-cm sheath was used initially but failed to remove the filter even with repeated attempts as it was tilted medially. An alternative approach using a rigid endobronchial forceps through 16 Fr sheath successfully removed the filter. The use of temporary IVC filters has increased due to the ease of insertion, increased reliability, short-term benefits and ease of removal. There are no definite guidelines for asymptomatic duodenal perforation of IVC filter; however, they must be removed if the patient has obvious symptoms. A minimally invasive endovascular approach was used in our patient although a non-traditional endobronchial forceps had to be used to remove the difficultly placed IVC filter. Endoscopist must be aware of this IVC filter complication when they are evaluating for duodenal penetrations.Figure 1: An UGI endoscopy shows anterior leg of the IVC filter in the 2nd part of the duodenum.