A RARE INSTANCE OF AN INFERIOR VENA CAVA FILTER FAILING TO PREVENT RECURRENT PULMONARY EMBOLISM

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is the third most frequent cause of cardiovascular disease [1]. PE is the most fatal clinical presentation of VTE with 1 month mortality between 9-11% and 3 month mortality up to 17% [2]. Anticoagulation by far remains the mainstay treatment for PE, however inferior vena cava (IVC) filters are placed to prevent recurrent PE in patients who have contraindications to anticoagulation. We hereby report an uncommon case of recurrent PE after placement of an IVC filter. CASE PRESENTATION: A 67 year old male with a past medical history of hyperlipidemia and family history of thrombotic events presented with reports of shortness of breath and left sided chest pain associated with cough and blood tinged sputum. On initial evaluation, he was tachypneic, tachycardic, and hypoxemic to 91% on room air. Computed tomography angiogram (CTA) demonstrated PE in the left lower lobe sub-segmental branches of the pulmonary artery (Image 1). Doppler studies of bilateral lower extremities demonstrated a DVT in the left peroneal vein. He was promptly started on a heparin drip and transferred to the intensive care unit (ICU). Due to continued hemoptysis, the decision was made to place an IVC filter and hold anticoagulation. However, three days after the placement of the IVC filter, he had worsening hypoxemia with new right sided chest pain. He underwent repeat CTA of the chest which revealed new PE involving the right main pulmonary artery (Image 2). He also got dopplers of bilateral upper and lower extremities which showed a new DVT in left posterior tibial vein along with DVT in left peroneal vein. He was again restarted on a heparin drip with close monitoring for hemoptysis, stabilized and discharged on oral anticoagulation in following weeks. DISCUSSION: Routine use of IVC filters in patients with PE is not recommended unless anticoagulation is contraindicated or there is recurrent PE while on adequate therapy for a DVT. Small thrombi can pass through filters or through collaterals around obstructed filters and lead to recurrent PE. However, data suggest that recurrent PE is unusual following filter insertion. One systematic review of retrievable IVC filters estimated an incidence of PE following filter placement of 1.3 % [3]. Though IVC filters are very efficient in preventing PE, our case represents one of those rare occurrences when IVC filters failed to prevent recurrent PE. In such cases, anticoagulation should be restarted as soon as possible after weighing risks and benefits. CONCLUSIONS: In high risk patients where anticoagulation is contraindicated, IVC filter placement remains an alternative to prevent PE. However, there remains a small risk of recurrent PE despite placement of IVC filters as evident by a small number of systematic reviews. Reference #1: Raskob GE, Angchaisukiri P, Blanco AN, et al. Thrombosis: a major contributor to global disease burden. Arterioscler Thromb Vasc Biol. 2014:34(11):2363-2371. [PubMed: 25304324] Reference #2: Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the international cooperative Pulmonary Embolism Registry (ICOPER). Lancet. 1999:353(9162):1386-1389. [PubMed: 10227218 Reference #3: Angel LF, Tapson V, Galgon RE, et al. Systematic review of the use of retrievable inferior vena cava filters. J Vasc Interv Radiol 2011; 22:1522 DISCLOSURES: No relevant relationships by John Mikhail, source=Web Response No relevant relationships by Mohammed Shariff, source=Web Response No relevant relationships by Vandan Upadhyaya, source=Web Response