Asymptomatic Duodenal Penetration by Inferior Vena Cava Filter: 3-Year Follow-up

Abstract

INTRODUCTION: Inferior vena cava (IVC) filters are used to reduce the risk of thromboembolic events in subjects who are either not a candidate for anticoagulant therapy (ACT) or have failed ACT. Complications of IVC filters could be either early (bleeding, infection, acute venous thrombosis, hematoma and arteriovenous fistula formation) or late (filter migration and chronic thrombosis/recurrent thromboembolism). IVC filter penetration of the surrounding structures including bowel (duodenum), is a known although rare complication which can manifest as abdominal pain, gastrointestinal bleeding, cava-duodenal fistula, or small bowel obstruction. We present a rare case of asymptomatic duodenal penetration by IVC filter which was managed conservatively. CASE REPORT A 64-year-old male with history of multiple, recurrent DVTs and pulmonary embolism secondary to heterozygous MTHFR gene mutation presented to our facility 3 years ago for progressively worsening dysphagia. He had Greenfield IVC filter placed a few years back and was on long term ACT. Esophagogastroduodenoscopy(EGD) incidentally revealed a piece of metal protruding from the second portion of the duodenal wall, as shown in figure 1.CT scan of the abdomen and pelvis showed multiple IVC filter struts extending beyond the IVC wall with one of the struts extending anteriorly to penetrate the duodenal wall, as in figure 2. IVC venography confirmed CT scan findings, showing four struts of a patent IVC filter extending beyond the IVC wall. Vascular surgery (VS) and interventional radiology (IR) recommended conservative management in the absence of any symptoms. He remained asymptomatic for the next three years. Repeat EGD performed 3 years later revealed unchanged IVC filter strut in the duodenum, as shown in figure 3.Figure: EGD performed in 2013 showing IVC filter strut in duodenum.Figure: CT scan of the abdomen and pelvis showing multiple IVC filter struts extending beyond the IVC wall, with one of the struts penetrating duodenal wall.Figure: EGD performed in 2016 showing IVC filter strut at the same location in duodenum.DISCUSSION IVC filter migration into the GI tract is extremely rare and patients are usually symptomatic. Duodenum is the most common extra-caval involved organ. Current literature directs surgical treatment of patients with symptomatic duodenal perforation, however, there are no consensus guidelines for management of asymptomatic IVC filter penetrations in GI tract. Such cases should be managed by a multidisciplinary team of IR, VS and gastroenterologist. CONCLUSION Our patient was managed successfully with a non-surgical approach and remained asymptomatic during next 3 years.