AVN 1. Capturing a Migrating Inferior Vena Cava Filter in a Migratory Patient

Abstract

Mobile patients present special challenges to their medical teams in solving the care puzzle and formulating an optimal treatment plan. This case of a migratory patient and a migrating filter illustrates the challenges of medical management in these medically complex patients. A 65-year-old patient taking warfarin since 2007 for deep venous thrombosis with an implanted inferior vena cava (IVC) filter since 2008 presented for IVC filter removal because of migration. He has an allergy to contrast material. Surgical history includes the following: IVC filter, Florida, 2008; renal transplantation, Michigan, 2008; bilateral hip replacements, Minnesota, 2015; C4-C7 cervical fusion, Minnesota, 2018; IVC removal, Georgia. His vital signs were normal (weight, 85 kg; height, 188 cm; blood pressure, 127/71 mm Hg). Laboratory values were as follows: hematocrit, 32%; platelet count, 172/mL; international normalized ratio, 2.1; blood urea nitrogen, 38 mg/dL; and creatinine, 1.88 μmol/L. Old outside imaging showed the filter tip near the cavoatrial junction. Under general anesthesia and a sterile preparation, the large patent external jugular vein was accessed. A diagnostic catheter was passed over a 0.035-inch Bentson wire (Cook Medical, Bloomington, Ind) into the iliac vein. A normal finding on carbon dioxide cavography was documented. Unsuccessful recovery with Cook retrieval kit caused the filter hook to straighten and the filter to sit higher in the right atrium. A 0.035-inch wire was passed and a 14F sheath placed in the atrium. An SOS-2 catheter (AngioDynamics, Amsterdam, The Netherlands) was passed over a Bentson wire and retracted to cross between the struts of the filter. The wire tip was ensnared and withdrawn through the sheath to form a completed loop between the legs of the filter. The 14F sheath was advanced over the wire and filter, thus disengaging the legs from the cavoatrial junction. The filter was intact. Completion carbon dioxide venography was unremarkable. This filter was placed more than a decade ago. Imaging from the original insertion was not available. An initial high insertion could not be entirely ruled out. However, the current location abutting the atrium precluded further watchful waiting. Initial filter capture was unremarkable, but straightening of the hook increased the technical difficulty. However, the looped wire technique provided a safe and effective alternative to a technically challenging case.