Interact CardioVasc Thorac Surg 2009;8:245-246. doi:10.1510/icvts.2008.189605
© 2009 European Association of Cardio-Thoracic Surgery
Negative results - Cardiac general |
Right atrial foreign body: transvenous migration of Greenfield filter
Geetali Mohan*,
Rahil Kasmani,
Kelechi Okoli and
Hussam Elkambergy
Department of Internal Medicine, St Vincent Mercy Medical Center, Toledo, Ohio 43608, USA
Received 29 July 2008;
received in revised form 23 October 2008;
accepted 28 October 2008
*Corresponding author. Tel.: +1-419-787-0634; fax: +1-419-251-6750.
E-mail address: Geetali_Mohan{at}yahoo.com (G. Mohan).
 |
Abstract
|
|---|
Migration of an inferior vena cava filter to the heart is a rare occurrence. Migration is usually to the right cardiac chambers, and is mostly detected incidentally. We report a 65-year-old woman with transvenous migration of an inferior vena caval filter to the right atrium in whom retrieval of the filter was not feasible due to prohibitive surgical risk. On subsequent follow-up at 10 months, the filter remains in the right atrium without complications.
Key Words: Greenfield filter; Right atrium; Filter migration
|
1. Introduction
|
|---|
The inferior vena cava (IVC) filter is an established therapeutic option for the prevention of pulmonary embolism in individuals with deep venous thromboembolism in whom conventional anticoagulation is contraindicated or deemed ineffective. Although clinically efficacious, filters are not exempt from complications. The major complications associated with IVC filters include intravascular and extravascular migration, filter and venous thrombosis, recurrent pulmonary emboli and inferior vena caval obstruction [1]. We report a case of transvenous migration of an IVC filter to the right atrium.
|
2. Case report
|
|---|
A 65-year-old morbidly obese woman on long-term warfarin therapy presented to the hospital with melena and shortness of breath. She had a history of pulmonary artery hypertension, cor pulmonale secondary to chronic thromboembolic disease, chronic obstructive pulmonary disease (COPD) and obesity hypoventilation syndrome (OHS). Due to her risk of further bleeding, warfarin was discontinued and a Greenfield® IVC filter was inserted under fluoroscopic guidance. Post procedure a radiograph showed the filter at the level of the fifth lumbar vertebra. During the course of her hospital stay, she developed pleuritic chest pain and hemoptysis. Concern for another pulmonary embolus necessitated a computed tomography angiogram (CTA) that did not demonstrate a new pulmonary embolism but revealed that the Greenfield® IVC filter had migrated to the right atrium (Fig. 1a,b). A transthoracic echocardiogram showed the apex of the filter projecting into the right atrium.
View larger version (59K):
[in this window]
[in a new window]
|
Fig. 1. (a) Computed tomography of chest (CT) revealing the dislodged Greenfield® IVC filter projecting into the right atrium (arrow). (b) A reconstructed image demonstrating the GFF projecting from the right atrium (arrow head).
|
|
After consideration of her surgical risk, it was agreed that a surgical attempt at retrieval of the filter posed a prohibitive risk. The patient remained asymptomatic without evidence of any arrhythmias or pericardial effusion. Her hemoptysis resolved with antibiotics but she developed chronic respiratory failure secondary to COPD and OHS and required a tracheostomy for long-term mechanical ventilation. At ten months follow-up there were no complications related to the filter.
|
3. Discussion
|
|---|
The incidence of IVC filter migration ranges from 0.3 to 6% with rare migration to the heart or lung [2, 3]. Misplacement (premature deployment) and/or secondary migration to the heart are the causes of intracardiac filters. Misplacement during filter insertion is more common than secondary migration. IVC filters have been reported to migrate to the right atrium, right ventricle and pulmonary arteries. The incidence of filter migration depends on the type of filter used. The occurrence has decreased over the last ten years because of improved filter design. The filter used in our patient, the percutaneous stainless steel GFF is currently the most commonly used. The filter is placed over a guide wire, which allows better alignment and has alternating hooks, which attach themselves to the inferior vena cava wall thus preventing migration. The earlier titanium GFF had a very high incidence of migration and tilting. Most of the cases of migration have been of the earlier versions of the GFF. One of the common explanations given for migration is miscalculation of the IVC size. The GFF can only be placed for an IVC size of <28 mm. Though our patient did have cavography to determine the IVC size it is possible that her IVC was bigger given her morbid obesity.
Most patients remain asymptomatic but tricuspid valve insufficiency, acute myocardial infarction, arrhythmias, pericardial tamponade, and sudden cardiac deaths have been described [4–6].
There is no definite consensus regarding the optimal management of patients with intracardiac IVC filters. Patients have been managed with only observation but extraction of filters (surgical extraction or percutaneous retrieval using guide wire and snare), especially for symptomatic patients, has been successfully attempted [7]. Long-term safety of leaving a filter in the heart is not yet established. Gelbfish and Ascer reported a follow-up of three patients with the filter in the right heart for 2, 45 and 60 months and detected no complications [8]. Similarly, Rodriguez and Saltiel followed a patient for more than seven years [9]. The reason to leave the filter in the heart has been mainly due to failure of percutaneous removal or a prohibitive operative risk. Periodic follow-up of such patients is advised with electrocardiogram and radiograph to detect conduction disturbances and to reconfirm the location of the filter, respectively. The use of anticoagulation in these patients is controversial given the higher risk of hemorrhagic pericardial effusion [10].
In the present case, she had a Greenfield® IVC filter inserted due to a contraindication to anticoagulation. Migration of the filter was detected incidentally. On follow-up at ten months, the filter remains in the right atrium with no further migration or complications.
|
References
|
|---|
- Joels CS, Sing RF, Heniford BT. Complications of inferior vena cava filters. Am Surg 2003 Aug;69:654–659.[Medline]
- Athanasoulis CA, Kaufman JA, Halpern EF, Waltman AC, Geller SC, Fan CM. Inferior vena caval filters: review of a 26-year single-center clinical experience. Radiology 2000;216:54–66.[Abstract/Free Full Text]
- Ferris EJ, McCowan TC, Carver DK, McFarland DR. Percutaneous inferior vena caval filters: follow-up of seven designs in 320 patients. Radiology 1993;188:851–856.[Abstract/Free Full Text]
- James KV, Sobolewski AP, Lohr JM, Welling RE. Tricuspid insufficiency after intracardiac migration of a Greenfield filter: case report and review of the literature. J Vasc Surg 1996;24:494–498.[CrossRef][Medline]
- Puram B, Maley TJ, White NM, Rotman HH, Miller G. Acute myocardial infarction resulting from the migration of a Greenfield filter. Chest 1990 Dec;98:1510–1511.[Abstract/Free Full Text]
- Haddadian B, Shaikh F, Djelmami-Hani M, Shalev Y. Sudden cardiac death caused by migration of a TrapEase inferior vena cava filter: case report and review of the literature. Clin Cardiol 2008 Feb;31:84–87.[CrossRef][Medline]
- Arjomand H, Surabhi S, Wolf NM. Right ventricular foreign body: percutaneous transvenous retrieval of a Greenfield filter from the right ventricle — a case report. Angiology 2003;54:109–113.[CrossRef][Medline]
- Gelbfish GA, Ascer E. Intracardiac and intrapulmonary Greenfield filters: a long-term follow-up. J Vasc Surg 1991;14:614–617.[CrossRef][Medline]
- Rodriguez LF, Saltiel FS. Long-term follow-up of ectopic intracardiac Greenfield filter. Chest 1993;104:611–612.[Abstract/Free Full Text]
- Lahey SJ, Meyer LP, Karchmer AW, Cronin J, Czorniak M, Maggs PR, Nesto RW. Misplaced caval filter and subsequent pericardial tamponade. Ann Thorac Surg 1991 Feb;51:299–300.[Abstract]
|
|
Top
Abstract
1. Introduction