Cas clinique

DOI of or1Service de

tance PubliqueFrance.

2Service deAssistance PubMarseille, Fran

3Service dePublique HopFrance.

CorrespondHopital de laFrance, E-mai

Ann Vasc Surghttp://dx.doi.or� Annals of V�Edit�e par ELS

Migration de filtre de veine cave : Unecomplication inappr�eci�ee. A propos de quatrecas et revue de la litt�erature

Pauline B�el�enotti,1 Gabrielle Sarlon-Bartoli,2 Michel-Alain Bartoli,2 Audrey Benyamine,1

Benjamin Thevenin,2 Cyril Muller,3 Jacques Serratrice,1 Pierre-Edouard Magnan,2

Pierre-Jean Weiller,1 Marseille, France

Le placement de filtres de veine cave inf�erieure est fait pour empecher le risque d’embolie pul-monaire secondaire �a une thrombose veineuse profonde. Les indications de ce traitement sontlimit�ees aux malades ayant des r�ecidives sous traitement anticoagulant bien-control�e ou unecontre-indication au traitement anticoagulant. Actuellement, comme ces situations cliniquessont rares, ce dispositif est de moins en moins utilis�e, d’autant plus que, depuis plusieursann�ees, la thrombose, la fracture, ou les complications infectieuses ainsi que la migration defiltre ont �et�e rapport�ees. Les migrations de filtre sont responsables de pr�esentations cliniquesatypiques et diverses susceptibles de retarder le diagnostic. Pour les traiter, le filtre est extrait,ce qui est tr�es risqu�e chez les malades ayant des ant�ec�edents thromboemboliques. Dans notrecentre, au cours d’une p�eriode de 14 ans, nous avons r�etrospectivement collect�e et �etudi�e lescas de migration partielle ou compl�ete de filtre de veine cave qui avaient �et�e trait�es parextraction. Nous rapportons quatre cas cliniques tr�es diff�erents et, plus sp�ecifiquement, ledeuxi�eme cas publi�e de migration dans une veine r�enale, qui imitait une maladie syst�emique. Enraison de ses pr�esentations cliniques tr�es atypiques, la migration cave de filtre est une com-plication inappr�eci�ee et certainement sous-diagnostiqu�ee. Cependant, cette complication ne doitpas remettre en cause le placement cave de filtre quand il est justifi�e. En revanche, elle incite �al’ablation rapide des filtres ou �a la surveillance radiologique �a long terme.

Inferior cava vena filter placement is performed to

prevent pulmonary embolism risk. It is applied to

patients presenting with venous thromboembolic

iginal article: 10.1016/j.avsg.2011.03.016.

M�edecine Interne, Universit�e de la M�editerran�ee, Assis-Hopitaux de Marseille, Hopital de la Timone, Marseille,

Chirurgie Vasculaire, Universit�e de la M�editerran�ee,lique Hopitaux de Marseille, Hopital de la Timone,ce.

Radiologie, Universit�e de la M�editerran�ee, Assistanceitaux de Marseille, Hopital de la Timone, Marseille,

ance : Pauline B�el�enotti, Service de M�edecine Interne,Timone, 264 rue Saint Pierre, 13685 Marseille Cedex 5,l: pauline.belenotti@ap-hm.fr

2011; 25: 1141.e9-1141.e14g/10.1016/j.acvfr.2013.02.010ascular Surgery Inc.EVIER MASSON SAS

disease that cannot be treated by anticoagulation

therapy, those presenting with recurrence, despite

a well-managed treatment, or those which expe-

rienced for massive pulmonary embolism.1

Nowadays, these indications are restricted

because of an increasing risk of lower-limb deep

venous thrombosis with postphlebitic syndrome

due to filter thrombosis and because of the absence

of benefit in terms of survival compared with clas-

sical anticoagulation therapy.2 Complications such

as thrombosis or filter infection are usual, whereas

migrations of a part or of the whole vena cava filter

are not well documented; these filter migrations

often generate atypical and varied clinical mani-

festations according to the migration sites.

Between 1996 and 2010, we retrospectively

collected and studied cases of vena cava filter

migration that were surgically treated in our center.

We report a series of four filter migration cases;

1215.e9

Fig. 1. Vena cava filter that migrated in a retrograde manner to the level of iliac vein confluence.

1215.e10 Cas cliniques Annales de chirurgie vasculaire

among these cases, we present the second publis-

hed case of a migration to a renal vein that

mimicked a systemic disease. For these four cases,

migrations were diagnosed and surgically treated

in our center, but filters had been placed in other

centers. A review of the literature confirms the

heterogeneity of clinical presentations and the diffi-

culty to make a diagnosis. However, this complica-

tion should not question vena cava filter placement

when it is recommended; instead, it suggests long-

term radiological surveillance or early withdrawal

when needed.

CASE 1

A 26-year-old girl had an Antheor (Boston Scientific) cava

vena filter 3 years earlier. This filter had been first placed,

in Italy, in 1996, after a cavography was performed to

explore a deep extensive left iliofemoral proximal venous

thrombosis that was complicating an ill-controlled Crohn

disease. Thrombophilia screening was negative. Since fil-

ter placement, this patient had been treated with curative

doses of warfarin, corticotherapy (0.5 mg/kg/day) and

wore support stockings.

Three years later, she underwent an exploration for

febrile inflammatory syndrome (C-reactive protein at 97

mg/L) and microcytic anemia. Thoracoabdominal and

pelvic computed tomographic (CT) scans, carried out to

detect deep infectious source, showed an abnormal posi-

tion of the vena cava filter that was placed at the level

of the iliac confluence (Fig. 1). Duplex scan did not

show any aftereffects of lower-limb deep venous

thrombosis.

This migration led to the vena cava filter removal; tem-

perature went down within 1 week. Vena cava filter

culture was sterile. Anticoagulant treatment at curative

dose was stopped 1 year after filter removal and, to date,

no recurrence has been noticed.

CASE 2

It concerned a 51-year-old man with a deep right proxi-

mal femoropopliteal venous thrombosis occurring after

inguinal hernia surgery.When heparin replaced warfarin,

this thrombosis became extensive with bilateral pulmo-

nary complication, which led to a percutaneous Cardial

vena cava filter placement. Three years later, this patient

was admitted in the rheumatology department for left

shoulder arthritis with Staphylococcus aureus sepsis. Trans-

esophageal ultrasonography was normal. For 3 weeks,

he was treated with four antibiotics in association

with vancomycin, metronidazole, sulfamethoxazoleetrimethoprim, and fusidic acid, which entailed apyrexia

and inflammatory syndrome regression; the treatment

was then replaced with sulfamethoxazoleetrimethoprim

and fusidic acid per os.

Onemonth later, this patient was urgently taken to the

hospital for painful rachidian syndrome with fever.

Magnetic resonance imaging and bone scan showed

lumbosacral L5-S1 and cervical C5C6 spondylodiscitis.

L5-S1 puncture revealed a rifampicin-resistant S aureus.

All blood cultures were sterile. Thoracoabdominal and

pelvic CT scans enabled detection of the migration of the

vena cava filter by perforation of the vena cava wall into

the duodenum (Fig. 2).

We decided to perform vena cava filter removal. This

procedure was very tricky because three filter branches

had perforated the posterior wall of the vena cava. Three

other filter branches were perforating the anterior wall

of the vena cava toward the duodenum. No deep abscess

was detected at rachis or at digestive tract contact point.

This patient was first treated with imipenem, gentamicin,

and penicillin and then with ofloxacin and fusidic acid for

12 months. He did not have any septic recurrences.

CASE 3

It concerned a 33-year-old female carrier of heterozy-

gous factor II Leiden with an Antheor (Boston Scientific)

Fig. 2. Vena cava filter that migrated in a juxtaduodenal

and juxtavertebral position.

Fig. 3. Vena cava filter that migrated in a juxtaduodenal,

juxta-aortic, and juxtavertebral position.

Fig. 4. Vena cava filter in the right renal vein, with

destruction of the ipsilateral renal parenchyma. The

second cava vena filter is situated in the lower vena cava.

Vol. 25, No. 8, 2011 Cas cliniques 1215.e11

vena cava filter that had been placed in England.

This patient presented with iterative pulmonary embo-

lism, despite an efficient antivitamin K treatment. Since

filter placement, she had been treated with warfarin but

was suffering from untypical pains, with cruralgia on her

right side. Lumbar magnetic resonance imaging did not

show any vertebral disc disorder.

Two years later, as painful symptoms were still

present, another CT scan was carried out, and it showed

that three filter branches were broken. One of them had

migrated toward the rachis, another toward the duode-

num, and the third was in contact with the right anterola-

teral aorta wall (Fig. 3). No inflammatory response was

detected. The vena cava filter was surgically removed,

which suppressed the abdominal painful syndrome. This

patient received a long-term warfarin treatment and did

not experience any other thromboembolic disorder

recurrence.

CASE 4

It concerned a 56-year-old woman who has been

presenting with chronic inflammatory syndrome

(C-reactive protein exceeding 50 mg/L) in association

with recurring episcleritis and peripheral adenopathy for

more than 6 months. Seven years before, she had pre-

sented with bilateral massive pulmonary embolism

requiring a vena cava filter placement. One year after

this placement, she had a pulmonary embolism recur-

rence; the vena cava filter had migrated. Another filter

had then been placed without removing the first one.

She was receiving a long-term warfarin treatment. In

the presence of this inflammatory response, thora-

coabdominal and pelvic CT scans showed the two

filters; the one in the inferior vena cava was in place

and did not appear to be thrombosed, whereas the other

had migrated into the right renal vein. The right

renal artery presented with an 80% stenosis (Fig. 4),

but renal function was not affected (creatinemia:

87 mmol/L). Usual tests to detect infectious endocarditis

(repetitive blood cultures, especially for slow-growing

bacteria, transesophageal cardiac ultrasound examina-

tion) or thrombophilia were normal. Viral serologies

were negative.

Because of the renal complication, the cava

vena filter which migrated into the right renal vein

was removed. Perioperative analysis showed that two

filter branches had migrated: one into the perirenal

space and the other into the retrocaval space. Filter

branches in the right kidney and renal vessels

were entwined in the venous wall, resulting in an

important reactive inflammatory fibrosis requiring

nephrectomy.

To date, this patient has not experienced any inflam-

matory syndrome. She is still being treated with warfarin.

Recurrent tomodensitometry checks allow monitoring of

the second vena cava filter.

Table I. Literature review of migration cases involving the Antheor filter (Boston Scientific)

Reference Number of patients Complication types Frequency (%)

St€osslein et al.12 1 Deadly migration into pulmonary artery

Miyahara et al.13 20 Migration 50

Fracture 33

Harries et al.14 20 Deadly migration into pulmonary artery 5

Fracture 15

1215.e12 Cas cliniques Annales de chirurgie vasculaire

DISCUSSION

Our study reports four cases of vena cava filter

migrations that had been collected during a

14-year period. These migrations were all the more

difficult to diagnose because their presentations

were very different.

Case 1 was detected because of a biological

inflammatory syndrome. Case 2 was more obvious,

with septicemia and recurring osteoarticular infec-

tions. Case 3 was insidious, with chronic lower

back pain. Case 4 was the trickiest one, with an

association of inflammatory syndrome, recurring

episcleritis, and peripheral adenopathy that could

mimic systemic disease.

In the literature, clinical presentations of migra-

tions are also reported to be very numerous and aty-

pical. Diagnosis of vena cava filter migration is then

confirmed with the help of specifically dedicated CT

scan images showing filter displacement or migra-

tion of one of the branches of the filter. However,

when carrying out a diagnosis, some signs are often

considered indicators of these migrations: pains at

site of migration and moderate biological inflamma-

tory response.

If a patient with a vena cava filter ex-

periences these symptoms, it is important to

know precisely the filter placement date because

of the possibility that migration may occur within

the next 5 years. The most impressive migra-

tion cases are intracardiac migrations; they are

also the most reported cases in the literature,

ranging from ventricular tachycardia to tamponade

by myocardial perforation and even to sudden

death.3-8

Tamponade cases, most often in patients with

anticoagulant treatment, may wrongly suggest

hemorrhagic pericarditis and filter implication may

not be obvious.9 Migration must be considered

whenever acute cardiac disorders occur in patients

with vena cava filters. Moreover, migration to a

renal vein has only been described once in post-

operative context, with a thrombus including the

filter and extending from hepatic veins to the

common iliac vein and causing anuria.10

In our series, case 4 also presentedwithmigration

to the renal vein, in association with an ipsilateral

renal artery stenosis. This stenosis due to extrinsic

compression by the filter was responsible for perio-

peratively diagnosed chronic hypoperfusion of the

right kidney requiring nephrectomy. Recently, a

case of right renal artery perforation complicated

with septic pseudoaneurysm was described; it also

entailed removing the filter and performing

nephrectomy to limit septicemia.11 Finally, as in

case 2, a recurring septic syndrome must suggest

rachidian or even duodenal perforation with an

enterocaval fistula.

Several elements can be held responsible for

migration occurrences, especially vena cava filter

brands. In our series, of four filters, two were

Antheor (Boston Scientific) filters, onewas a Cardial

filter, and the last one brand was an unknown. In

the literature, Antheor (Boston Scientific) filters

are reported to be more likely to generate such

type of complications (Table I12-14), mostly because

of their faulty venous wall anchorage system.15

Cardial filters seem to be less likely to migrate

than the Greenfield (Boston Scientific) filters16-19

because of their rigid steel structure20 and their great

number of branches (eight branches). A recent

study has compared fracture prevalence between

first- and second-generation filters; nitinol wear and

tear (first-generation filters) seems to be a possible

cause of rupture of filter branches and therefore of

their migration.3 In addition to filter composition,

Kassavin et al. described external cardiac massage as

a possible mechanical cause of vena cava filter

migration process.21

Recently, all kinds of mechanical stress, such as

repetitive physical activities entailing abdominal

hypertension, have been suspected of causing filter

migration.22-24 Finally, in their study, Fotiadis

et al. imply that precocious migrations can be

explained by faulty filter deployment during its

implantation.25 All these data tend to show that

strength and anchorage properties of filters and

therefore their likelihood to migrate or get fractured

depend on the filter brand, external factors, and

placement conditions.

Table II. Literature review of vena cava filter

complications and their frequencies reported in

different series

ReferenceNumber ofpatients

Complicationtypes Frequency

Nazzal et al.27 400 Thrombosis 19 (4.8%)

Migration 6 (1.5%)

Usoh et al.28 156 Thrombosis 6 (3.8%)

Migration 0 (0%)

Kalva et al.29 70 Thrombosis 3 (4.3%)

Perforation 2 (2.9%)

Fracture 1 (1.4%)

Kalva et al.30 96 Perforation 11 (11.5%)

Fracture 3 (3.1%)

Thrombosis 2 (2%)

Migration 1 (1%)

Johnson et al.31 100 Thrombosis 3 (3%)

Migration 2 (2%)

Phelan et al.32 69 Thrombosis 14 (20%)

Fracture 1 (1.4%)

Vol. 25, No. 8, 2011 Cas cliniques 1215.e13

The onlyway to treat themanifestations resulting

from vena cava filter migration is to extract the fil-

ter, most often by surgery. This extraction is dange-

rous because filter branches may be entwined in the

venous wall, as was the case in the renal venous

migration, which entailed extensive thrombosis.

The branches may also perforate the venous wall

and threaten vital organs, for example, by myocar-

dial perforation. Thrombotic susceptibility of the

patient, be it recognized thrombophilia or idiopathic

venous thromboembolic disease, renders postopera-

tive course very complex. Endovascular extraction

can be useful in some cases of intracardiac migra-

tions or in an emergency context.26

However, we want to stress on that these cases

are not frequent and must not question filter place-

ment indication when it is justified. As far as our

center is concerned, it was difficult to evaluate

migration frequency because the studied filters

had been placed in other centers. However, in our

center, between 1996 and 2010, six filters were pla-

ced and, to date, no migration cases have been

detected.

Table II shows frequencies of thrombotic com-

plications, migrations, fractures, and venous wall

perforations reported in different series of the lite-

rature.27-32 On average, filter thrombosis has been

described in 6.3% of the cases, and migrations or

perforations or fractures have been found in 4.1%of

the cases. When filter placement is carried out,

patients have to undergo an adequate and targeted

clinical and radiological follow-up to limit occur-

rence of complications or to early detect them and

lessen their aftereffects. Moreover, as soon as

thromboembolic risk is under control, early filter

removal enables to reduce these complications as

much as possible.

CONCLUSION

Vena cava filtermigration can be responsible for aty-

pical, very different, and sometimes serious clinical

presentations. In patients with vena cava filters,

every acute or systemic-looking clinical presenta-

tion must suggest ectopic migration. When clinical

diagnosis is not clear, a targeted CT scanning enables

confirmation by showing the migration and the

associated lesions. In fragile patients despite high

thromboembolic risk the only treatment is surgical

extraction, which is a difficult, but rarely complica-

ted, procedure. However, these complications are

rare and should not question vena cava filter place-

ment when it is recommended, especially in elderly

patients or in patients with hemorrhagic risk con-

traindicating any curative anticoagulant treatment.

REFERENCES

1. Recommandations de Bonne Pratique. Pr�evention et traite-

ment de lamaladie thromboembolique veineuse enm�edecine.

Afssaps (in press).

2. PREPIC Study Group. Eight-year follow-up of patients with

permanent vena cava filters in the prevention of pulmonary

embolism: the PREPIC (Prevention du Risque d’Embolie

Pulmonaire par Interruption Cave) randomized study. Cir-

culation 2005;112:416-422.

3. Nicholson W, Nicholson WJ, Tolerico P, et coll. Prevalence

of fracture and fragment embolization of bard retrievable

vena cava filters and clinical implication including cardiac

perforation and tamponnade. Arch Intern Med 2010;170:

1827-1831.

4. Owens CA, Bui JT, Knuttinen MG, et coll. Intracardiac

migration of inferior vena filters: review of published data.

Chest 2009;136:877-887.

5. Cappelli F, Vignini S, Baldereschi GJ. ALN inferior vena cava

filter upside down rotation with chest caval migration in an

asymptomatic patient. J InvasiveCardiol 2010;22:E153-E155.

6. Desjardins B, Kamath SH, Williams D. Fragmentation,

embolization, and left ventricular perforation of a recovery

filter. J Vasc Interv Radiol 2010;21:1293-1296.

7. Janjua M, Omran FM, Kastoon T, Alshami M, Abbas AE.

Inferior vena cava filter migration: updated review and case

presentation. J Invasive Cardiol 2009;21:606-610.

8. Haddadian B, Shaikh F, Djelmami-Hani M, Shalev Y. Sud-

den cardiac death caused by migration of a TrapEase inferior

vena cava filter: case report and review of the literature. Clin

Cardiol 2008;31:84-87.

9. Kalavakunta JK, Thomas CS, Gupta V. A needle through the

heart: rare complication of inferior vena caval filters.

J Invasive Cardiol 2009;21:E221-E223.

10. Janvier AL, Hamdan H, Malas M. Bilateral renal vein

thrombosis and subsequent acute renal failure due to IVC

filter migration and thrombosis. Clin Nephrol 2010;73:

408-412.

1215.e14 Cas cliniques Annales de chirurgie vasculaire

11. Becher RD, Corriere MA, Edwards MS, Godshall CJ. Late

erosion of a prophylactic Celect IVC filter into the aorta,

right renal artery, and duodenal wall. J Vasc Surg 2010;52:

1041-1044.

12. St€osslein F, Altmann E. A rare complication with an Antheor

vena cava filter. Cardiovasc Intervent Radiol 1998;21:

165-167.

13. Miyahara T, Miyata T, Shigematsu K, et coll. Clinical out-

come and complications of temporary inferior vena cava

filter placement. J Vasc Surg 2006;44:620-624.

14. Harries SR, Wells IP, Roobottom CA. Long-term follow-up of

the Antheor inferior vena cava filter. Clin Radiol 1998;53:

350-352.

15. O’Sullivan GJ, Buckenham TM, Belli AM. Early structural

failure of an Antheor inferior vena cava filter. Clin Radiol

1998;53:155.

16. Ferdani M, Rudondy P, Caburol G, Jausseran JM. In vitro

testing of six inferior vena cava filters: filtering efficiency

and pressure measurements. J Cardiovasc Surg 1995;36:

127-133.

17. Jausseran JM, Rubondy P, Caburol G, Ferdani M,

Lalanne B, Chabert B. In vitro bench test of caval umbrella

filters. Phlebologie 1993;46:429-440.

18. Narayan H. Experience with the cardial inferior vena cava

filter as prophylaxis against pulmonary embolism in pre-

gnant women with extensive deep venous thrombosis. Br J

Obstet Gynaecol 1992;99:637-640.

19. von Bary S, K€uhn J, Krieger S, Sobala KH. Vena cava filtere

prevention of pulmonary embolism: report of clinical

experiences. Zentralbl Chir 1999;124:27-31.

20. Schleich JM, Laurent M, Le Helloco A, Langella B, Ram�ee A,Almange C. Short-term follow-up of inferior vena caval

filters: comparison of imaging techniques. Am J Roentgenol

1993;161:799-803.

21. Kassavin DS, Constantinopoulos G, Ansari S. Cardio-

pulmonary resuscitation and associated anatomic and

hemodynamic changes in the vena cava: risk factors for

inferior vena cava filter migration? Cardiovasc Intervent

Radiol 2011;34(Suppl. 2):S318-S320.

22. Nathani N, Barzallo M, Mungee S. Myopericarditis secon-

dary to embolization of fractured inferior vena cava filter

limbs. J Invasive Cardiol 2010;22:E225-E228.

23. Chandra PA, Nwokolo C, Chuprun D, Chandra AB. Cardiac

tamponade caused by fracture and migration of inferior

vena cava filter. South Med J 2008;101:1163-1164.

24. Rossi P, Arata FM, Bonaiuti P, Pedicini V. Fatal outcome in

atrial migration of the Tempofilter. Cardiovasc Intervent

Radiol 1999;22:227-231.

25. Fotiadis NI, Sabharwal T, Dourado R, Fikrat S, Adam A.

Technical error during deployment leads to vena cava filter

migration and massive pulmonary embolism. Cardiovasc

Intervent Radiol 2008;31:S174-S176.

26. Kuo WT, Loh CT, Sze DY. Emergency retrieval of a G2 filter

after complete migration into the right ventricle. J Vasc

Interv Radiol 2007;18:1177-1182.

27. Nazzal M, Nazzal M, Chan E, et coll. Complications related

to inferior vena cava filters: a single-center experience. Ann

Vasc Surg 2010;24:480-486.

28. Usoh F, Hingorani A, Ascher E, et coll. Prospective rando-

mized study comparing the clinical outcomes between

inferior vena cava Greenfield and TrapEase filters. J Vasc

Surg 2010;52:394-399.

29. Kalva SP, Chlapoutaki C, Wicky S, Greenfield AJ,

WaltmanAC,Athanasoulis CA. Suprarenal inferior vena cava

filters: a 20-year single-center experience. J Vasc Interv

Radiol 2008;19:1041-1047.

30. Kalva SP, Athanasoulis CA, Fan CM, et coll. ‘‘Recovery’’

vena cava filter: experience in 96 patients. Cardiovasc

Intervent Radiol 2006;29:559-564.

31. Johnson MS, Nemcek AA Jr, Benenati JF, et coll.

The safety and effectiveness of the retrievable option

inferior vena cava filter: a United States prospective multi-

center clinical study. J Vasc Interv Radiol 2010;21:

1173-1184.

32. Phelan HA, Gonzalez RP, Scott WC, White CQ, McClure M,

Minei JP. Long-term follow-up of trauma patients with per-

manent prophylactic vena cava filters. J Trauma 2009;67:

485-489.