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Eur J Cardiothorac Surg 2002;22:460-461
© 2002 Elsevier Science NL

Case report

Intracardiac migration of nitinol TrapEase^TM vena cava filter and paradoxical embolism

^a Department of Vascular and Endovascular Surgery, Medical School, Federico II University, Naples, Italy
^b Department of Cardiac Surgery, Medical School, Federico II University, Naples, Italy

Received 13 March 2002; received in revised form 22 May 2002; accepted 24 May 2002.

* Corresponding author. Via le Letizia 2, 80131 Naples, Italy. Tel.: +39-81-7462630; fax: +39-81-5452893
e-mail: chirvasc{at}unina.it

	Abstract

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 
The nitinol TrapEase^TM inferior vena cava filter is a new device for pulmonary embolism prophylaxis. No cases of filter migration or filter-related complications with this type of device have so far been described. We report a case of intracardiac migration of this filter in a patient with a patent foramen ovale, resulting in severe cardiogenic shock, cerebral and right arm paradoxical embolism. Surgical treatment, results, causes of these complications are discussed.

Key Words: Embolism • Pulmonary vena cava • Filter embolism • Paradoxical

	1. Introduction

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 
Vena cava filters are widely used to prevent pulmonary embolism (PE). Placement problems, recurrent PE and filter occlusion are infrequent complications, while migration to the heart or pulmonary arteries is rare [1,2].

We report a case of delayed intracardiac migration of a nitinol TrapEase^TM filter in a patient with patent foramen ovale (PFO), who also experienced a concomitant paradoxical embolism (PDE) with cerebral and arm ischemia. He underwent successful surgery with cardiopulmonary bypass (CPB) associated with a brachial artery embolectomy.

	2. Case report

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 
A 53-year-old man with a PFO and insulin-dependent diabetes underwent surgery for intratrocanteric fracture of the left femur. One month later, he was referred to the Department of Vascular Surgery with a diagnosis of free-floating deep venous thrombosis and bilateral PE despite adequate anticoagulation. A ventilation-perfusion lung scan confirmed the diagnosis. An insertion of an inferior vena cava (IVC) filter was planned. At venocavography the IVC had a diameter of 24 mm.

Under fluoroscopic guidance, a nitinol vena cava filter (Cordis TrapEase^TM, Cordis Europa N.V., Roden, The Netherlands) was inserted through the right femoral vein at L2 level. The patient was given a regimen of oral warfarin and was discharged home in good condition, with an international normalized ratio (INR) of 2.2.

One week later he was readmitted to our department. On examination the patient was in respiratory distress, mental confusion, and in severe hypotension. The right arm was pale and pulseless. He was intubated, put on mechanical ventilation and pharmacological support was initiated. His INR was 2.5.

A spiral computerized tomography (CT) scan showed filter migration into the right ventricle (RV) (Fig. 1 ). A transthoracic echocardiogram confirmed the diagnosis and also demonstrated a clot trapped in the struts. Because of the filter position and clot, a percutaneous retrieval was not attempted. For reversal of warfarin therapy, 4 units of frozen pooled plasma, solvent/detergent-treated (Octaplas®, Octapharma, Wien, Austria) were administered. The patient was put on CPB, the right atrium was opened, and the filter was found in the RV with the struts embedded into the tricuspid valve cordae. The filter, with a large clot in the struts, was removed (Fig. 2 ) and the right atrium was closed. An incision was then carried out in the trunk of the pulmonary artery. The pulmonary arteries were free of thrombi. In addition the PFO was closed. Weaning from CPB was uneventful and the chest was closed. An incision on the right brachial artery was undertaken and a thrombus removed. A postoperative CT scan revealed an ischemic infarction in the area of the anterior cerebral artery. During serial duplex scanning, there was no evidence of propagation or floating clot. The patient's neurologic status slowly improved and was ultimately discharged in stable condition and on oral anticoagulation.

View larger version (103K): [in this window] [in a new window]   Fig. 1. Spiral CT scan showing intracardiac filter migration.

View larger version (114K): [in this window] [in a new window]   Fig. 2. The Cordis TrapEase TMfilter with thrombus trapped within the struts.

	3. Discussion

Top Abstract 1. Introduction 2. Case report 3. Discussion References

In a series of 2215 patients with the Mobin-Uddin umbrella , there were 13 cases of migration to the pulmonary artery (PA) (with a 46% mortality rate), and six cases of migration to the heart (with a mortality of 50%) [5]. Because of high vena caval occlusion rate, its use was discontinued.

In 1972, the Greenfield filter was introduced and has been widely adopted. Our experience with this filter is quite good with only one case (out of 154 devices implanted) of filter migration to the heart and successfully percutaneously removed with Greenfield's transvenous retrieval device [6].

James reported a case of tricuspid insufficiency caused by Greenfield filter dislodgement with fatal outcome and his literature review revealed 22 cases of migration to the heart or to the PA [7].

In 2000 we started to use the Cordis TrapEase^TM filter, and since then 12 patients have been treated. This filter is fitted with proximal and distal hooks to insure an optimal fixation to vessel wall, and it has been approved for insertion in an IVC up to 30 mm in diameter. In a multicenter prospective study with 65 patients, there were no cases of filter migration or other filter-related complications [8]. The cause of migration in this patient is unknown. Probably a new massive embolization, demonstrated by the large clot entrapped in the filter, may have resulted in sudden venous hypertension with distension of the IVC and filter's dislodgement and migration. The right atrial hypertension, caused by filter's entrapment in the tricuspid valve, associated with a PFO, determined a right-to-left shunt and subsequent embolization to the brachial and anterior cerebral arteries. PDE has seldom been reported as a complication in patients with caval filters probably because of their inadequate protection from small thrombi [9,10]. In our patient the filter prevented a massive and potentially lethal PE but could not avoid a cerebral and arm embolisms due to the fragmentation of the clot.

From our experience we may suggest that if a nitinol TrapEase^TM filter has migrated into RV, time should not be wasted in attempting its percutaneous retrieval, but prompt surgery is mandatory.

	References

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 

1. Greenfield L.J., Zocco J., Wilk J.D., Schroeder T.M., Elkins R.C. Clinical experience with the Kimray Greenfield vena caval filter. Ann Surg 1977;185:692-698.[Medline]
2. Greenfield L.J., Michna B.A. Twelve-year clinical experience with the Greenfield vena caval filter. Surgery 1988;104:706-712.[Medline]
3. Athanasoulis C.A., Kaufman J.A., Halpern E.F., Waltman A.C., Geller S.C., Fan C.M. Inferior vena caval filters: review of a 26-year single-center clinical experience . Radiology 2000;216:54-66.[Abstract/Free Full Text]
4. Ferris E.J., McCowan T.C., Carver D.K., McFarland D.R. Percutaneous inferior vena caval filters: follow-up of seven designs in 320 patients. Radiology 1993;188:851-856.[Abstract/Free Full Text]
5. Mobin-Uddin K., Utley J.R., Bryant L.R. The inferior vena cava umbrella filter. Prog Cardiovasc Dis 1975;17:391-399.[Medline]
6. Greenfield L.J., Crute S.L. Retrieval of the Greenfield vena cava filter. Surgery 1980;88:719-722.[Medline]
7. James K.V., Sobolewski A.P., Lohr J.M., Welling R.E. Tricuspid insufficiency after intracardiac migration of a Greenfield filter: case report and review of the literature. J Vasc Surg 1996;24:494-498.[Medline]
8. Rousseau H., Perreault P., Otal P., Stocks L., Golzarian J., Oliva V., Reynaud P., Raat F., Szatmari F., Santoro G., Emanuelli G., Nonent M., Hoogeveen Y. The 6-F nitinol TrapEase inferior vena cava filter: results of a prospective multicenter trial. J Vasc Interv Radiol 2001;12:299-304.[Medline]
9. Dahlman R., Kohler T.R. Cerebrovascular accident after Greenfield filter placement for paradoxical embolism. J Vasc Surg 1989;9:452-454.[Medline]
10. Greenfield L.J., Proctor M.C. Twenty-year clinical experience with the Greenfield filter. Cardiovasc Surg 1995;3:199-205.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Paolo Stassano Antonino Musumeci Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Porcellini, M. Articles by Bracale, G. Search for Related Content PubMed PubMed Citation Articles by Porcellini, M. Articles by Bracale, G. Related Collections Cardiac - other