Covered aortic stent graft reconstruction of the inferior vena cava after iatrogenic injury during inferior vena cava filter retrieval

Abstract

Complications during inferior vena cava (IVC) filter retrieval can be catastrophic, particularly in cases of filter penetration or embedment. The present report describes a 59-year-old woman who developed acute hemodynamic instability because of IVC laceration during complex retrieval of an IVC filter complicated by extensive iliocaval thrombosis. Management included aspiration thrombectomy, filter removal, and reconstruction of the infrarenal IVC using a covered abdominal aortic stent graft with iliac extensions, achieving hemostasis and restoration of venous flow. This case highlights the successful use of a covered aortic stent graft for emergent IVC repair.

Inferior vena cava (IVC) filters are used to prevent pulmonary embolism in patients with acute venous thromboembolism with contraindications to, or who have failed, anticoagulation therapy. Complications during IVC filter retrieval are rare but can be catastrophic, particularly in cases of extensive penetration or embedment of filter components into the caval wall. This can result in caval injury with venous extravasation, leading to acute hemodynamic instability necessitating emergent intervention.¹ Historically, open surgical repair has been the definitive management for severe caval injury, but endovascular techniques have since emerged as an alternative, particularly in unstable patients or those with high surgical risk.²

Endovascular venous reconstruction using stents and stent grafts has been described in the literature for chronic iliocaval thrombosis, filter exclusion, and traumatic or iatrogenic IVC injuries. Iliocaval stent reconstruction in the setting of IVC filter-associated thrombosis has shown high technical success and favorable medium-term patency, even when filters are excluded with stents across indwelling devices.³ In addition, covered stent grafts, including thoracic and abdominal aortic endografts, have been successfully used in a limited series of reported cases to manage IVC and iliac vein injuries, providing immediate hemostasis and exclusion of venous defects, although long-term follow-up data remain limited.⁴ This case illustrates the potential role of covered aortic stent grafts in emergent IVC repair in a patient who experienced iatrogenic IVC laceration during IVC filter retrieval.

Case presentation

A 59-year-old woman presented from an outside hospital following a complex removal of a malpositioned Greenfield IVC filter with components extending beyond the caval wall and minimal mobility. During attempted retrieval, the patient developed acute hemodynamic instability, and venography demonstrated active caval extravasation with loss of IVC flow, consistent with major caval injury (Fig 1, A). Emergent balloon tamponade of the IVC and bilateral iliac veins achieved hemodynamic stabilization but resulted in extensive iliac venous thrombosis. An uncovered self-expanding Abre stent (Medtronic) was placed in the infrarenal IVC with bilateral aspiration thrombectomy of the iliac veins, followed by placement of bilateral kissing Abre iliac stents and infrarenal OptionELITE retrievable IVC filter (Argon Medical Devices) placement before transfer for further care (Fig 1, B). A noncontrast computed tomography was obtained at the outside hospital demonstrating a large pericaval retroperitoneal (RP) hematoma. During intensive care unit admission, she endorsed severe bilateral leg and right flank pain, along with bilateral leg swelling on examination. Moreover, the patient developed anuric acute kidney injury requiring intermittent hemodialysis. Interval computed tomography angiography of the abdomen and pelvis revealed an expanding right-sided (RP) hematoma without contrast extravasation adjacent to the IVC, resulting in lateral displacement of the right kidney and extensive thrombosis from below the filter to the bilateral common femoral veins (CFVs; Fig 1, C and D). The plan was to perform aspiration thrombectomy and IVC filter retrieval as well as diagnostic venography to assess caval injury. Preparations were made to reconstruct the IVC and bilateral common iliac veins with covered stents should active bleeding or pseudoaneurysm occur following thrombectomy.

Fig 1.

A, Left iliocaval digital subtraction angiography (DSA) demonstrating inferior vena cava (IVC) extravasation into the retroperitoneal (RP) after filter removal. B, Post-balloon tamponade and iliocaval Abre stent placement demonstrating hemorrhage resolution with in-line flow. C, Axial computed tomography (CT) 1 day later showing thrombosed IVC stent and large right RP hematoma (white arrow) with layering contrast, likely from prior angiography. D, Coronal CT shows IVC thrombus extending into iliac stent limbs with adjacent RP hematoma.

Multivessel venous access was obtained via the right internal jugular vein, right CFV, and bilateral popliteal veins (PVs) for IVC reconstruction. Diagnostic venography demonstrated extensive thrombus extending from the right CFV and left PV to the infrarenal IVC, just inferior to an indwelling IVC filter (Fig 2, A and B). Large-volume suction thrombectomy using a 16F Lightning Flash catheter (Penumbra), resulted in improved blood flow. Residual synechiae in the left PV and bilateral CFV were treated with balloon maceration using a 12 × 80-mm Atlas balloon (Bard). IVC venography demonstrated contrast extravasation through the bare-metal stent, consistent with persistent IVC wall injury (Fig 3, A). The IVC filter was subsequently removed via the right internal jugular vein approach (Fig 3, B), and a 24 × 80-mm Endurant II stent graft (Medtronic) was deployed in the infrarenal IVC, followed by postdilation with a Coda balloon (Cook Medical). A repeat venogram demonstrated improved flow within the IVC and right lower-extremity venous system, with sluggish flow in the left lower-extremity venous system and extravasation of contrast just below the stent graft and above the bare-metal iliac stents. Two 11 × 79-mm VBX stent grafts (Gore Medical) were placed simultaneously within the existing kissing iliac stents, overlapping the distal margin of the IVC stent graft and flared with two 14 mm × 40 mm Atlas balloons to obtain a seal. Completion venography demonstrated exclusion of the perforation and restoration of in-line flow (Fig 3, C). Subsequent filling defects within the left external iliac vein were treated with repeated aspiration thrombectomy using the 16F Lighting Flash Catheter. The final bilateral lower extremity venogram demonstrated brisk antegrade flow and no evidence of contrast extravasation. At 1- and 5-month clinic follow-up visits, the patient was asymptomatic and adherent to Apixaban 5 mg twice daily for lifelong anticoagulation. Computed tomography imaging obtained at both visits demonstrated patent iliac and IVC stent grafts, with resolving thrombus (Fig 4, A-C) and continued resolution of the RP hematoma without secondary intervention. Written informed consent was obtained from the patient for publication of this case report and accompanying images.

Fig 2.

A, Right common femoral vein (CFV) digital subtraction angiography (DSA) shows multiple filling defects consistent with thrombus. B, Left common iliac vein DSA after left lower extremity thrombectomy showing inferior vena cava (IVC) stent occlusion to the level of the IVC filter.

Fig 3.

A, Fluoroscopy shows inferior vena cava (IVC) filter retrieval with snare via right internal jugular vein (IJV) approach. B, IVC digital subtraction angiography (DSA) shows contrast extravasation through the uncovered stent into the right retroperitoneal (RP) (black arrow). C, Post-iliocaval stent graft placement DSA shows inline flow with cessation of extravasation.

Fig 4.

A, Axial computed tomography (CT) at 1 month shows evolving right retroperitoneal (RP) hematoma (white arrow) and patent inferior vena cava (IVC) stent with peripheral residual thrombus. B, Axial CT at 5 months shows decreased hematoma size (white arrow), patent IVC stent, and decreased peripheral residual thrombus. C, Coronal CT with maximum intensity projection demonstrates the entirety of the iliocaval reconstruction in a single image.

Discussion

Endovascular approaches have emerged as effective alternatives for traumatic and iatrogenic injuries of the IVC and iliac veins, offering rapid hemorrhage control while avoiding laparotomy, particularly in high-risk patients.⁴ A surgical approach was considered in this case, but given the high mortality rate with open infrarenal caval repair, an endovascular approach to thrombectomy was preferred.⁵ Placement of covered stent grafts allows for immediate exclusion of venous perforations and restoration of in-line flow, and their use has been described in multiple case reports and small series.

Available venous stents are all uncovered; therefore, they would not be able to effectively manage the IVC injury presented in this case. Prior reports have demonstrated the successful use of thoracic and abdominal aortic stent grafts to reconstruct the IVC or iliac veins following traumatic or iatrogenic injury, with high technical success and short-term patency.⁴ In this case, deployment of an infrarenal abdominal aortic stent graft with extension into the iliac veins achieved exclusion of the caval perforation, restoration of venous patency, and sustained symptomatic improvement at follow-up.

Despite encouraging outcomes, the current literature remains limited, reflecting both the rarity of these complications and the use of arterial stent grafts in the venous system. Consequently, long-term outcome data are sparse, and further investigation is warranted to better define durability, patency, and complication profiles, particularly given the growing evidence of short-term technical and clinical success following covered stent graft placement for hemorrhage control and thrombus management. In addition, there is currently no consensus regarding optimal stent selection, sizing strategies, or the role of adjunctive IVC filter placement following venous stent graft reconstruction in patients with residual thrombi, underscoring the need for continued reporting and standardization of these complex interventions.

Conclusions

In conclusion, this case underscores the evolving role of advanced endovascular techniques in the management of venous complications during complex IVC filter retrieval. When conventional venous repair options are limited, the use of arterial stent grafts may provide an effective solution for hemostasis and venous reconstruction in appropriately selected patients.

Funding

None.

Disclosures

A.G. is a consultant for Medtronic, Replimune, and Penumbra. The additional authors declare that they have no conflict of interest.