Penetration of inferior vena cava filter strut through an introducer sheath inserted from the left internal jugular vein: An anatomical pitfall

Abstract

The report describes a case of penetration of an inferior vena cava filter (IVCF) strut through an introducer sheath inserted from the left internal jugular vein. A 64-year-old woman was admitted to our hospital with pulmonary embolism and lower extremity deep vein thrombosis. We attempted to implant a retrievable type IVCF via the left internal jugular vein. However, an unexpected resistance occurred during the advancement of the filter after passing the first few inches within the 8-Fr introducer sheath. Immediately, we checked the insertion site using fluoroscopy, which demonstrated penetration of the filter struts to the outside of the sheath. We speculate that a strong angulation in the vessel from the left internal jugular to superior vena cava might have contributed to this rare complication.

<Learning objective: Penetration of an inferior vena cava filter (IVCF) strut through an introducer sheath is a rare complication. However, physicians should recognize that this complication could occur in cases of IVCF placement, especially when insertion is done via the left internal jugular vein.>

Introduction

Most pulmonary emboli arise as thromboses in the deep veins of the lower extremities and may result in serious complications. An inferior vena cava filter (IVCF) is intended to prevent the passage of deep vein thrombosis (DVT) to the pulmonary arteries [1], [2]. Complications related to insertion of IVCF have been reported in 4% to 15% of patients and include puncture site-related problems, misplacement, migration, failure of the filter to deploy properly, and vena cava perforation [3]. The present report describes a case with penetration of an IVCF strut through an introducer sheath inserted from the left internal jugular vein (IJV).

Case report

A 64-year-old woman was admitted to our hospital with pulmonary embolism and lower extremity DVT. She had a past medical history of colostomy for colon cancer 4 months before admission. Contrast-enhanced computed tomography, which was performed to evaluate for metastasis and recurrence of colon cancer, incidentally detected thrombi in her right middle lobe pulmonary artery. In addition, venous ultrasonography of lower limbs revealed the DVT extending from the right popliteal vein to the right common femoral vein and in the left soleus muscle vein. She had slight edema in her right leg, but no dyspnea with arterial oxygen saturation level of 97%. Transthoracic echocardiography showed no signs of pulmonary hypertension. After admission, anticoagulation therapy was initiated, and implantation of IVCF was planned because the thrombi in the femoral vein were floating.

We attempted to implant a retrievable type IVCF (Günther Tulip filter, Cook, Bloomington, IN, USA). The left IJV was chosen as the access site for filter placement, because a central venous catheter had already been inserted from the right IJV for total parenteral nutrition. After insertion of an 8-Fr introducer sheath to the level below the orifice of the right renal vein, an IVCF was inserted through the sheath. However, unexpected resistance occurred during the advancement of the filter after passing the first few inches within the sheath. Although stronger force was applied, the IVCF could not be advanced. Immediate fluoroscopy showed penetration of one of the filter struts to the outside of the sheath (Fig. 1). Fortunately, the IVCF was easily and successfully removed without resistance using manual pullback. The patient did not develop new symptoms, and extravasation was not detected by venography. Finally, a new IVCF was carefully implanted via the right IJV with special attention given to avoid injury to the central venous catheter.

Fig. 1.

(A) Fluoroscopic image demonstrates a filter strut penetrating the sheath in the innominate vein (yellow arrow). (B) Schematic illustrations of (A).

Inspection of the removed IVCF and sheath introducer failed to detect deformations of the IVCF (Fig. 2A). However, a crack was identified near the angulation portion of the sheath (Fig. 2B and C). This crack presumably formed secondary to penetration by an IVCF strut.

Fig. 2.

(A) Removed inferior vena cava filter. There are no fractures of the filter struts. (B) Removed introducer sheath. An angulation is identified in the middle portion of the sheath (white arrow). (C) Magnified image of the dotted line area in (B). Linear scar (black double arrow line) is shown at the distal portion of angulation site (white arrow). Furthermore, the penetration point (white arrow head) is clearly identified at the distal site of linear scar.

Discussion

An IVCF can be used for the treatment of venous thromboembolic disease when a patient is not a candidate for anticoagulant therapy, when a patient has failed anticoagulant therapy, and when patients have a free-floating iliofemoral DVT [1], [2]. In the present case, we placed IVCF because of the floating thrombi in the femoral vein. However, most recent guidelines do not recommend the routine use of IVCF [3], even if in patients with free-floating thrombi in the proximal veins [4]. Therefore, we need further discussion about the indication of IVCF insertion in daily practice.

Complications associated with IVCF implantation include bleeding, infection at the puncture site, malposition of the filter, pneumothorax, vena cava perforation, strut penetration, and fracture [5]. Interestingly, there have been two case reports of penetration of an IVCF strut through the sheath [6], [7]. In these cases, the angulation between the end of the IVCF strut and the wall of the sheath was considered to be a possible cause for IVCF penetration. Salik et al. [8] described the following three strong angulated points: between the left IJV and superior vena cava, between the innominate vein and superior vena cava, and where the innominate vein crosses the aorta. In the present case, a sharper angulation of the sheath was identified between the left IJV and innominate vein where the end of the filter hook contacted the wall of the sheath. With such an angulation point, addition of excessive force to advance the filter could promote penetration of filter struts through the sheath. In fact, we found a linear scar at the distal portion of the angulation and a penetration point at the distal site of the scar (Fig. 2C). These findings suggest that the sheath wall was injured and eventually penetrated by the filter hook, which was pushed with excessive force at the angulation point.

The right IJV is a common approach site for insertion of an IVCF. However, the left IJV approach is sometimes used when the right IJV has already been used for central venous catheter insertion, as in the present case. There are no studies that have compared the rate of complications related to IVCF insertion between the right and left IJV approaches. A previous study showed that the insertion of a central venous catheter via the left IJV was associated with a higher frequency of incidence of venous perforation and was associated with longer procedural time because of the angulations related to the innominate vein [9]. A much greater degree of angulation would be expected if the IVCF had been delivered via the left IJV rather than the right IJV. Therefore, clinicians should pay attention to the angulation of the sheath when inserting an IVCF from the left IJV. Furthermore, clinicians should avoid pushing the IVCF with excessive force when resistance is appreciated during insertion. Finally, the movement and passage of IVCF through the sheath should be followed under fluoroscopy. If we did not omit this fluoroscopic check, penetration of IVCF strut through the sheath might be avoided or detected earlier.

Conflict of interest

The authors declare that there are no conflicts of interest.