Abstract
A 70-year-old man with history of osteomyelitis receiving intravenous antibiotics developed lower extremity weakness; magnetic resonance imaging was consistent with epidural abscess with cord compression requiring spinal laminectomy. Postoperative day 4, he developed chest pain, hypoxia, and tachycardia. Computed tomography (CT)-angiography showed extensive bilateral pulmonary embolism (PE) with right ventricular strain (Panels A1 and A2). Venous duplex showed extensive acute deep vein thrombosis (DVT). In lieu of his PE and ongoing symptoms, he underwent EKOS catheter-directed thrombolysis (Boston Scientific, Marlborough, MA, USA). A retrievable inferior-vena cava (IVC) Cook Celect filter (Cook Medical, Bloomington, IN, USA) was placed due to anticipated interruption of anticoagulation. Post-filter deployment, significant angulation of the filter was noted (> 15° angulation from long axis of IVC; 1 Panel B-1). The next day, he presented to the catheterization laboratory to replace the angulated filter for efficacy concerns. However, digital subtraction venography showed a significant amount of thrombus within the filter (Panel B-2 [star], Supplemental Video 1), and a single EKOS thrombolysis catheter was placed across the filter for localized treatment. Post-lytic rotational venography (Supplemental Video 2) showed improvement, but still retained the thrombus burden. Thus, plans for IVC filter replacement were aborted.
The role of an IVC filter is to trap venous emboli from the lower extremities in order to prevent hemodynamically significant PE. All guidelines agree that IVC filters are recommended in patients with proximal DVT or PE and contraindication to anticoagulation. 2 IVC filter-related complications include thrombotic occlusion, penetration, movement, tilt, and others. 3 The risk of tilt and thrombosis is dependent upon filter type, but is uncommon in the Cook Celect IVC filter. 4 Tilt may be associated with a higher risk of PE; 5 however, treatment is controversial, and may include filter replacement, placement of a second filter, or expectant management. 1
‘Images in vascular medicine’ is a regular feature of Vascular Medicine. Readers may submit original, unpublished images related to clinical vascular medicine. Submissions may be sent to: Heather Gornik, Editor in Chief, Vascular Medicine, via the web-based submission system at http://mc.manuscriptcentral.com/vascular-medicine
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Supplementary material
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References
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