Late complication from a retrievable inferior vena
cava filter with associated caval, aortic, and
duodenal perforation: A case report
Massimiliano Veroux, MD, PhD,a Tiziano Tallarita, MD,a Monica Pennisi, MD,b and
Pierfrancesco Veroux, MD,a Catania, Italy
Inferior vena cava filters are an excellent therapeutic method for those patients in whom anticoagulant therapy is
contraindicated or ineffective. However, filter placement is associated with a high rate of serious complications (>30%),
with death occurring in 3.7% of patients. The most common complication is an asymptomatic inferior vena cava penetration
and perforation. In some rare circumstances, however, therapeutic intervention may be required because of perforation of
adjacent organs. W e report a clinical case of a patient with simultaneous caval, duodenal, and aortic perforation resulting
from penetration of inferior vena cava filter hooks. A brief review of the literature discusses presenting symptoms and
treatment of such rare complications. ( J Vasc Surg 2008;48:223-5.)
Anticoagulant therapy is the treatment of choice of
deep venous thrombosis (DVT), and secondary prevention
of pulmonary embolism is achieved in up to 95% of pa-
tients.1-3 However, when warfarin and heparin are contra-
indicated or ineffective, especially in those patients who are
at high risk for major bleeding, the placement of an inferior
vena cava (IVC) filter could be appropriate.3-5 Insertion of
IVC filters may result in clinically significant complications,
such as IVC thrombosis and perforation of inferior vena
cava and adjacent organs.4,6,7
We report the unique case of multiple late complica-
tions of a retrievable ICV filter that caused a complete IVC
thrombosis and wall perforation, with penetration of the
filter’s hooks in the aorta, duodenum, and retroperitoneal
A 46-year-old woman was referred to our institution because
of diffuse swelling to her left leg. A Recovery (Bard Peripheral
Vascular, Tempe, Ariz) nitinol IVC filter had been placed in 2005
at another institution after the patient had recurrent DVT with
pulmonary embolism while taking warfarin. The patient was dis-
charged with anticoagulant therapy and did well for 2 years.
An echo color Doppler study demonstrated a complete occlu-
sion of the left iliac vein and a moderate reduction of arterial flow
to both legs (ankle-brachial index, 0.75). A thoracoabdominal
computed tomography (CT) angiography confirmed the diagnosis
of complete thrombosis of the left iliac vein extending to the
inferior vena cava. The IVC filter was completely fractured, with
multiple perforations of the IVC wall, producing a perforation of
the aortic wall with a mural thrombus (Fig 1). There were no signs
of pulmonary embolism.
The patient’s anticoagulant therapy was transitioned from
warfarin to heparin, and she underwent abdominal exploration.
The duodenum and the right colon were completely reflected, and
the IVC and aorta were exposed. The dissection of the duodenum
from the anterior surface of the IVC revealed a filter strut had
perforated the IVC wall into the duodenum (Fig 2). The strut was
removed from the duodenal lumen and trimmed flush with the
IVC, and hemostasis was obtained. The duodenal perforation was
found to be no larger than the diameter of the strut itself and was
closed by a simple suture. Further dissection of the IVC revealed two
struts had perforated the IVC wall into the retroperitoneal space.
After a careful dissection, the infrarenal aorta was clamped and
opened longitudinally, revealing a mural thrombus occupying about
one-third of the aortic lumen (Fig 3). The strut, which protruded
through the right lateral aortic wall, was trimmed flush and an aortic
thrombectomy was performed; then, the aortotomy was sutured.
A careful dissection of suprarenal IVC and a longitudinal
cavotomy confirmed the complete thrombosis of the IVC. The
extraction of the filter was technically difficult because the prongs
at the distal ends of the struts were included into the posterior wall
of IVC. A thrombectomy of the iliac vein and ICV was attempted
without restoring a satisfying caval flow, and the IVC wall was
closed by reducing its diameter to less than one-third of the
original lumen to avoid thrombus migration.
The patient’s postoperative course was uneventful, and she
was resumed on anticoagulant therapy with warfarin because of the
presence of caval thrombosis. The leg swelling gradually reduced,
and the patient was discharged on postoperative day 10. During
the 6 months after surgery, the patient remained symptom free. An
abdominal CT angiography confirmed the residual thrombosis of
the IVC, with a partial restoring of caval flow.
There is a general consensus that an IVC filter is indi-
cated for secondary prophylaxis in the setting of acute DVT
that is accompanied by an absolute contraindication to
From the Vascular Surgery and Organ Transplant Unit–Department of
Surgery, Transplantation and Advanced Technologies,aand Department
of Radiology,bUniversity Hospital of Catania.
Competition of interest: none.
Reprint requests: Massimiliano Veroux, MD, PhD, Vascular Surgery and
Organ Transplant Unit-Department of Surgery, Transplantation and
Advanced Technologies, University Hospital of Catania, Via Santa Sofia
83, 95123 Catania, Italy (e-mail: firstname.lastname@example.org).
Copyright © 2008 by The Society for Vascular Surgery.
anticoagulant therapy, such as major bleeding, need for
surgery ?2 weeks, severe and prolonged thrombocytope-
nia, or in patients with recurrent DVT disease despite
Only one randomized trial3has compared anticoagu-
lant therapy and IVC filter on the efficacy of thrombosis
rate reduction in high-risk patients, demonstrating the
initial efficacy of filters in the prevention of pulmonary
embolism, albeit without any long-term reduction in
A large variety of permanent, temporary, and retriev-
able caval filters are currently available, all of which are
roughly equivalent in efficacy.1,9Retrievable filters may be
considered as the best option for prophylactic filter inser-
tion because the risk of pulmonary embolism is for a short
time1,5,10; however, although most retrievable filters are
inserted with the intention of removal, about 50% of these
filters are not retrieved.11
insertion, device failure, and long-term complications arising
from the filter device itself.12The reported rate of complica-
ring in 3.7% of patients.1,5,9,13Delayed complications of IVC
filters may include recurrent pulmonary embolism (2% to
5.6%), IVC thrombosis (3.6% to 30%), DVT (5.9% to 32%),
and filter migration (3% to 69%).1,2,9,13
To the best of our knowledge, this is the first report of
simultaneous caval, duodenal and aortic perforation caused
by an IVC filter. The clinical evolution in our patient was
determined by the progressive penetration of IVC filter’s
hooks in the vena cava wall, with consequent perforation
and penetration in aortic wall, duodenum, and retroperito-
neal space. The patient was clinically asymptomatic, except
Fig 1. A, Computed tomography angiography of the abdomen
demonstrated the complete thrombosis of the inferior vena cava,
just above the renal veins, which were not involved by thrombosis.
The filter’s hooks perforated the inferior vena cava wall and aorta,
raphy axial view showed the perforation of duodenum by the
filter’s hook (arrow). Note the partial thrombosis of aortic lumen.
Fig 2. This intraoperative view shows that the filter strut (arrow)
has perforated the inferior vena cava (IVC) wall into the duode-
Fig 3. Intraoperative view shows the perforation of the right
lateral aortic wall by the filter strut.
JOURNAL OF VASCULAR SURGERY
224 Veroux et al
for a swelling of the left leg related to the iliac vein throm- Download full-text
Inferior vena cava penetration and wall perforation are
relatively common complications of IVC filters but are not
clinically relevant in most patients. In as many as 38% of
patients, aorta pulsation and respiratory motion may con-
tribute to caval penetration by filter hooks, which are
necessary to attach the filter to the IVC.7,14,15Inferior vena
cava penetration may be asymptomatic in most patients,15
but some symptomatic patients16may require therapeutic
intervention for duodenal perforation11,15-17and aortic
Duodenocaval fistula may exceptionally occur in pa-
tients who have undergone IVC filter placement: a recent
review of the literature16reported 37 cases, 10 of which
were associated with an IVC filter. Duodenocaval fistula is
usually a late complication, with an average of 6 years
between filter placement and the occurrence of a fistula.
Duodenal perforation is usually asymptomatic, but rarely
may present as abdominal pain.12A prompt diagnosis and
surgical intervention is mandatory to achieve a better prog-
nosis and a low mortality rate (10%).16Aortic perforation
after IVC filter placement is exceptional19and may be
associated with mural thrombus,18which may eventually
cause a peripheral arterial occlusion.
an excellent therapeutic method for the prevention of
pulmonary embolism in patients with DVT; however, they
may be rarely associated with serious complications that
may evolve in an asymptomatic fashion and may occasion-
ally be diagnosed late in the follow-up. When complica-
tions are suspected, a prompt diagnosis is mandatory to
prevent dramatic clinical consequences such as aortic em-
bolism from a luminal thrombus, massive bleeding from a
caval perforation, or a duodenocaval fistula. In this view, a
careful CT scan imaging follow-up should be performed,
even in asymptomatic patients, every 6 months. The surgi-
cal treatment is challenging, but it may guarantee the best
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Submitted Dec 3, 2007; accepted Feb 1, 2008.
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