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OBJECTIVES: Percutaneous inferior vena cava (IVC) filter placement has successfully replaced ligation or interruption procedures as the optimal interventional modality for pulmonary embolism prophylaxis. However, IVC filter deployment is not without risk and may be associated with puncture site bleeding, higher venous thrombotic or occlusion rates as well as filter migration and perforation.
METHODS: We present the successful robotic removal of a symptomatic IVC filter.
RESULTS: A 23-year old female presented with deteriorating severe right lower back and right upper quadrant pain with associated left lower extremity discomfort. She had a previous history of left lower extremity DVT five years ago. She had been prescribed oral contraceptives for two months but was otherwise well with no other prothrombotic risk factors. Venous duplex imaging confirmed left iliac vein thrombosis. She proceeded to left common iliac vein stenting for presumed May-Thurner syndrome combined with retrievable IVC filter insertion. Warfarin therapy was continued for two months. She had two failed attempts to retrieve the IVC filter the following year due to filter had migration and perforation of struts through the IVC wall. Clinically, she had mild generalised abdominal tenderness and no evidence of any lower extremity arteriovenous pathology. CT venography identified three separate filter struts that had perforated the IVC adjacent to the duodenum and lumbar vertebrae wall. Due to severe ongoing pain, the patient was scheduled for robotic removal of her IVC filter. Patient positioning was completed using a modified 30^o flank position with slight table flexion and reverse trendellenberg positioning. After creation of the pneumoperitoneum, a 12mm camera port was inserted followed by insertion of the remaining robotic ports under direct vision (5mm x 1,8mm x 3 and 12mm x 1). Key procedural steps included mobilization of the duodenum and right colon, IVC dissection using Split and Roll technique, vascular control of the IVC, creation of the cavotomy, mobilization and robotic fracture of the IVC filter struts, removal of the IVC filter followed by closure of the cavotomy. The patient made an uneventful recovery and was discharged well on post-operative day-two. She remains symptomatically well six-months later.
CONCLUSIONS: Following failed percutaneous retrieval, we suggest robotic removal of IVC foreign bodies as a safe and less morbid technique providing shorter recovery and improved patient quality of life.