Open Removal of Greenfield IVC Filter Penetrating the Head of the Pancreas
Cynthia J. Tsay, MPhil1, Sareh Rajaee, MD, MPH2, Charles Cha, MD3, Timur P. Sarac, MD2, Cassius I. Ochoa Chaar, MD, MS2.
1Yale School of Medicine, New Haven, CT, USA, 2Yale New Haven Hospital, Department of Vascular Surgery, New Haven, CT, USA, 3Yale New Haven Hospital, Department of Surgical Oncology, New Haven, CT, USA.
OBJECTIVES: Complications associated with inferior vena cava (IVC) filters include fracture, migration, tilt, and penetration of surrounding structures. Greenfield filters are intended to be permanent non-retrievable filters with recurved hooks designed to protect against penetration through the IVC. Pancreatic penetration is rare. We present a case of open retrieval of an IVC filter that was penetrating the head of the pancreas and resulting in chronic abdominal pain.
METHODS: A 34-year-old female with a history of deep vein thrombosis, pulmonary embolism and suspected thrombophilia who had undergone a Greenfield IVC filter placement 13 years prior presented with chronic epigastric abdominal pain. CT showed erosion of the IVC filter into the duodenum and pancreas. An esophagogastroduodenoscopy revealed normal anatomy and no endoscopic evidence of perforation into the duodenum.
RESULTS: The patient was taken to the OR for open removal of the IVC filter and exploration. Two hooked struts were incorporated in the pancreatic parenchyma and could not be removed with firm traction. In order to avoid injury to the pancreas through an extensive dissection, the struts of the filter were transected close to the parenchyma and left in situ (Figure 1A). Additional struts penetrating into the spine were removed. The filter was removed and patch angioplasty was performed. The patient's post-operative course was complicated by ileus and nausea. Postoperative CT imaging demonstrated 10.4 mm and 9.1 mm struts in the pancreas (Figure 1B). Upon resumption of oral intake, serum amylase and lipase levels were found to be within normal limits. Her abdominal pain resolved eventually and she was discharged home after 13 days.
CONCLUSIONS: Open surgical removal of permanent IVC filters is an option when endovascular retrieval is not possible. Leaving segments of IVC filter struts in situ to avoid disruption of the pancreas seems to be a safe option in the short term with no evidence of postoperative pancreatic leak or pancreatitis.
Figure 1: A) Intraoperative photo demonstrating filter strut penetrating through the IVC and in the pancreas (arrow) B) Postoperative CT without contrast showing two struts in the pancreas (arrows).
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