PMC4857308_01
Side by side comparison demonstrating anterior and posterior penetration of vena cava filter tips as seen on computed tomography (a, b) in axial and (c, d) sagittal planes. Filter tip seen penetrating through the cava, abutting the duodenum (white arrow; a, c) and retroperitoneal soft tissue (b, b), presenting as the likely source for the patient's pain. Patient's large body habitus evident from abdominal soft tissue.. Duo = duodenum.
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The patient continued to complain of severe, disabling abdominal pain, and 2 months later, she underwent computed tomography angiography (CTa) which demonstrated severe malpositioning of the device, with orientation at a near-transverse angle and the filter hook protruding beyond the wall of the IVC just caudal and anterior to the right renal vein (Figures 1 and 2(a)).
Intraoperative venography at time of laparoscopic-assisted filter retrieval. (a) Evident is the severe angulation with penetration of the head and feet of the inferior vena cava (IVC) filter through the caval wall, with adjacent loops of small bowel and duodenum. (b) Completion venography following laparoscopic-assisted mobilization of duodenum and bowel demonstrating no extravasation from IVC wall following balloon occlusion.
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The patient continued to complain of severe, disabling abdominal pain, and 2 months later, she underwent computed tomography angiography (CTa) which demonstrated severe malpositioning of the device, with orientation at a near-transverse angle and the filter hook protruding beyond the wall of the IVC just caudal and anterior to the right renal vein (Figures 1 and 2(a)). After a 3-month course of anticoagulation, venogram was again performed which showed no residual thrombus in the IVC (Figure 2(a)), and the patient decided on another attempt at laparoscopic IVC filter retrieval with an open approach if it could not be extracted laparoscopically. There was minimal bleeding and after 3 min of balloon inflation and completion venography demonstrated no extravasation (Figure 2(b)).
Plain fluoroscopic sagittal view of intraoperative balloon occlusion of inferior vena cava with Coda balloon, demonstrating liver retractor (black arrow), laparoscopic port, and laparoscopic instruments utilized in visceral mobilization.
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Prior to removal of the filter, a Coda balloon (Cook, Bloomington, IN, USA) had been positioned at and level of the filter, and concomitant with filter extraction was inflated to balloon tamponade any bleeding from the IVC (Figure 3).