Intensive Care Med (1990) 16:457-459 Intensive Care Medicine �9 Springer-Verlag 1990

Failure of the intracaval filter of Giinther to prevent recurrence of pulmonary embolism - report of two cases

E Lofaso, A . A . Messadi , M . C . A n g l a d e a n d Y. H u e t

Intensive Care Unit and Radiology Service, Henri Mondor Hospital, Cr6teil, France

Received: 12 November 1989; accepted: 7 May 1990

Abstract. Two out of n ine patients in which inferior vena cava in te r rup t ion was performed with a Gi inther filter de- veloped a recurrent p u l m o n a r y embolism. In bo th cases, the filter had moved down and the anchor ing legs had perforated the wall of the vena cava. The source of the p u l m o n a r y embol ism was a clotted basket filter. Ant ico- agula t ion was given for two weeks in one pat ient and six mon ths in the other after inser t ion of the filter, but it had been stopped before the th rombot ic event leading to the recurrent p u l m o n a r y embolism. The format ion of the th rombi had probably been caused by the migra t ion of the filter and the subsequent perforat ion, which may have been facilitated by the cessation of the ant icoagula t ion.

Key words. P u l m o n a r y embol ism - Caval filter - Infe- rior vena cava - Gun the r filter

Infer ior vena cava in te r rup t ion (IVCI) is performed to prevent emboli produced in the lower body from reaching the lung, in cases where an t icoagula t ion is contra indicat- ed or when a recurrent p u l m o n a r y embol ism occurs de- spite effective an t icoagula t ion [1, 2]. It can be executed either by a direct surgical approach, e.g. by a l igature or a clip on the vena cava, or by t ransvenous inser t ion of a filter into the vena cava. IVCI via direct surgical ap- proach has a higher morta l i ty and morbid i ty t han via t ransvenous inser t ion of filters [1]. Transvenous place- men t of a Mob in Udd in or a Hun te r Bal loon needs a sur- gical approach to the jugu la r vein, whereas the Green- field filter can be placed t ranscutaneous ly via a 24 gauge sheath. However, venous thrombosis at the site o f the fil- ter inser t ion occurred frequently [3]. With the new Gfin- ther filter, a percutaneous inser t ion with a ]0-French catheter can be performed wi thout complicat ions at the punc ture site [4, 51.

Thrombosis and pu lmona ry embol ism have been de- scribed with both the Gtinther filter and the Greenfield filter [2]. We report on two patients with recurrence of p u l m o n a r y embol i sm after IVCI with a G~inther filter.

Case reports

Patient 1. A 67-year-old man was admitted to the Intensive Care Unit because of cardiovascular collapse occurring 5 days after a left hemicolectomy for cancer. Massive pulmonary embolism was con- firmed by pulmonary angiography (Miller index: 18/34, corresponding to a vascular obstruction of 53~ and by venography, that showed a thrombosis of the right popliteaI vein. Because of recent surgery, throm- bolytic therapy was contraindicated and heparin treatment with high dose dobutamine was given. As the haemodynamic condftion deterio- rated, a pulmonary embolectomy was performed during extracorporeal circulation.

For technical reasons, [VCI could not be performed during the same surgical procedure. As the condition of the patient improved, IVCI was performed on the first postoperative day with percutaneous insertion, via a femoral vein, of a 25 mm basket Gtinther filter. The filter was placed below the renal veins at the L 2 -L 4 level. Anticoagulation thera- py was maintained until the 14th postoperative day, when it had to be stopped because of haemorrhagic cardiac tamponade necessitating sur- gical drainage. The patient was finally discharged on the 20th postoper- ative day, with no anticoagulant therapy.

Four weeks later, the patient was readmitted because of cardiogenic shock secondary to a recurrent pulmonary embolism, which was docu- mented by angiography (Miller index: 20/34, corresponding to a vascu- lar obstruction of 58%). At this time, a venogram showed an only par- tial patency of the inferior vena cava with a large thrombus trapped in the filter and extending 8 cm above the basket (Fig. I). Furthermore, the filter had migrated downward, and the anchoring legs of the filter had perforated the wall of the vein. Thrombolytic therapy and heparin were given; during which the patient rapidly improved. Because of the inef- fectiveness of the filter, a veno-caval clip was surgically placed below the renal veins. During the surgery the perforation of the vena cava by an- choring legs was confirmed, but there had been no retroperitoneal bleeding. The patient was subsequently treated with long-term oral an- ticoagulant and has had no further recurrence of thromboembolic events,

Patient 2. A 44-year-oId man was admined to the Intensive Care Unit because of a suspected pulmonary embolism. He had a previous history of deep vein thrombosis 5 years ago. Massive pulmonary embolism was confirmed by pulmonary angiography (Miller index: 23/34 correspond- ing to a vascular obstruction of 67%), and venography showed a right femoral vein thrombosis.

When the haemodynamic condition of the patient rapidly deterio- rated with development of right heart failure (cardiac index: 2.21-min -~ "m -~, mean PAP of 36mmHg), thrombolytic therapy (urokinase 15000 iu kg -j, given intraveneously as a bolus) was started in association with heparin. The clinical condition of the patient ira-

458 E Lofaso et al.: Failure of intracaval GOuther filter

Fig. la, b. Contrast venocavogram, in the frontal (a) and lateral (b) views; to show a large thrombus extending proximally from the basket of the Gfinther filter. The anchor- ing legs of the filter are shown to have per- forated the wall of the inferior vena cava (ar- rows in a and b)

proved but on the 5th day, a new episode of PE occurred despite effec- tive anticoagulation. A 25 mm basket GOnther filter was inserted via a femoral vein and placed at the L 2 - L 4 level. The patient was dis- charged 10 days later on oral anticoagulant therapy; at that time, the pulmonary perfusion scan had returned to normal. Oral anticoagula- tion with warfarin was given for 6 months and then discontinued. Two months later, the patient was readmitted because of recurrent pulmo- nary embolism documented by pulmonary angiography. Venography showed that the Gfinther filter had moved down into the right iliac vein and that a large floating thrombus had developed extending from the basket of the filter up to the renal vein. In addition, the anchoring legs had perforated the wall of the vena cava. No thrombosis was present in the distal veins. A surgical thrombectomy was performed; the filter, which had performed the vena cava, was removed and a veno-caval clip was positioned below the renal veins. The patient was then put onto long-term oral anticoagulant therapy and has had no further thrombot- ic complications.

Discussion

These two cases o f recurrent p u l m o n a r y embo l i sm de- spite a IVCI with a basket fi l ter pose two m a j o r p rob- lems: Firstly, the eff icacy o f the GUnther fi l ter i tself and secondly the necessi ty o f an t i coagu lan t the rapy when such a device is inserted.

Recurrence o f p u l m o n a r y embo l i sm const i tutes a wel l -known compl i ca t i on o f IVCI with filters, bu t its inci- dence is usua l ly low, e.g., 2 % with the Greenf ie ld fi l ter [2]. In the repor t by GUnther [4], one out o f 15 pa t ien ts d ied f rom recurrent p u l m o n a r y embo l i sm one m o n t h af- ter inser t ion. Other au thors r epor ted excellent results wi thou t an ly recurrent p u l m o n a r y embo l i sm [5]. Howev- er, the m e a n t ime interval between fi l ter inser t ion and fol- low-up o f thei r 54 pa t ien ts was on ly 3.3 months ; more - over, the mos t f requent ind ica t ion for filter inser t ion in

thei r s tudy was prophylax is only. Hence this s tudy canno t be easi ly c o m p a r e d with those on o ther filters.

A l toge the r we have inser ted the Gt in ther fi l ter in 9 pa- t ients, this n u m b e r being l imi ted because we s topped us- ing the Gt~nther fi l ter when the two incidents which we repor ted here occurred. The ind ica t ions for filter inser- t ion were: (i) inab i l i ty to use an t i coagu la t ion because o f a s ignif icant con t r a ind ica t ion in 2 cases; (ii) recurrent p u l m o n a r y embol i despi te an t i coagu la t ion the rapy in 3 cases; (iii) compl i ca t i on o f an t i coagu la t ion which neces- s i ta ted d i scon t inua t ion o f the the rapy in 3 cases; and (iv) a surgical embo lec tomy in one case. N o o ther side effect o f the fi l ter has been detected in our study. The mos t fre- quent mechan i sm for f o r m a t i o n o f p u l m o n a r y embo l i sm despi te f i l ter inser t ion is p rox imal p r o p a g a t i o n o f a clot t r a p p e d wi thin the filter. In our pat ients , it cou ld have been a genuine t h rombus developing on the filter, e.g., be- cause o f pe r fo ra t ing lesions o f the caval walls by the an- chor ing legs. The absence o f an t i coagu la t ion at the t ime o f the t h r o m b o t i c event cou ld have been an add i t i ona l r isk fac tor as descr ibed for o ther devices.

The ques t ion as to whether an t i coagu lan t the rapy should be used dur ing the few weeks af ter inser t ion o f an IVCI fi l ter remains unset t led. Mos t au thor s r e c o m m e n d shor t - t e rm an t i coagu la t ion therapy unt i l endothe l ia l i sa- t ion o f the vein. This cou ld be d i spu ted since filters are of ten inser ted due to con t ra ind ica t ions o f an t i coagu lan t t rea tment .

A l t h o u g h it can be p laced easily, the Gi in ther fi l ter appea r s to move down frequently, thereby pe r fo ra t ing the vessel wall [5]. I nadequa t e fi l ter pos i t i on appears to in- duce t h r o m b o e m b o l i c compl ica t ions , pa r t i cu la r ly when an t i coagu lan t t r ea tmen t is cont ra ind ica ted .

E Lofaso et al.: Failure of intracaval G0nther filter 459

References

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2. Greenfield L J, Peyton R, Crute S, Barnes R (1981) Greenfield vena caval filter experience. Late results in 156 patients. Arch Surg 116:1451

3. Kantor A, Glanz S, Gordon DH, Sciafani SJA (1987) Percutaneous insertion of the Kimray-Greenfield filter: Incidence of the femoral thrombosis. AJR 149:1065

4. Gtinther RW, Schild H, Hollman JP, Worwerk D (1987) First clin-

cical results with a new caval filter. Cardiovasc Intervent Radiol 10:104

5. Fobbe F, Dietzel M, Korh R, Felsenberg D, Bender S, Hamed M, Laass C, Sorensen R (1988) Giinther vena cavat filter: results of long-terra follow up. AJR 151:1031

E Lofaso Service de R6animation M6dicale H6pital Henri Mondor 51, Av. De Lattre Tassigny F-94010 Cr6t~il, France