Removing a Misplaced or Migrated Greenfield Filter From the Right Renal Vein

Surgical Rounds®, January 2007, Volume 0, Issue 0

Nicole A. Mah, Department of Urology; Jeko M. Madjarov, Department of Vascular Surgery; Timothy S. Roush, Department of Vascular Surgery; Chris M. Teigland, Department of Urology, Carolinas Medical Center, Charlotte, NC

Nicole A. Mah, BS Department of Urology

Jeko M. Madjarov, MD

Department of Vascular Surgery

Timothy S. Roush, MD

Department of Vascular Surgery

Chris M. Teigland, MD

Department of Urology

Carolinas Medical Center

Charlotte, NC

The authors report on the surgical removal of a misplaced or migrated Greenfield inferior vena cava filter from the right renal vein of a 56-year-old woman. The procedure involved exploratory laparotomy, vena cavotomy, removal of the filter, repair of the right renal vein, and right nephropexy. No major complications ensued, and the patient was discharged from the hospital after 12 days, ambulatory and tolerating a regular diet. The authors describe the techniques they employed to manage this unusual complication.

Inferior vena cava (IVC) filters are used in the prevention of pulmonary thromboembolism. The earliest Greenfield filters were composed of stainless steel and inserted via the right jugular or femoral vein.1 In the late 1980s, the filter material was changed to titanium, which allowed the filters to be introduced through smaller, 14F polytetrafluoroethylene sheaths.2 Unacceptably high rates of migration, tilting, and vascular penetration were reported when using these initial models of the Greenfield filter. In 1991, the filter hooks were modified, and a multicenter study found that filter migration (defined as movement greater than 9 mm) of the new model occurred in only 11% of patients.3

Case report

A 56-year-old Hispanic woman came to our office complaining of hematuria and right flank pain. The patient had received a titanium Greenfield IVC filter through her right internal jugular vein in 1988 following a hypertensive stroke, cerebral aneurysm rupture, and the development of bilateral pulmonary emboli. A radiograph taken 2 months after placement showed the IVC filter above the L2 level.

In February 2005, the patient began experiencing intermittent episodes of gross hematuria. She was passing blood clots, which were accompanied by right costovertebral soreness and discomfort in the right lower quadrant. In addition to a stroke and aneurysm rupture, her medical history was significant for deep vein thrombosis, pulmonary embolism, hypertension, hypothyroidism, hyperlipidemia, and depression. Her current medications included warfarin, trandolapril, and labetalol HCl. Because the patient was having repetitive bouts of gross hematuria while receiving warfarin, we felt the filter should be removed, possibly through nephrectomy, to decrease her risk of severe hemorrhage with clot retention and perhaps even an exsanguinating bleed.

Computed tomography (CT) angiography scans taken in early May 2005 showed the Greenfield IVC filter in the L1-L2 region, lodged in the right renal vein (Figures 1 and 2). The proximal portion of the IVC filter was in the lumen of the IVC. Two of the struts protruded through the lateral IVC wall, two were in the anterior wall of the right renal vein, and two went through the posterior wall of the right renal vein into the renal hilum. The patient underwent cystoscopy to rule out other reasons for her hematuria. She then consented to surgery for extraction of the filter and possible nephrectomy.

The patient discontinued using warfarin during the 5 days prior to surgery. Her abdomen was entered through an extended right subcostal incision, and the colon and duodenum were fully mobilized. The IVC and both renal veins were carefully dissected out, allowing visualization of two filter struts, which exited through the anterior surface of the IVC at the origin of the right renal vein. These struts were clipped flush with the IVC and removed. The IVC was freed proximally and distally.

The origin of the right renal artery was encircled with a vessel loop. After heparinizing the patient, Rummel tourniquets were placed proximally and distally on the IVC, above and below the renal veins. Care was taken not to disturb the portion of the Greenfield filter still protruding into the lumen of the IVC. The left and right renal veins were encircled with vessel loops distal to the struts, and the kidney was completely mobilized.

Test occlusion of the IVC was performed before proceeding with IVC cavotomy. The right renal artery and left renal vein were controlled with Potts vessel loops. A longitudinal cavotomy was made anteriorly using a No. 11 surgical blade and Potts scissors. The superior portion of the filter was removed from within the IVC by cutting the struts with a wire cutter and leaving the struts lodged within the right renal vein. The cavotomy was then closed using running 6-0 polypropylene sutures, and blood flow was restored. Total occlusion time was 14 minutes, and the patient remained hemodynamically stable with a systolic blood pressure between 80 and 90 mm Hg.

The right kidney was allowed to completely perfuse for 6 minutes before the right renal artery and Rummel occlusion of the right renal vein were bulldog clamped at the caval junction. A longitudinal venotomy was made in the right renal vein, and the remaining posterior struts were extracted from inside the vein (Figure 3). The vein was reconstructed with running 6-0 polypropylene sutures (Figure 4). After primary repair of the right renal vein, arterial flow was restored to the kidney. Renal occlusion lasted 5 minutes. Color Doppler ultrasonography confirmed excellent blood flow through the renal vein. The mobilized right kidney was secured to the retroperitoneal fascia with a single size-0 chromic catgut suture (nephropexy). The abdomen was closed after establishing hemostasis. The patient tolerated the procedure well and was extubated in the operating room. Total operative time was 160 minutes.

Renal ultrasonography 5 days after surgery confirmed excellent flow in the renal veins bilaterally (Figure 5). CT imaging 8 days postoperatively was normal, except for finding a simple cyst in each kidney and some fluid around the infrarenal IVC (Figure 6). There was no evidence of renal vein thrombosis. The patient experienced a prolonged ileus postoperatively; she was discharged on postoperative day 12 and resumed taking warfarin.

Conclusion

Complications associated with IVC filters are rare. Even when filter migration occurs, many patients remain asymptomatic and do not require removal of the IVC filter. However, migrated filters reportedly have caused symptomatic hydronephrosis,4 duodenal perforation and severe abdominal pain,5,6 small bowel obstruction,7 abdominal aortic perforation,8 and valvular dysfunction from intracardiac migration.9 Symptomatic patients generally have been treated by surgically removing the filter10 or using percutaneous retrieval methods, such as a guide wire and snare.11,12

The patient described in this report was on anticoagulation therapy and had a risk of life-threatening hemorrhage should another episode of hematuria arise; thus, we felt it necessary to remove the filter. Percutaneous retrieval was not possible due to the entanglement of the IVC filter within the renal vasculature. We were able to remove the filter operatively without nephrectomy, and the patient experienced no complications.

It is not certain why this patient’s Greenfield filter was located at the L1-L2 level in the renal vein. The patient received a Greenfield filter during a time when percutaneous insertion using a polytetrafluoroethylene sheath was popular, and this was the likely method of insertion. As previous studies have noted, the early model of the titanium Greenfield filter had increased risk of migration, tilting, and perforation of the IVC.13-15 However, because of its unusual location, it is possible that this filter was misplaced and did not migrate. Our literature search found no other reports of migration of an intact IVC filter into the renal vein, although fracture and penetration of struts into the renal vein has been documented.8

References

Surgery

1. Greenfield LJ, McCurdy JR, Brown PP, et al. A new intracaval filter permitting continued flow and resolution of emboli. . 1973;73(4):599-606.

Arch Surg

2. Greenfield LJ, Cho KJ, Pais SO, et al. Preliminary clinical experience with the titanium Greenfield vena caval filter. . 1989;124(6):657-659.

J Vasc Surg

3. Greenfield LJ, Cho KJ, Proctor M, et al. Results of a multicenter study of the modified hook-titanium Greenfield filter. . 1991;14(3):253-257.

J Urol

4. Jackson Slappy AL, Kennedy RJ, Hakaim AG, et al. Delayed transcaval renal penetration of a Greenfield filter presenting as symptomatic hydronephrosis. . 2002;167(4):1778-1779.

Aust N Z J Surg

5. Appleberg M, Crozier JA. Duodenal penetration by a Greenfield caval filter. . 1991;61(12):957-960.

J Vasc Surg

6. Feezor RJ, Huber TS, Welborn MB 3rd, et al. Duodenal perforation with an inferior vena cava filter: an unusual cause of abdominal pain. . 2002;35(5):1010-1012.

J Vasc Surg

7. Kupferschmid JP, Dickson CS, Townsend RN, et al. Small bowel obstruction from an extruded Greenfield filter strut: an unusual late complication. . 1992;16(1):113-115.

8. Dabbagh A, Chakfe N, Kretz JG, et al. Late complication of a Greenfield filter associating caudal migration and perforation of the abdominal aorta by a ruptured strut. J Vasc Surg. 1995; 22(2):182-187.

J Vasc Surg

9. James KV, Sobolewski AP, Lohr JM, et al. Tricuspid insufficiency after intracardiac migration of a Greenfield filter: case report and review of the literature. . 1996;24(3):494-498.

J Vasc Surg

10. Taheri SA, Kulaylat MN, Johnson E, et al. A complication of the Greenfield filter: fracture and distal migration of two struts”--”a case report. . 1992;16(1):96-99.

Angiology

11. Arjomand H, Surabhi S, Wolf NM. Right ventricular foreign body: percutaneous transvenous retrieval of a Greenfield filter from the right ventricle—a case report. . 2003;54(1):109-113.

Vasc Interv Radiol

12. Bochenek KM, Aruny JE, Tal MG. Right atrial migration and percutaneous retrieval of a Gunther Tulip inferior vena cava filter. J . 2003;14(9 Pt 1):1207-1209.

Radiology

13. Teitelbaum GP, Jones DL, van Breda A, et al. Vena caval filter splaying: potential complication of use of the titanium Greenfield filter. . 1989;173(3):809-814.

J Vasc Surg

14. Greenfield LJ, Cho KJ, Tauscher JR. Evolution of hook design for fixation of the titanium Greenfield filter. . 1990;12(3):345-353.

AJR Am J Roentgenol

15. Ramchandani P, Koolpe HA, Zeit RM. Splaying of titanium Greenfield inferior vena caval filter. . 1990; 155(5): 1103-1104.