A 52 year-old male with a history of multiple myeloma undergoing treatment, hepatitis C cirrhosis, tricuspid valve endocarditis, deep vein thrombosis with a pulmonary embolism, and previous placement of a Greenfield inferior vena cava (IVC) filter presented to the emergency room with weakness, dyspnea on exertion, and a possible syncopal episode. The patient admitted to having an episode of nausea and vomiting of dark red blood and clots following a fall earlier that day. He denied any melena or bright red blood per rectum. He was currently on coumadin, but denied any NSAID or antiplatelet use.
His laboratory studies on admission revealed a stable hemoglobin of 12.9 and a subtherapeutic international normalized ratio (INR) of 1.5, despite being on coumadin. His hemoglobin dropped slightly to 10.2 the following day and his INR rose to 1.9, but no more active signs of bleeding were observed. He was asymptomatic and without any abdominal pain or other gastrointestinal complaints.
An esophagogastroduodenoscopy was performed and showed a metallic foreign body piercing through the duodenal wall with some surrounding ulceration, erythema, and edema.(Figure 1A/B) The object traversed the duodenal lumen to the opposite side of the duodenum. No active bleeding was noted at the time of the procedure and there was no fresh or old blood in the stomach or small bowel visualized.
A CAT scan angiogram was performed and illustrated that the foreign body identified endoscopically was indeed a prong of his Greenfield filter, originating from his inferior vena cava, penetrating through his duodenum.(Figure 2) There was also evidence of inflammation in the second portion of the duodenum, but no extravasation of contrast from the vessels was seen.
An evaluation was conducted by vascular surgery and the details and risks of a surgical repair were discussed. The patient did not experience any further bleeding and remained stable. It was determined to hold off on surgery at this time and consider an elective repair of the defect. He was placed on a proton pump inhibitor to aid with the healing of his duodenal ulcerations and his Coumadin was held.
Complications from IVC filter migration has been observed in the past, with injury and penetration of the surrounding structures. The frequency of migration has been quoted as high as 5%, however, clinical consequences occur in only 0.3-0.4% of cases. Ventricular arrhythmias have occurred due to invasion of an IVC filter into the heart. Small bowel injury and perforation has been reported before, mainly presenting as nonspecific and persistent abdominal pain. Surgical repair is invasive and entails an exploratory laparotomy with small bowel repair and trimming of the strut of the IVC filter flush with the vessel wall or an extensive vascular repair.