A 53-year-old woman comes to the emergency department with a 1-day history of hematemesis and hypotension. She was hospitalized for unprovoked right femoral vein thrombosis and pulmonary embolism 1 month ago and has been taking warfarin since. In the emergency department, the patient is resuscitated with intravenous fluids and fresh frozen plasma. Warfarin is discontinued and she is started on intravenous pantoprazole. Upper gastrointestinal endoscopy shows several deep gastric ulcers. Later during the hospital course, the option of inferior vena cava (IVC) filter placement is discussed with the patient. Which of the following complications would this patient be at highest long-term risk for developing following IVC filter placement?

Question

A 53-year-old woman comes to the emergency department with a 1-day history of hematemesis and hypotension.  She was hospitalized for unprovoked right femoral vein thrombosis and pulmonary embolism 1 month ago and has been taking warfarin since.  In the emergency department, the patient is resuscitated with intravenous fluids and fresh frozen plasma.  Warfarin is discontinued and she is started on intravenous pantoprazole.  Upper gastrointestinal endoscopy shows several deep gastric ulcers.  Later during the hospital course, the option of inferior vena cava (IVC) filter placement is discussed with the patient.  Which of the following complications would this patient be at highest long-term risk for developing following IVC filter placement?

Quizplus · Accepted Answer

Explanation: Inferior vena cava (IVC) filters are an option for patients with acute deep venous thrombosis (DVT) who have contraindications to anticoagulation (eg, recent surgery, hemorrhagic stroke, bleeding diathesis, active bleeding). IVC filters can be permanent or retrievable and are usually placed via a transvenous approach. They inhibit progression of lower extremity clots through the IVC toward the lungs. Acute complications of IVC filter placement include guidewire entrapment within the filter and post-procedural complications (eg, acute insertion site thrombosis, hematoma, arteriovenous fistula). The main long-term complication of IVC filter placement is recurrent DVTs. The filter can prevent clot progression to a pulmonary embolism, but it does not prevent future DVTs or treat the underlying thrombotic predisposition. As a result, patients can develop both acute and recurrent thrombosis at the insertion site. IVC thrombosis can also occur due to thrombogenicity of the filter, new local thrombus formation, or trapped embolus. IVC filters do not appear to affect overall mortality significantly. (Choice A) IVC filter migration and perforation through the IVC are much less common complications than recurrent DVT. (Choice B) IVC filters are usually placed in the IVC just below the renal veins to decrease risk of venous thromboembolism from all likely venous pathways. The portal vein drains into the liver above this level and would be unlikely to be affected by an IVC filter. (Choice D) Small thrombi can extend through the IVC filter or go through collateral circulation, but most studies have shown that recurrent pulmonary thromboembolism is an uncommon complication of IVC filters. (Choice E) Retroperitoneal bleeding is most commonly due to trauma to the lower back, vascular procedures near the retroperitoneal space (eg, cardiac catheterization, aortic catheter), anticoagulation, or hemorrhage from a malignancy in the retroperitoneal organs (eg, pancreas). However, retroperitoneal bleeding is not a common complication of IVC filter placement. Educational objective: Inferior vena cava (IVC) filters are an option for patients with acute deep venous thrombosis (DVT) who have contraindications to anticoagulation. Long-term complications of IVC filter placement include recurrent DVTs and IVC thrombosis. IVC filters do not appear to affect overall mortality significantly. References: Vena caval filters: current knowledge, uncertainties and practical approaches (http://www.ncbi.nlm.nih.gov/pubmed/19550322) Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d'Embolie Pulmonaire par Interruption Cave) randomized study. (http://www.ncbi.nlm.nih.gov/pubmed/16009794)

A 53-Year-Old Woman Comes to the Emergency Department with a 1-Day