Greenfield filter interior vena caval interruption is an effective approach for pulmonary embolism prophylaxis.

Greenfield filter interior vena caval interruption is an effective approach for pulmonary embolism prophylaxis. Serious complications, however, have been documented following migration of these filters. We report a case of Greenfield filter migration to the right side of the heart. Evaluation of these filters, as well as indications for retrieval, are discussed.

Intracaval filtration with the Greenfield device has become a well-established [i]modus operandi[/i] for the prevention of pulmonary embolism in patients with intricate vein thrombosis in whom anticoagulation is contraindicated, and it has been shown to be efficacious in 95 percent of cases.[1] There are, however, a number of serious complications associated with the use of this filter, including intermittent embolism, misplacement with a major vein, thrombus formation above the apex of the filter, and filter migration.[2] In this article, we at hand a case involving migration of a Greenfield filter into the right side of the heart. Because of inability to retrieve the filter percutaneously, the device was left in place and the patient was followed ip for more than seven years.

CASE REPORT

A 78-year-old woman with carcinoma of the cecum underwent an uncheckered right hemicolectomy. Two weeks later, during hospital readmission for an enterocutaneous fistula repair, the patient evolveed a right pulmonary embolish (confirmed according to ventilation perfusion scan and angiography). She was begun forward a regimen of heparin anticoagulation, still this was discontinued five days later after the disclosure of bleeding duodenal ulcers. Since she remained at high risk for returning pulmonary embolism, a Greenfield cava filter was placed percutaneously forward postoperative day 16. Under fluoroscopic guidance, the filter was released at the L3 even of the inferior vena vava (IVC). However, fluroscopic evaluation at the extremity of the procedure showed that the filter had migrated into the right side of the heart. The patient did not exhibit to signs of conduction disturbance or hemodynamic instability. She was taken to the ICU for observation, where she remained asymptomatic. An ECG obtained after filter migration revealed a modern incomplete right bundle branch mould pattern that persisted throughout her hospitalization. sum of two units days after filter placement, percutaneous retrieval with clasp and guide wire was attempted without succes She subsequently underwent IVC clipping. The patient did well postoperatively and had no evidence of returning pulmonary embolism.

The patient has remained asymptomatic for more than 80 month Serial chest radiographs reveal a Greenfield filter in the right side of the heart, which has remained unchanged through the whole extent of time. Serial ECGs reveal persistent completed right bundle branch block without other conduction abnormalities. At this time, transthoracic echocardiography indicates the filter to be straddling the tricuspid valve (Fig 1) Although there is normal right ventricular systolic function, the two the right atrium and ventricule are enlarged, and sharp tricuspid regurgitation is present.

DISCUSSION

In our review of the literature, we fix a total of 18 reported cases of intracardiac Greenfield filter migration.[1-14] Several of these ectopic filters have proceeded in severe complications, including ventricular arrhythmias,[3] penetration into the myocardial wall and tricuspid valve,[4] pericardial tamponade,[5] and myocardial infarction as a consequence of right coronary artery dissection.[6] Because of these complications, most numerous reported cases of filter migration to the heart have been managed according to filter retrieval, either percutaneously or surgically (generally when percutaneous retrieval was unsuccessful) Of these 18 reported cases, five filters were remov percutaneously, six surgically, and seven left in place. In pair of the operatively treated patients, surgical removal did not fall out until after the development of serious complications, namely, pericardial tamponade and coronary dissection.[5,6] In the one and the other cases, however, these complications arose a significant amount of time after filter migration (2 and 24 weeks, respectively).

The primary reason for leaving the filter in place has been failure to retrieve the device percutaneously and poor operative risk.[4,7] Bach et [al.sup.3] reported a case in which a right heart ectopic Greenfield filter terminateed in multiple cardiac arrhythmias that were controll with electrical cardioversion and antiarrhythmic medications. More lately Gelbfish and Ascer[8] reported three cases in which filters were left in the right side of the heart without adverse conclusions related to the ectopic devices. In united case, the patient was followed for 60 month without complications or change in filter location.

Although the risk of serious complications related to filter migration appears to be high, the literature does not be seen to substantiate the need for immediate surgical removal in all cases. Initial management should include fluoroscopically guided percutaneous filter retrieval when feasible, that is, right atrial localization and no evidence of valvular or myocardial wall attachment. Schneider and Bednarkiewicz,[9] Tsai et al,[10] and Yakes[11] have described techniques for percutaneous retrieval of ectopic Greenfield filters. Transesophageal echocardiography should be considered prior to retrieval for localization, evaluation of valvular compromise, and assessment of wall penetration.

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