Spondylodiscitis and psoas abscess as a delayed

Spondylodiscitis and psoas abscess as a delayed complication of inferior vena cava filter strut failure R Ramnarine, M Daneshi, GT Yusuf, H Slim, D Huang

No financial disclosures

Clinical History: 68 Year Old Female 2011  Long history of atrial fibrillation.

 Suffered a pulmonary embolus followed by pulseless electrical activity arrest.

 IVC filter inserted.  Converted to oral anticoagulation; subsequent attempts to retrieve the filter failed. Device left in-situ.

Sept 2014  Presented with 1 week history of confusion and backache.

 On examination, fever, right flank pain, abnormal liver function tests.

 Admitted with presumed biliary sepsis; unresponsive to treatment.

 Patient underwent CT imaging to investigate cause of sepsis.

CT Imaging  Arrow 1: Right iliopsoas abscess.

 Arrow 2: L3/4 infective discitis. 3

 Arrow 3: IVC filter strut fracture with perforation through IVC.

2

1

Fig 1: Coronal CT post contrast

CT Imaging

Fig 2: Coronal CT post contraststrut perforation of L3/4 disc space

Fig 3: Volume rendered CT image demonstrating position of filter and perforated strut

Management  Multidisciplinary discussion  Interventional Radiology  Vascular Surgery  Neurosurgery

 Deemed too high risk for surgical management.

 Endovascular retrieval of filter body unlikely to be successful and high risk for IVC rupture. Strut not retrievable.

 Patient managed with percutaneous (USS guided) drainage of the psoas abscess and intravenous antibiotics.

Fig 4: Axial T1 post contrast MR image demonstrating resolution of psoas abscess but persistent endplate changes and canal stenosis

Discussion (1)  IVC filter placement advocated for prophylaxis in patients with high risk of thromboembolic disease.

 Complications related to IVC filter insertion1.  Procedural related (venous access site)  Delayed related; migration, filter fracture, IVC penetration.  Retrieval related.

 IVC Penetration definition: Society of Interventional Radiology  Vein wall penetration by filter strut or anchor device with transmural incorporation

Discussion (2)  Asymptomatic IVC penetration occurs in 4 to 38% of patients2.  Symptomatic penetration; variation in reported rate 0.4%2 but upto 15%3 in other series.

 Studies suggest fewer than 20% of filters are retrieved3,4.  Example reported complications:  Pancreatitis secondary to IVC penetration by filter5.  Aortic, ureteral, duodenal penetration6,7,8.  Aortic pseudoaneurysm9.  Lumbar artery pseudoaneurysm/laceration10,11.

Conclusion  IVC filter placement and subsequent IVC penetration can lead to serious complications.

 Complications can be difficult to manage and require multidisciplinary input.

 The use of temporary filters and timely retrieval is universally advocated to reduce the risk of IVC penetration.

 There are some groups advocating serial CT follow-up of patients with filters in-situ particularly if longterm or known asymptomatic penetration.

References 1.

Van Ha TG. Complications of Inferior Vena Caval Filters. Semin Intervent Radiol 2006; 23: 150-155.

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Streiff MB. Vena caval filters: a comprehensive review. Blood 2000; 95: 3669-77.

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Sangwaiya MJ et al. Safety and effectiveness of the Celect inferior vena cava filter: preliminary results. JVIR 2009; 20(9): 1188-1192.

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Charles HW et al. G2 inferior vena cava filter: retrievability and safety. J Vasc Inter Radiol 2009; 20(8): 1046-51.

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Ford ME, Lippert JA, McGraw JK. Symptomatic filter penetration presenting as pancreatitis. J Vasc Inter Radiol 2010; 21(4): 574-6

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Kinney TB. Update on inferior vena cava filters. J Vasc Inter Radiol 2003; 14(4):425-40.

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Veroux M et al. Late complication from a retrievable inferior vena cava filter with associated caval, arotic and duodenal perforation: a case report. J Vasc Surg 2008; 48(1): 223-5.

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Haga et al. Penetration of an inferior vena cava filter in the aorta. Ann Vasc Dis 2014; 7(4): 413-416.

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Putterman D et al. Aortic pseudoaneurysm after penetration by a Simon nitinol inferior vena cava filter. J Vasc Inter Radiol 2005; 16: 535-538.

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Tsekouras N, Whalen RC, Comerota AJ. Lumbar artery pseudoaneurysm in a patient with inferior vena cava filter and history of strenous physical exercise. J Vasc Surg 2015; 61(3): 796-9.

11.

Amole AO et al. Lumbar artery laceration with retroperitoneal haematoma after placement of a G2 inferior vena cava filter. Cardiovasc Intervent Radiol 2008; 31(6): 1257-9.