Lumbar Artery Laceration with Retroperitoneal Hematoma After Placement of a G-2 Inferior Vena Cava Filter

Inferior vena cava (IVC) filters have been shown to be effective in reducing pulmonary embolism in certain highrisk individuals with deep venous thrombosis (DVT) [1]. While anticoagulation therapy remains the standard of care, vena caval filter placement is an alternative management in selected patients [1]. Although penetration of the wall of the IVC following insertion of an IVC filter is a well-recognized event, serious symptoms are rare. A 75-year-old female with recurrent pulmonary embolism from lower extremity DVT despite adequate anticoagulation (prothrombin time [PT], 31 s; International Normalized Ratio [INR], –3.0) underwent IVC filter placement. Her medical history included hypertension, diabetes mellitus type 2, hyperlipidemia, and DVT. She was discharged from the hospital 4 days later on warfarin, 3 mg p.o daily, with PT/ INR in the therapeutic range. She reported to the emergency room 10 days after discharge from the hospital, complaining of colicky abdominal pain associated with nausea and vomiting without radiation. A contrast-enhanced CT examination of the abdomen showed a large acute retroperitoneal hematoma on the right, compressing and displacing the IVC anteriorly. Two contrast-filled areas within the hematoma were suggestive of pseudoaneuryms (Figs. 1A and B). The patient was admitted on the floor; anticoagulant was discontinued and she was monitored with serial hemoglobin level and telemetry. On day 1 of admission her blood pressure and pulse rate were 155/80 mm Hg and 75/min, respectively. On the second day of admission her hemoglobin dropped rapidly from 10.0 to 6.9 g/dl. Blood pressure and pulse rate measured 100/45 mm Hg and 90/min, respectively. Coagulation profile and platelet counts were normal. Blood transfusion was offered to her several times but was refused. In view of evidence of continued blood loss, deterioration in clinical condition, and CT findings of pseudoaneuryms adjacent to a lumbar artery, a consult was sent to interventional radiology for possible embolization. A frontal abdominal aortogram was done and confirmed the two pseudoaneuryms from the fourth right lumbar artery about 3 cm from its origin. Close observation showed two hooks of the filter contiguous to the pseudoaneurysms (Figs. 2A and B). Selective catheterization of this artery was done using a 5-Fr Sos Omni angiographic catheter (Angiodynamics Inc., Queensbury, NY, USA). A Renegade microcatheter (Boston Scientific Inc., Natick, MA, USA) was coaxially placed distal to the lacerated areas of the artery. Embolization of the artery was performed using 3-mm fibered stainless-steel coils (Cook Medical Inc., Bloomington, IN, USA) across the lacerations. Follow-up angiogram showed successful embolization, with nonvisualization of the pseudoaneurysms (Fig. 3). Over the next 3 days the vital signs and hemoglobin remained stable (7.2 g/dl). Follow-up contrast-enhanced CT examination of the abdomen 4 days after embolization showed no active bleeding, with a decrease in the size of the hematoma. The patient was discharged to a nursing home 6 days following endovascular embolization. Anticoagulant therapy was stopped considering her risk of bleeding. Use of percutaneous insertion of a vena cava filter has grown at a steady rate over the last 3 decades due to its reduced cost, availability, and ease of placement. IVC filter placement is an endovascular procedure commonly performed to reduce the incidence of pulmonary embolism, but with its share of complications. The major complications A. O. Amole M. K. Kathuria (&) O. S. Ozkan A. S. Gill E. O. Ozkan Section of Vascular and Interventional Radiology, Department of Radiology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA e-mail: mkkathur@utmb.edu