Our patient is a 23 year old Caucasian female who presented to the emergency department complaining of severe, sharp mid-chest pain that increased with inspiration. The patient stated that the pain started while she was lifting a stroller and stooping to prepare a vehicle seat for her four month old child.
On presentation, she was in obvious distress and complaining of chest pain. She denied shortness of breath or any other symptoms. She denied any prior symptoms. On examination, she was found to be tachycardic, her blood pressure was normal and review of all other systems was negative.
Her electrocardiogram showed sinus rhythm and was within normal limits. The first troponin was elevated at 0.40 and the second was 0.29. All other labs were within normal limits.
CT angiography revealed no evidence of pulmonary embolism; however, four tiny metal objects consistent with fractured struts from an IVC filter were identified in the heart, left and right pulmonary arteries, and upper abdomen.
Records obtained from another hospital revealed that a Bard Recovery IVC filter (Bard Peripheral Vascular, Tempe, Arizona) was placed in the course of treating a life-threatening multiple trauma from a motor vehicle accident eight years previously. The patient apparently was in coma for a month and was unaware of the existence of the IVC filter.
The first strut was protruding inferiorly through the free wall of the right ventricle and was associated with a small pericardial effusion (Figure 1). Two were found in the subsegmental branches of the pulmonary arteries of the left and right lungs. The fourth fragment was found outside the inferior vena cava along the duodenal sweep adjacent to the anterior-inferior margin of the uncinate process (Figure 2). A limb of the remaining structure of the IVC filter was observed to be penetrating into the adjacent abdominal aortic wall superior to the iliac bifurcation.
Initial treatment was limited to in-hospital observation with pain management. However, the pain progressed and became intolerable with excruciating left shoulder pain over the ensuing 48 hours. A repeat CT revealed further penetration of the right ventricular strut through the ventricular wall and into the diaphragm with increasing pericardial effusion. Consequently, the patient was taken to the operating room where midline sternotomy and pericardiotomy was performed. Approximately 300 cc of blood was drained from the pericardial space. An intact, 2.5 cm metal strut was found protruding from the free wall of the right ventricle and was removed (Figure 3). The small laceration was repaired with a pledgeted 4–0 proline horizontal mattress suture. No cardiopulmonary bypass was needed.
The patient tolerated the procedure well and had immediate relief of her preoperative pain. She had an uneventful recovery and was discharged 3 days postoperatively. At a 3 month follow up appointment, the patient was doing well and had no symptoms. The patient subsequently had successful endovascular removal of the main fractured IVC filter.