IVC filter removal and thrombectomy in a 76-year-old woman with extensive IVC thrombosis resulted in paradoxical submassive pulmonary embolism despite therapeutic anticoagulation.
Case Report (n=1)
This case highlights the risk of paradoxical pulmonary embolism from thrombus migration following IVC filter manipulation and thrombectomy, even while on therapeutic anticoagulation.
Abstract Introduction Venous thromboembolism (VTE) remains a major cause of morbidity and mortality, particularly in older adults with multiple comorbidities. Inferior vena cava (IVC) filters are used in patients with contraindications to anticoagulation or recurrent VTE despite adequate therapy. Although designed to prevent pulmonary embolism (PE), IVC filters may paradoxically serve as a nidus for thrombosis or embolic complications if not retrieved in a timely fashion. Managing such patients becomes especially challenging when balancing thrombotic and bleeding risks, particularly in those with a prior intracranial hemorrhage. Case Description A 76-year-old woman with a history of breast cancer on anastrozole, subdural hematoma post-burr hole evacuation (2023), and recurrent Deep vein thrombosis (DVT) with prior IVC filter placement (off anticoagulation due to her intracranial bleed) presented with three days of progressive exertional dyspnea. A nuclear stress test showed a lateral wall perfusion defect with preserved ejection fraction (60%). Initial CT Angiogram (CTA) of the chest was negative for PE. Bilateral lower extremity Doppler studies were negative for DVT. The following day, she developed fever, tachycardia, and hypotension, prompting empiric IV antibiotics. CT Chest, Abdomen and Pelvis (CT CAP) imaging revealed extensive thrombosis below and within the IVC filter extending into both iliac veins. After neurosurgical clearance, IV heparin was initiated, and she underwent IVC filter removal with bilateral iliofemoral and femoral-popliteal thrombectomy. Despite being continued on a therapeutic heparin infusion post-thrombectomy, she developed new lower-extremity mottling, increasing oxygen requirements. Repeat CT CAP revealed bilateral submassive PE with right-heart strain from thrombus migration. Emergent bilateral pulmonary artery thrombectomy successfully removed an extensive clot burden, and she remained hemodynamically stable thereafter. Follow-up duplex ultrasound and CT venography demonstrated residual thrombus within the left femoral and popliteal veins, extending into both internal iliac veins. Given her stable clinical status, no further surgical intervention was pursued, and therapeutic anticoagulation was maintained. A comprehensive evaluation of inherited and acquired coagulopathies was unremarkable, and there was no family history suggestive of clotting disorders. Conclusion This case highlights the complex interplay of Virchow’s triad—venous stasis from filter obstruction, endothelial injury from thrombectomy and filter manipulation, and underlying hypercoagulability driven by recurrent VTE. The paradoxical PE despite therapeutic anticoagulation illustrates the potential risk of thrombus migration following IVC filter manipulation. Vigilant multidisciplinary coordination among hematology, neurosurgery, and interventional radiology is essential both before and after filter intervention, along with close post-procedural monitoring and individualized anticoagulation strategies to mitigate recurrence in high-risk patients. This abstract is funded by: None
Barua et al. (Fri,) conducted a case report in Venous thromboembolism and IVC filter thrombosis (n=1). IVC filter removal and thrombectomy was evaluated. IVC filter removal and thrombectomy in a 76-year-old woman with extensive IVC thrombosis resulted in paradoxical submassive pulmonary embolism despite therapeutic anticoagulation.