Description of Event or Problem · 1
PATIENT WITH HISTORY OF CHRONIC DEEP VEIN THROMBOSIS/PULMONARY EMBOLUS (DVT/PE) WITH A PRE-EXISTING BARD G2X RETRIEVAL-OPTIONAL FILTER, PLACED APPROXIMATELY ONE YEAR AGO FOR PE PRESENTED TO THE ED APPROXIMATELY TWO MONTHS AGO WITH CHEST PAIN. CARDIAC CATHETERIZATION FINDINGS SHOWED NORMAL CORONARY ARTERIES AND AN INCIDENTAL FINDING OF A FRACTURED MIGRATED LIMB OF THE FILTER IN THE RIGHT VENTRICLE. THE FRACTURED MIGRATED LIMB OF THE FILTER IN THE RIGHT VENTRICLE WAS RETRIEVED IN INTERVENTIONAL RADIOLOGY, BUT ATTEMPTS FAILED AT FILTER RETRIEVAL AT THAT TIME. CHEST PAIN RESOLVED AND THE PATIENT WAS SCHEDULED FOR RE-ATTEMPT FOR RETRIEVAL, BUT FOLLOW-UP WAS NOT COMPLETED.PATIENT PRESENTED TO THE ED AGAIN ALMOST TWO WEEKS AGO WITH SHORTNESS OF BREATH (SOB) AND A MARKEDLY TILTED. DIAGNOSIS WAS A LARGE ACUTE NONOCCLUSIVE PE IN THE LEFT MAIN PULMONARY ARTERY AND SMALLER ACUTE RIGHT MAIN PULMONARY ARTERY THROMBUS AT THE BIFURCATION WITH OCCLUSIVE EXTENSION INTO THE RIGHT MIDDLE LOBE SEGMENTAL ARTERY. ADDITIONAL ACUTE NONOCCLUSIVE THROMBI WERE SEEN IN THE INTERLOBAR ARTERY AND RIGHT LOWER LOBE SEGMENTAL BRANCHES - NEW SINCE PRIOR EXAM.A REATTEMPT AT FILTER RETRIEVAL AND PLACEMENT OF A NEW FILTER THREE DAYS LATER REVEALED A LARGE THROMBUS WITHIN THE G2X FILTER. A PORTION OF THE THROMBUS WAS SEEN EXTENDING ABOVE THE LEGS OF THE FILTER. IT WAS NOT REMOVED, BUT A NEW JUXTA-RENAL INFERIOR VENA CAVA (IVC) FILTER (CELECT) WAS PLACED. THE PLAN WAS TO THROMBECTOMIZE THE RESIDUAL IVC THROMBUS AND ANOTHER ATTEMPT TO REMOVE THE TILTED G2X FILTER VIA THE RIGHT COMMON FEMORAL VEIN ACCESS, TRELLIS PHARMACOMECHANICAL THROMBECTOMY DEVICE WAS ADVANCED INTO THE INFRA-RENAL IVC. BOTH THE PROXIMAL AND DISTAL BALLOONS IN THE JUXTA-RENAL IVC AND RIGHT COMMON ILIAC VEINS RESPECTIVELY WERE INFLATED TO ACHIEVE OCCLUSIONS AT CORRESPONDING LEVELS. A 11.5 MM OCCLUSION BALLOON WAS ADVANCED VIA LEFT COMMON FEMORAL VEIN AND INFLATED IN THE LEFT COMMON ILIAC VEIN. THIS WAS DONE TO CREATE AN ENCLOSED SPACE IN THE INFRA-RENAL IVC BETWEEN THE BALLOONS.SELECTIVE PHARMACOMECHANICAL LYSIS OF THE INFRA-RENAL IVC WAS PERFORMED USING THE TRELLIS DEVICE AND 10 MG OF ALTEPLASE VIA THE DEVICE. AT THE END, ENCLOSED SPACE WITHIN THE INFRA-RENAL IVC WAS ASPIRATED ALONG WITH MOST OF THE ADMINISTERED ALTEPLASE AND SMALL AMOUNTS OF CLOTS WERE REMOVED. AT THIS POINT, DECISION WAS MADE TO REMOVE THE G2X FILTER AS THIS FILTER IS LIKELY TO PREDISPOSE FUTURE IVC THROMBOSIS. AFTER SEVERAL ATTEMPTS, USING SNARE RETRIEVAL SYSTEM AND ENDOBRONCHIAL BIOPSY FORCEPS, ALL VIA RIGHT INTERNAL JUGULAR VEIN (IJV) ACCESS, THE G2X FILTER WAS REMOVED INTACT, ALBEIT WITH ONE SHORT LEG MISSING (THE ONE THAT HAD FRACTURED AND DISLODGED INTO THE RIGHT VENTRICLE AND RETRIEVED TWO MONTHS AGO.DURING THE ATTEMPTS TO REMOVE THE G2X FILTER, THE CELECT FILTER IN THE SUPRA-RENAL IVC HAD TILTED. THEN AFTER FEW ATTEMPTS, CELECT FILTER WAS REMOVED USING A SNARE. A NEW CELECT FILTER WAS THEN DEPLOYED IN THE INFRA-RENAL IVC JUST ABOVE THE RESIDUAL SMALL VOLUME ADHERENT CLOT.COMPLETION CAVOGRAM WAS OBTAINED IN MULTIPLE PROJECTIONS INCLUDING AN INJECTION VIA A PIGTAIL CATHETER AT THE SITE OF THE PRIOR G2X FILTER. NO EXTRAVASATION WAS SEEN. THE SHEATHS WERE REMOVED AND HEMOSTASIS WAS SECURED WITH MANUAL COMPRESSION. FOLLOWING SHEATH REMOVAL, THE PATIENT DEVELOPED SEVERE SOB AND HYPOTENSION AND WENT INTO A CARDIAC ARREST. ATTEMPTS TO RESUSCITATE FAILED AND THE PATIENT DIED.