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Table 1. Table 1. Summary of reported cases of IVC filter retrieval-related cardiac complications
This report presents the clinical details and management of a 58-year-old Caucasian male with pericardial effusion and cardiac tamponade following outpatient inferior vena cava (IVC) filter removal. The patient was unresponsive and experienced cardiac arrest minutes after the procedure, requiring cardiopulmonary resuscitation. After return of spontaneous circulation he displayed somnolence, confusion and chest discomfort. Investigations revealed a large pericardial effusion, and an echocardiography confirmed cardiac tamponade. Prompt intervention involved pericardiocentesis, resulting in haemodynamic stabilisation and reduction in effusion size. The patient responded favourably with treatment. Differential diagnoses were considered and treatment options were discussed, highlighting the importance of timely recognition and appropriate intervention in managing pericardial effusion and cardiac tamponade. This report adds to the limited literature on pericardial effusion and cardiac tamponade following a scheduled outpatient IVC filter removal, emphasising the unique clinical presentation and successful management of this rare phenomenon.
IVC filter retrieval, pericardial effusion, cardiac tamponade
Pericardial effusion is a pathological condition characterised by the abnormal accumulation of fluid within the pericardial sac enveloping the heart. If left untreated, it can progress to cardiac tamponade, an acute and potentially life-threatening condition that compromises cardiac filling due to elevated intrapericardial pressure, leading to haemodynamic instability. Timely recognition and prompt intervention are paramount in effectively managing pericardial effusion to mitigate adverse outcomes[1-5].
In this report, we present a unique and rare case of pericardial effusion with cardiac tamponade following endovascular removal of an inferior vena cava (IVC) filter. Our report underscores the critical importance of early diagnosis and emphasises the significant role of timely intervention through pericardiocentesis in successfully managing this challenging condition. By sharing our experience, our objective is to raise awareness, enhance understanding and facilitate improved management of similar cases within the medical community.
The patient is a 58-year-old male of Caucasian ethnicity with a notable medical background suggestive of a potential prothrombin gene mutation. In 2019, following an arthroscopic procedure on his left knee, he experienced bilateral pulmonary embolism accompanied by right ventricular strain. He was initiated on a prolonged course of apixaban. Additionally, in anticipation of future knee procedures, an IVC filter was surgically implanted in 2021.
The patient presented to the emergency department (ED) from outpatient interventional radiology following unresponsiveness, minutes after IVC filter removal in 2023. During the event, cardiac monitoring demonstrated the presence of pulseless electrical activity. Naloxone was administered and cardiopulmonary resuscitation (CPR) was initiated, resulting in return of spontaneous circulation after approximately 4 minutes. Upon arrival at the ED, the patient remained sluggish despite an additional dose of naloxone given by emergency medical services. He exhibited drowsiness and confusion and reported chest discomfort. A comprehensive review of systems was limited due to the patient’s critical condition.
Upon examination the patient presented with somnolence and disorientation, and responsiveness solely to voice. Diaphoresis, cool skin and evident shivering were observed. Cardiovascular, respiratory and abdominal examinations yielded unremarkable findings. The patient also experienced a bout of emesis.
Initial vital signs were stable upon presentation. Laboratory results demonstrated significantly elevated lactic acidosis, sensitive troponin levels and a negative delta.
Other laboratory findings were within normal limits.
Within 1 to 2 hours, the patient experienced a notable drop in blood pressure to the low 60s systolic and developed hypoxia, necessitating 6 L of oxygen therapy and IV fluid boluses. Repeat laboratory tests indicated worsening lactic acidosis and significant metabolic acidosis on blood gases.
A pan CT scan unveiled a moderate-sized pericardial effusion. Bedside transthoracic echocardiography (TTE) confirmed the presence of a large pericardial effusion with evidence of cardiac tamponade physiology. The arterial line demonstrated pulsus paradoxus, while telemetry exhibited electrical alternans, which was confirmed by electrocardiography. More focused examination revealed distant heart sounds.
Assessment: This case involves a 58-year-old Caucasian male with no significant cardiac history, who was on apixaban due to a previous bilateral pulmonary embolism with right ventricular strain following an orthopaedic procedure. The patient presented to the hospital after experiencing cardiac arrest and unresponsiveness following outpatient IVC filter removal by interventional radiology. Clinical and radiographic findings revealed a significant pericardial effusion with suspected cardiac tamponade. The patient was admitted to the ICU for pressor support, and the cardiology department was consulted for emergent pericardiocentesis.
The likely reason behind the complication was iatrogenic. It is believed to be secondary to IVC filter removal causing vasculature damage in the context of anticoagulation therapy.
Management: The patient received three boluses of normal saline for haemodynamic stabilisation. A bicarbonate drip was initiated to treat severe acidosis, norepinephrine bitartrate was administered and broad-spectrum antibiotics were started for suspected aspiration.
Immediate pericardiocentesis was performed, draining 250 ml of dark blood initially, followed by an additional 600 ml of serosanguinous fluid over 24 hours.
Post-procedure, the patient remained haemodynamically stable without pressor support. A subsequent TTE revealed reduced pericardial effusion and normal right ventricular function.
A repeat TTE conducted after 12 hours showed minimal pericardial effusion. Laboratory findings normalised, and the patient’s mental status gradually improved; he only experienced some chest pain, which worsened on inspiration secondary to CPR and pericardial drain.
A contrast-enhanced chest CT scan did not reveal any extracardiac haematoma and showed residual posterior fusion. The pericardial effusion remained minimal and stable. The drain was successfully removed after 2 days due to continued reduction in drain output and stable TTE findings, obviating the need for a pericardial window.
During hospitalisation, the patient experienced intermittent fever spikes. However, blood and pericardial fluid cultures were repeatedly negative. A chest X-ray showed no signs of pneumonia. Antibiotics were discontinued, and ibuprofen and colchicine were administered for pericarditis.
The patient was transferred to the general ward on a heparin infusion with continued trivial pericardial effusion seen on TTE. Subsequently, the patient transitioned to low-dose apixaban and was discharged on colchicine only, with close follow-up by the cardiology and haematology departments.
Pericardial effusion occurs when an abnormal accumulation of fluid collects within the pericardial space, which is located between the visceral and parietal layers of the pericardium surrounding the heart. This condition can arise from various aetiologies including inflammation, infection, malignancy, trauma or iatrogenic causes. As the volume of the effusion increases, it elevates the intrapericardial pressure. Cardiac tamponade arises when the pericardial effusion restricts the expansion of the cardiac chambers, compromising diastolic filling of the heart. Consequently, cardiac output and systemic perfusion are impaired, leading to clinical manifestations such as hypotension, tachycardia and altered mental status, as observed in our patient. It is crucial to consider and differentiate other potential conditions that may present with similar clinical features, including acute coronary syndromes, pulmonary embolism, aortic dissection and tension pneumothorax. In our case, the presence of pericardial effusion and subsequent cardiac tamponade was confirmed, and it was likely attributed to trauma, possibly resulting from iatrogenic injury during outpatient IVC filter removal[1-3].
The incidence of pericardial effusion and cardiac tamponade following IVC filter insertion or removal is very rare, ranging from 0.1% to 0.6% in different studies. Case reports[6-8] highlight the occurrence of cardiac tamponade as a complication of IVC filter removal, emphasising the importance of prompt recognition and intervention. Factors such as filter design and duration of implantation may contribute to the risk of complications, including cardiac tamponade[9]. These case reports, alongside a 2015 retrospective study on IVC filter complications[10], collectively underscore the importance of vigilance during the retrieval procedure. Overall, these findings emphasise the significance of promptly recognising and effectively managing cardiac tamponade associated with IVC filter retrieval to optimise patient outcomes[6-12].
There are published case reports demonstrating the migration of IVC filter fragments to the heart, leading to a wide range of clinical presentations. However, complications occurring during or after the procedure of IVC filter retrieval are scarce. To our knowledge, only four cases are reported; they are summarised in Table 1. We believe that our case is unique as it is the only reported incidence of cardiac arrest happening soon after the procedure of IVC filter retrieval[13-16].
Regardless of this, the primary goal in managing pericardial effusion and cardiac tamponade is to promptly relieve increased intrapericardial pressure and restore normal cardiac function. Immediate pericardiocentesis – the drainage of pericardial fluid – is the preferred treatment, providing rapid relief by reducing pressure and improving cardiac output. Surgical interventions such as pericardial window creation are typically reserved for recurrent or persistent effusion cases, which was not necessary for our patient[4-5].
Prognosis in pericardial effusion depends on the underlying cause, effusion size and timely intervention. Prompt recognition and treatment, particularly pericardiocentesis, can lead to favourable short-term outcomes by restoring cardiac function and preventing complications. Reversible causes such as inflammation, infection or trauma generally have better prognoses with appropriate treatment leading to resolution. However, if the effusion is due to malignancy or chronic conditions, prognosis may be influenced by disease progression[6,7].
In our case, the patient responded well to pericardiocentesis, with reduced effusion and improved clinical and radiographic findings. The short-term prognosis is favourable. Close monitoring, follow-up with cardiology and haematology specialists and consideration of long-term management, including anticoagulation therapy, are crucial for optimal long-term outcomes and prevention of recurrence.
The timely recognition and intervention in managing pericardial effusion and cardiac tamponade are crucial. A thorough understanding of the pathophysiology, accurate differentiation from similar conditions and appropriate treatments such as pericardiocentesis are key contributors to favourable outcomes. Our report is unique as it investigates the occurrence of pericardial effusion and cardiac tamponade following outpatient IVC filter removal performed by interventional radiology and leading to cardiac arrest. By presenting a comprehensive analysis of the patient’s clinical course and successful management, this report contributes valuable insights to enhance the understanding and treatment of similar cases in the future.
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Table 1. Table 1. Summary of reported cases of IVC filter retrieval-related cardiac complications