Inferior vena cava filter penetration following Whipple surgical procedure causing ureteral injury

摘要

We report a case of an indwelling inferior vena cava filter that penetrated the IVC wall after Whipple’s pancreatico-duodenectomy procedure performed in a patient with ampullary carcinoma, resulting in right ureteral injury and obstruction with subsequent hydroureter and hydronephrosis. This was incidentally discovered on a computed tomography scan performed as routine follow up to evaluate the results of the surgery. We retrieved the inferior vena cava filter and placed a nephrostomy catheter to relieve the ureteral obstruction. Our case highlights the importance of careful inferior vena cava manipulation during abdominal surgery in the presence of an inferior vena cava filter, and the option of temporary removal of the filter to be placed again after surgery in order to avoid this complication, unless protection is required against clot migration during the surgical procedure. Keywords: IVC filter, Ureteral injury, Hydroureter, Hydronephrosis, penetration, Whipple procedureCASE REPORTAn 80-year old male with epigastric pain and jaundice, initially thought to be due to pancreatitis (Fig 1), but was found to have a fungating pancreatic mass on Endoscopic Retrograde Cholangiopancreatography (ERCP). A common bile duct stent was placed at an outside hospital to relieve the biliary obstruction. The patient was transferred to our hospital for evaluation and staging of his pancreatic cancer and possible surgical resection. During the course of his hospital stay, he developed lower extremity swelling which was investigated using ultrasound. A non-occlusive thrombus was found in the right common femoral vein. The clinical team requested an inferior vena cava (IVC) filter placement to prevent pulmonary embolism (PE), since a planned Whipple procedure constituted a contraindication to anticoagulation. An IVC filter (Gunther Tulip; Cook, Bloomington, Indiana) was deployed after initial IVC venogram to measure IVC diameters and confirm normal flow through IVC and renal veins. The filter was placed infrarenally at the level of renal veins influx opposite L1 through a right femoral approach without complication (Fig 2). Open in a separate windowFigure 1 An 80-year-old male patient with a history of periampullary pancreatic adenocarcinoma who underwent Whipple’s pancreatico-duodenectomy procedure resulting in IVC filter penetration and chronic ureteral injury. (a) Axial CT image of the abdomen showing marked dilatation of intrahepatic biliary radicals associated with dilated pancreatic duct. (b) A mixed density pancreatic head mass lesion is noted without infiltration of the IVC. Technique: 120kV. 282mAs, 5 mm slice thickness, Intravenous contrast: 120 mL of contrast medium.