CHRONIC RIGHT HEART-FAILURE AND A-V FISTU LA FORMATION AFTER IMPLANTATION OF AN INFERIOR VENA-CAVA FILTER

History and clinical findings: A 39-year-old woman complained of dyspn oea and increasing abdominal pressure sensation. A Greenfield filter h ad been implanted into her inferior vena cava (IVC) 4 years previously because of pulmonary embolism from a deep vein thrombosis after a hys terectomy with abscess formation. Physical examination revealed neck v ein congestion, jaundiced sclerae, a tense abdominal wall, ascites and a soft machinery murmur in the paraumbilical region. Investigations: Transaminase activities were slightly raised (GOT 38 U/l, GPT 20 U/l), but total bilirubin and direct bilirubin were markedly elevated (2.9 mg/dl and 1.1 mg/dl, respectively). There was no evidence of cholestas is or decreased liver synthesis. Ultrasound showed marked dilatation o f the IVC and hepatic veins, and echocardiography revealed right ventr icular enlargement with grade II tricuspid regurgitation. Calculated p ulmonary arterial systolic pressure averaged 50 mm HG. Colour-coded Do ppler sonography demonstrated an aortocaval shunt at the level of the filter in the IVC and penetration of a filter strut into the aortic lu men. Treatment and course: After removing the ascitic fluid by fluid a nd sodium restriction, and administration of an aldosterone antagonist and a loop diuretic, the A-V fistula was closed surgically and the fi lter removed. Three months after operation she was put on phenprocoumo n (Quick value 20-30%). At the latest outpatient examination, 6 months after the operation, she was free of symptoms. Conclusion: As filter implantation in the IVC may produce severe complications, indications for it need to be demonstrated by further studies of its efficacy.