title: Technical error during deployment leads to vena cava filter migration and massive pulmonary embolism.
abstract: The Günther Tulip vena cava filter is a safe, effective, well-established device for pulmonary embolism prophylaxis. We report a patient in whom there was migration of the filter to the right atrium, 2 weeks after insertion, caused by a technical error during deployment. An attempt to retrieve the filter percutaneously failed, necessitating removal at open-heart surgery. The potential causes of migration are described and the lessons learned from this unusual case are outlined.
authors.affiliation: Interventional Radiology Department, Guy's and St. Thomas' Hospital, Lambeth Palace Road, London SE1 7EH, UK. fotiadis.nicholas@gmail.com
authors.forename: Nikolas I
authors.initials: NI
authors.lastname: Fotiadis
authors.forename: Tarun
authors.initials: T
authors.lastname: Sabharwal
authors.forename: Renato
authors.initials: R
authors.lastname: Dourado
authors.forename: Shabbo
authors.initials: S
authors.lastname: Fikrat
authors.forename: Andreas
authors.initials: A
authors.lastname: Adam
mesh_terms: D020878:Device Removal; D005548:Foreign-Body Migration / Q000150:complications* / Q000000981:diagnostic imaging / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D010690:Phlebography; D011655:Pulmonary Embolism / Q000209:etiology* / Q000517:prevention & control; D013902:Radiography, Thoracic; D014057:Tomography, X-Ray Computed; D016306:Vena Cava Filters / Q000009:adverse effects*