Case Reports Excision of a Permanent Inferior Vena Cava Filter with Multiple Vena Caval Perforations Yannick Georg, 1 Theresa Khalife, 1 Faris Alomran, 1 Julien Gaudric, 1 Laurent Chiche, 1 and Fabien Koskas, 1 Paris, France Perforation of an inferior vena cava filter by one the filter device hooks is a recognized possible complication of this device. We describe a case of surgical excision of a permanent inferior vena cava filter associated with multiple perforations of surrounding structures by each of the 6 hooks of the device. Structures affected include the third lumbar vertebral body, transverse mesocolon, the infrarenal aorta, the duodenum, and the psoas muscle. A thorough understanding of the filter design and adequate preoperative imaging were vital in planning the safe surgical excision of this device. Current indications for the placement of an inferior vena cava filter (IVCF) include the presence of deep vein thrombosis in a patient with a failed treatment or patients with a contraindication to anticoagula- tion therapy. 1 The clinical scenario commonly in- cludes polytrauma, where the risk of cerebral or internal hemorrhage must be balanced against the elevated thromboembolic risk. In other cases, an IVCF can prevent additional pulmonary embolisms (PEs) in patients that had continued to experience PEs in spite of anticoagulation therapy. IVCFs have risks, including thrombosis of the inferior vena cava (IVC) or perforation of the vein and sur- rounding organs. We describe a unique case where all 6 hooks of the IVCF had perforated each of the third lumbar vertebral body, transverse mesocolon, the infrarenal aorta, the duodenum, and the psoas muscle, respectively. CASE REPORT A 74-year-old woman presented to our outpatient clinic with chronic lower back pain of increasing intensity. In 1991, at a different institution, she underwent implanta- tion of a metallic IVCF (Steel Greenfield; Boston Scientific, Watertown, MA) as a treatment for recurrent PEs despite anticoagulation with vitamin K antagonist (fluindione). This PE was diagnosed 15 days posthysterectomy for endo- metrial cancer. In 1999, she was diagnosed with gastric adenocarcinoma and was treated by total gastrectomy and associated splenectomy. There was no thromboem- bolic event of note after IVCF placement. In 2003, epigas- tric and lumbar pain raised the suspicion of tumour relapse; however, a full laboratory work-up was negative, except for IVCF migration to the level of the renal veins at L2/L3, and the presence of osteoarthritis at the L3/L4 level. Patient management included annual computed tomography (CT) imaging and conservative management. A CT scan performed in 2006 confirmed the absence of tumor recurrence; however, the IVCF was shown to have perforated the IVC, and one of its hooks was lodged into the third vertebral body, with an associated osteolytic lesion. The lumbar pain was thought to be a likely secondary effect of L3/L4 degeneration, and conservative management was advocated. The patient’s symptoms progressed, and a CT scan per- formed in 2010 (Fig. 1) revealed discrete progression of the osteolytic L3 lesion and narrow contacts between multiple IVCF hooks and the transverse mesocolon, the infrarenal aorta, the duodenum, and the psoas muscle, respectively, with no evidence of a false aneurysm or 1 Department of Vascular Surgery, Groupe Hospitalier Piti  e Salp^ etri  ere, Paris, France. Correspondence to: Fabien Koskas, Department of Vascular Surgery, Hopital Piti  e-Salp  etri  ere, 83 boulevard de l’h^ opital, 75013 Paris, France; E-mail: fabien.koskas@psl.aphp.fr Ann Vasc Surg 2013; -: 1–4 http://dx.doi.org/10.1016/j.avsg.2013.05.004 Ó 2013 Elsevier Inc. All rights reserved. Manuscript received: May 30, 2012; manuscript accepted: May 8, 2013; published online: ---. 1