Your thoughts on this case?

[Austin1983]

I have an upcoming case presentation on the following case: Pulmonary Angiogram w/ FB removal. 27F, 63 kg, ASA 2, NPO >10hrs, NKDA. PMH includes DVT s/p factor V Leiden and AT III deficiency. Otherwise perfectly healthy. Pertinent PSH is permanent IVC filter placement 10 y/a. Pre-Op dx was PE due to fragmentation of the IVC filter. Chem 7 and H/H are WNL; PT is 18.2, PTT is 33.6, INR 1.5, D-Dimer is 0.21.

As an anesthesia provider, what are your primary concerns--i.e., among all the possible adverse event scenarios, which concern you the most, and what intervention would each require? Bear in mind the procedure is being performed in a quasi-remote location--an IR room outside of the main OR suite--though the facility is a modern level I trauma center with myriad resources/pharmaceuticals available.

I am not asking in order to Bogart your ideas...my presentation is already finished! I am simply interested to hear other points of view

---

Members don't see this ad.

 

[Planktonmd]

Fragmentation of the IVC filter sounds like trouble to me and the presence of a sharp piece of metal in the pulmonary circulation that someone is going to try to fish out with some sort of wire is also very concerning.
Dissection or rupture of the pulmonary artery is the first thing you want to be concerned about and preparing for.
You should have a big central line and the ability to do massive fluid resuscitation, you also need to be able to go on bypass quickly if needed.
The IR radiology room might not be ideal.

 

[CVRN]

I had a patient almost exactly like this as an ICU nurse: factor V Leiden, 27 y/o F, h/o DVT and PE. Had an IVC filter spoke fragment and pierce the RV --> pericardial effusion --> surgery, etc. She did fine and is probably very wealthy by now. I wonder if it is the same faulty IVC filter as your patient given the similar ages and hx. Anyways, I thought it was an interesting coincidence. Carry on.

 

[Idiopathic]

im not sure why the preop diagnosis is PE related to filter fracture (very rare) as opposed to just simple PE (still almost 5% risk even with filter). if they see metal on the CTA then that makes more sense, but otherwise.

I think broken filter probably necessitates being able to go on CPB so lines in perfusion ready CT surgery on standby. Otherwise i think a clot retrieval or TPA lysis could be done as you would normally