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Kevin XXXX - Case Report

|Parameter |Findings |

|Date of IVC Filter Placement |XX/XX/XXXX |

|Reason for IVC Filter Placement |Prophylaxis for Gastric LapBand Surgery to prevent embolic problems.|

|Procedure Name |NA. |

|Did the pre-image the vena cava to determine size and any anomalies? |NA |

|What was the size of the vena cava? |NA |

|Was placement done with fluoroscopic guidance? |Yes. |

|Did they confirm good placement with imaging? |Yes. |

|Was placement infrarenal? |Yes |

|Was patient told it was retrievable? |Yes (Per intake sheets) |

|Implant Details: |Bard’s Recovery IVC filter |

| |Lot #: GFPDXXXX |

| |Ref #: RXXXXX |

|Device Failure and Complications | |

|Did one of the struts fracture? |No |

|Did the entire device migrate? Where? (Heart, Lungs) |Yes, the entire device migrated towards the heart (Right atrium) |

|Did the device tilt and have a strut(s) perforate the IVC? |The device was tilted during placement. The IVC fitter wires were |

| |visible as they had eroded through the right atrial wall near the |

| |inferior vena cava |

|Device Removal | |

|Was the device removed in full? Open procedure? |Yes. Open procedure (Cardiopulmonary Bypass Surgery) on 04/30/XXXX |

| | |

|Failed Removal Attempt |No |

|If Yes, is patient put on lifetime anticoagulation? |Yes |

|If Yes, is patient now stuck with it for life? |No |

MEDICAL SUMMARY

Client: Kevin XXXX

DOB: 11/21/XXXX

Brief Case Summary: Kevin XXXX, 37-year-old male with a history of pacemaker implanted, had a Bard’s Recovery IVC filter placed on 08/04/XXXX on the right femoral vein as a prophylaxis to prevent embolic problems. Due to his morbid obesity, he underwent LapBand gastric surgery on 08/17/XXXX. On 04/26/XXXX, he developed chest pain and shortness of breath and went to ER and was diagnosed with large pulmonary emboli attached to the pacemaker wire. On 04/30/XXXX, fluoroscopy imaging showed migration of the filter to the right atrium. Subsequently, an emergent pulmonary thromboembolectomy, retrieval of migrated IVC filter, cardiopulmonary bypass (Open procedure) was performed and the filter was removed.

Past Medical History: Diabetes mellitus, lower extremity venous stasis, obstructive sleep apnea gastroesophageal reflux disease, pneumonia, Shortness of breath, morbid obesity, and pulmonary embolism on Coumadin therapy.

Surgical History: Cardiac Pace maker (06/XXXX), IVC filter (XXXX), Gastric surgery in (XXXX).

Family History: Positive for hypertension, diabetes mellitus, dyslipidemia heart disease, gall bladder disease. Brother known hyper coagulopathy

Social History: Smokes 6-7 cigarettes per day, alcohol on occasion. Unmarried and works as a DJ and dances.

Allergy: Vicodin

|DATE |PROVIDER |OCCURRENCE/TREATMENT |PDF REF |

|07/07/XXXX |John Joseph, M.D. |Pre-operative Evaluation for IVC Filter placement: |423 |

| | |HPI: Patient who was asked to evaluate on behalf of Dr. Gensar for evaluation for possible preoperative temporary | |

| | |inferior vena cava filter. The patient is being evaluated for a Lap Band procedure due to his morbid obesity. | |

| | | | |

| | |Impression: | |

| | |1. Morbid obesity with multiple medical problems as result of his obesity. | |

| | |2. History of pulmonary embolism on coumadin therapy. | |

| | | | |

| | |I recommended placement of a temporary inferior vena cava filter prior to the surgical intervention. | |

|08/04/XXXX |Saint Luke’s |Operative report: |59, 431, |

| |Regional Medical |Pre & Post-operative Diagnosis: Morbid obesity, history of pulmonary embolus. |465, 448 |

| |Center |Anesthesia: Sedation/local | |

| | |Procedure performed: Placement of temporary inferior vena cava filter. Venogram, inferior vena cava. Catheter placement, | |

| |John Joseph, M.D. |inferior vena cava. | |

| | | | |

| | |Description of procedure: Using an ultrasound, an 18 gauge needle was inserted into the right common femoral vein and a | |

| | |J-wire was advanced into the inferior vena cava under direct fluoroscopic guidance. A 6 French sheath was placed in the | |

| | |inferior vena cava under direct ultrasound guidance over a wire. The inner dilator was removed, the catheter sheath was | |

| | |then brought down to the distal inferior vena cava and a venogram was performed, which documented the location of the | |

| | |renal veins and the confluence of the iliac veins. A recovery filter by Bard was advanced through the sheath into proper | |

| | |position at the L3 position and was deployed. A completion venogram demonstrated opposition of the catheter to the caval | |

| | |wall. There was a slight tilt within the inferior vena cava filter, but other than the slight tilt it was in satisfactory| |

| | |position. The sheath was removed and direct pressure was held on the right groin. There was good hemostasis. A band-aid | |

| | |was placed in the puncture site and the patient was taken to recovery. | |

| | | | |

| | |Radiology report- Infrarenal IVC filter percutaneous placement | |

| | |This procedure was performed in the hospital operating room. Therefore, to see the operative report for the results of | |

| | |any fluoroscopy or the interpretation of any imaging done in association with this procedure. | |

|08/04/XXXX | |Implant Details: |438-439 |

| | |Filter vena cava | |

| | |Description: Bard | |

| | |Ref #: Rf048f | |

| | |Lot #: GFPD4713 | |

|04/26/XXXX |Sridevi Narayan, |Echo report: |71-72 |

| |M.D. |Indications: Pericardial Effusion And Chest Pain | |

| | |Impression: Pacer wire seen in right ventricle. Appears to have large mass attached to pacer wire mostly within right | |

| | |atrium. Right ventricular systolic pressure is estimated to be 45rnmHg consistent with moderate pulmonary hypertension. | |

| | |No significant pericardial effusion. | |

|04/28/XXXX |Sridevi Narayan, |Transesophageal Echo report: |73-75 |

| |M.D. |Impression: Echogenic mobile mass large extending from Right Atrium (RA) to Right Ventricle (RV) almost obstructing the | |

| | |Tricuspid Valve (TV). Pacer in Right Heart. Small pericardial effusion noted. | |

|04/29/XXXX |Robert M Witt, |CT Abdomen and Pelvis |48-50 |

| |M.D. |Findings: There is a small pericardial effusion. The patient has a gastric Lap-Band in place. Accompanying tubing is | |

| | |noted extending out subcutaneously over the left anterior abdominal wall. IVC shows no evidence of any filter. The iliac | |

| | |and femoral vessels appear unremarkable. Small umbilical hernia with mesenteric fat is demonstrated. Degenerative changes| |

| | |are seen in the spine. | |

| | | | |

| | |Impression: | |

| | |1. There is pleural reaction in both lung bases with infiltrates, scarring or atelectasis present at the bases as well. | |

| | |2. No IVC filter is demonstrated. | |

| | |3. No definite venous thrombus is seen on this study. | |

|04/30/XXXX |Mark R Wellness, |Chest Fluoroscopy-IVC filter migration |51-52 |

| |M.D. |Impression: Inferior vena cava filter migrated to the right atrium. | |

|04/30/XXXX |Crown Health |Surgical Consultation for emergent pulmonary embolectomy and retrieval of capsularis IVC filter: |92-94, |

| |Center |HPI: The patient became acutely hemodynamically unstable and was transferred from telemetry to the coronary care unit. |250-252 |

| | | | |

| |Athan Ramona, M.D.|Impression : | |

| | |1. Migrated IVC filter into the heart. | |

| | | | |

| | |Plan: I recommend that he undergo emergent pulmonary thromboembolectomy, retrieval of migrated IVC filter, | |

| | |cardiopulmonary bypass, possible circulatory arrest, and intraoperative transesophageal Echocardiography. | |

|04/30/XXXX |Crown Health |Operative notes: |89-91, 160,|

| |Center |Procedure performed: Cardiopulmonary bypass, relief of pericardial tamponade, and evacuation of hemopericardium, removal |232 |

| | |of displaced IVC filter, right atrial thrombectomy, and intraoperative transesophageal Echocardiography. | |

| |Athan Ramona, M.D.|Anesthesia : General endotracheal | |

| | | | |

| | |Indications: The filter migrated into the right atrium and eroded the right atrial wall resulting in hemopericardium and | |

| | |pericardial tamponade. | |

| | | | |

| | |Procedure: Intraoperative Transesophageal Echocardiography showed a large, dense thrombus and echogenic wires in the | |

| | |right atrium. An incision was made from the sternal notch to the xiphoid. The sternum was opened longitudinally with a | |

| | |sternal saw. Hemostasis was obtained with electrocautery and bone wax at the sternal edges. The patient was systemically | |

| | |heparinized. The pericardium was opened longitudinally and tented anterior with Ethibond stay stitches. | |

| | | | |

| | |Approximately 800cc of dark blood was evacuated from the pericardial cavity. The heart was covered with a fibrinous | |

| | |exudate. The IVC fitter wires were visible as they had eroded through the right atrial wall near the inferior vena cava. | |

| | |The aortic cannula was inserted first followed by superior and inferior vena caval cannulas. An antegrade cardioplegic | |

| | |cannula was placed in the ascending aorta. Cardiopulmonary bypass was instituted. The aorta was crossclamped and the | |

| | |patient was given 900cc of cold cardioplegia in an antegrade fashion. There was prompt cardiac arrest/ice was placed on | |

| | |the heart for further myocardial protection. A phrenic nerve protector pad was used. The superior vena cava and inferior | |

| | |vena cava were occluded around the cannulas. A right atriotomy was performed. The inferior vena cava filter and organized| |

| | |thrombus were removed. Some more thrombus was removed from the pacemaker wire. The right atrial wall perforations were | |

| | |repaired with #5-0 Prolene stitches in a Figure-of-eight fashion. The right atrial incision was closed in 2 layers using | |

| | |#5-0 Prolene sutures. | |

|05/08/XXXX |Crown Health |Discharge Summary |237-239; |

| |Center |Discharge diagnoses | |

| | |1. Bilateral pulmonary embolism with right lower extremity deep venous thrombosis on admission | |

| | |2. IVC filter displaced: Hemopericardium: Cardiac tamponade status post removal of displaced IVC, right arteriotomy and | |

| | |right thrombectomy and relief of pericardial tamponade on 04/30/10. | |

| | |3. Hypercoagulable state with elevated homocysteine. | |

| | |4. History of second-degree block Mobitz II status post pacemaker placement in XXXX. | |

| | |Discharged: Home | |

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