A 53 year old woman with a past history of hypertension suffered a left middle cerebral artery territory infarct as a result of paradoxical embolisation of a lower limb deep venous thrombosis likely through a PFO after a long haul international plane flight. She also suffered a pulmonary embolism at this time. She was commenced on Apixaban and had an IVC filter inserted (Günther Tulip, Cook Medical, Bloomington, Indiana, United States of America). After approximately four-and-a-half-months, the patient had her PFO closed successfully using an Amplatzer PFO Occluder (Abbott, Abbott Park, Illinois, United States of America) (Fig. 1). This was deployed via a sheath passed through the IVC filter (Fig. 2).
Eight weeks after her PFO was closed, the patient attended to have her IVC filter retrieved. Given that the retrieval hook of the IVC filter was directed superiorly, a right internal jugular vein approach was used. The IVC filter was firmly embedded in the IVC wall, which was not unexpected as the IVC filter had been in-situ for just over six months. The IVC filter was able to be detached from the IVC however as a result of the firm embedment, the legs of the filter were bent and did not completely retract into the guiding sheath. As the sheath and IVC filter were being withdrawn, a hook at the end of one of the legs of the IVC filter caught on the Amplatzer PFO Occluder and pulled it out of position. The Amplatzer PFO Occluder became lodged in the patient’s right subclavian vein (Fig. 3).
The patient required a general anaesthetic and vascular surgical intervention via a right brachial vein cut-down to retrieve the Amplatzer PFO Occluder. A trans-oesophageal echocardiogram showed a PFO but no evidence of injury to any intra-cardiac structure. Her PFO was closed successfully two days later using a second Amplatzer PFO Occluder. Whilst the patient did not suffer a stroke or any other major cardiovascular complication, she did suffer significant psychological trauma and injury and a long scar on her right arm as a result of the unplanned removal of her Amplatzer PFO Occluder.