Anticoagulant therapy is the mainstay of treatment for VTE [4]. The use of inferior vena cava (IVC) filters have gained acceptance for patients in whom standard anticoagulant therapy is contraindicated or ineffective [5,6]. IVC filters are designed to trap possible thromboemboli, while preserving normal blood flow in the IVC. The Mobin-Uddin umbrella filter (1967) was the first filter designed for this purpose, followed by the Kimray-Greenfield stainless steel IVC filter in 1973 [7]. Over the last decades, several IVC filters have been developed, featuring various materials, designs and delivery systems.

Two years later, the patient underwent exploratory laparotomy, total abdominal hysterectomy, salpingo-oophorectomy, and lysis of adhesions. Considering the history of pulmonary embolism and noncompliance with the oral anticoagulation therapy, the decision was made to place an IVC filter during the same admission. A Recovery filter was successfully deployed in an infrarenal position via a right femoral approach. A caval venogram after filter placement showed no extravasation of contrast and good filter alignment. Six months after filter placement, the patient was prompted to return for consultation. However, at this time, the patient was not receptive and refused filter removal.

IVC filters have been shown to be relatively safe. The most common complications after IVC filter placement are recurrent PE, thrombosis of the IVC, and local access site complications [6,12,13]. Migration of the filter is a relatively rare complication [14]. Filter fractures are extremely rare and have been reported in 1 to 2 percent of cases [15]. There is limited data published on the long-term outcomes with the Bard Recovery filter. This filter, described in our case, was commercially available until August 2005, when it was voluntarily withdrawn from the market and replaced by the Bard G2 filter [8,9]. The modified G2 filter was designed to decrease risk of perforation, migration, and fracture.

The risk of these long-term complications of indwelling filters increases with time; therefore, retrievable filters are considered beneficial to avoid possible late complications [16,17]. Despite the advantages of retrieval, only a small number of patients return for filter removal [18,19]. Grande et al. reported a less than 15 percent retrieval rate in all Recovery filters placed with the intention of future retrieval [20]. An overestimation of the number of patients who need only temporary IVC filtration combined with high rates of loss to follow-up probably contribute to this low retrieval rate. The filter in our case was placed with the intent of removal, however, due to poor patient compliance, was never retrieved.

Nicholson et al. reported a 25 percent (seven of 28) prevalence of device fragmentation and embolization in patients with the Bard Recovery filter. All the fractured fragments embolized to an end organ [21]. Another study showed filter leg fractures with migration into the right ventricle, the pulmonary artery, and the retroperitoneum in 21 percent of the patients (three of 14) [18]. A MAUDE database search performed by Desjardins et al. demonstrated 329 reported cases of significant malfunction of the Recovery filter within a 6-year period, including 69 cases of filter migration, 149 cases of filter fragmentation, and 88 cases of filter fragment migration [22]. The migrated fragments were reported to be lodged within the heart and lungs. The unique feature in our case is the fact that two of the filter arms underwent consecutive fracture and pulmonary migration. This highlights the increased risk for a subsequent filter fragment migration after the first event.