Recurrent pulmonary embolism despite the use of a greenfield filter

A 71-year-old man had multiple episodes of sudden substernal chest pressure, shortness of breath, and a history of pulmonary embolism (PE) that was treated with a Greenfield inferior vena cava (IVC) filter 6 months earlier. A ventilation-perfusion scan indicated a high probability of PE. Doppler ultrasound and venography excluded neck and upper extremity venous system thrombi. A subsequent lower extremity venogram showed a thrombus in the right iliac vein and a small vessel arising caudal to the IVC filter anastomosed with the left renal vein (LRV). The diagnosis was recurrent PE caused by thrombus migration through a circumaortic LRV bypassing a normally positioned filter.