Early and Late Retrieval of the ALN Removable Vena Cava Filter: Results from a Multicenter Study

The application of inferior vena cava filters in orthopaedics and current research advances

Deep vein thrombosis is a common clinical peripheral vascular disease that occurs frequently in orthopaedic patients and may lead to pulmonary embolism (PE) if the thrombus is dislodged. pulmonary embolism can be prevented by placing an inferior vena cava filter (IVCF) to intercept the dislodged thrombus. Thus, IVCFs play an important role in orthopaedics. However, the occurrence of complications after inferior vena cava filter placement, particularly recurrent thromboembolism, makes it necessary to carefully assess the risk-benefit of filter placement. There is no accepted statement as to whether IVCF should be placed in orthopaedic patients. Based on the problems currently displayed in the use of IVCFs, an ideal IVCF is proposed that does not affect the vessel wall and haemodynamics and intercepts thrombi well. The biodegradable filters that currently exist come close to the description of an ideal filter that can reduce the occurrence of various complications. Currently available biodegradable IVCFs consist of various organic polymeric materials. Biodegradable metals have shown good performance in making biodegradable IVCFs. However, among the available experimental studies on degradable filters, there are no experimental studies on filters made of degradable metals. This article reviews the use of IVCFs in orthopaedics, the current status of filters and the progress of research into biodegradable vena cava filters and suggests possible future developments based on the published literature by an electronic search of PubMed and Medline databases for articles related to IVCFs searchable by October 2022 and a manual search for citations to relevant studies.

Vena Cava Filters: Toward Optimal Strategies for Filter Retrieval and Patients' Follow-Up

Mortality rates associated with venous thromboembolism (VTE) are high. Inferior vena cava filters (IVCFs) have been frequently placed for these patients as part of their treatment, albeit the paucity of data showing their ultimate efficacy and potential risk of complications. Issues regarding long-term filter dwell time are accounted for in society guidelines. This topic has led to an FDA mandate for filter retrieved as soon as protection from pulmonary embolism is no longer needed. However, even though most are retrievable, some were inadvertently left as permanent, which carries an incremental lifetime risk to the patient. In the past decade, attempts have aimed to determine the optimal time interval during which filter needs to be removed. In addition, distinct strategies have been implemented to boost retrieval rates. This review discusses current conflicts in indications, the not uncommon complications, the rationale and need for timely retrieval, and different quality improvement strategies to fulfill this aim.

Inferior Vena Cava Filter-Induced Thrombosis: Filter Insertion Prior to Catheter-Directed Thrombolysis and Successful Double-Filter Retrieval after Prolonged Indwelling Time

Extended inferior vena cava (IVC) filter implantation time increases the risk of complications in patients. Here we present the case of a 72-year-old woman with IVC filter-induced thrombosis who underwent catheter-directed thrombolysis with prophylactic IVC filter placement. Two IVC filters were successfully retrieved 70 and 1858 days post placement. The decision to insert an IVC filter should be carefully considered with appropriate indications and all filters should be removed after the risk of deep vein thrombosis has resolved.

Incomplete opening of an ALN-type inferior vena cava filter due to entanglement of the filter legs resulting in filter migration and inferior vena cava perforation

Incomplete filter opening, causing filter migration and inferior vena cava (IVC) perforation, have often been observed with the Greenfield-type IVC filter, but reports of incomplete opening of the ALN-type IVC filter are extremely rare. We present herein the case of incomplete opening of an ALN-type IVC filter due to entanglement of the filter legs, which caused filter migration, IVC wall perforation, and penetration into the kidney and iliopsoas muscle. Successful percutaneous retrieval was performed without complications. Our experience provides guidance for similar situations in the future, including the need to check for complete filter opening.

Spanish multicenter real - life registry of retrievable vena cava filters (REFiVeC)

BACKGROUND

The treatment of venous thromboembolic disease the treatment of choice is systemic anticoagulation. However, the interruption of the inferior vena cava with filters has been recommended when anticoagulation fails or there is a contraindication. Due to the rising inferior vena cava filter (IVCF) complications, physicians are encouraged to retrieve them when there is no longer recommended. In daily practice, it may be a difficult close follow-up of these patients. In this study, the primary objective was to evaluate the IVCF retrieval rate of all implanted filters in a Spanish registry. Secondary objectives were to analyze the causes of failed retrieval, procedure-related complications, and outcomes at a 12-month follow-up.

RESULTS

Three hundred fifty-six vena cava filters were implanted in 355 patients. The types of filter were: Gunther Tulip (Cook Medical) 160 (44.9%), Optease (Cordis) 77 (21.6%), Celect (Cook Medical) 49 (13, 7%), Aegisy (Lifetech Scientific) 33 (9.2%), Option ELITE (Argon Medical devices) 16 (4.4%), Denali filter (BD Bard) 11 (3.08%), ALN filter (ALN) 10 (2.8%). Removal was achieved in 274/356 (76,9%). eighty-two (23,1%) IVCF were not retrieved due to the following: 41 (11,5%) patients required ongoing filtration, 24 IVCF (6,7%) patients died before retrieval, and 17 (4,7%) impossibility of retrieval because of a tilted and embedded filter apex. There were no major complications observed.

CONCLUSIONS

The global retrieval rate of IVCF was achieved in 76.9%, and the adjusted retrieval rate was of 94.15% with no major complications. IVCF tilting was associated with failure of filter removal in less than 5% of cases. This study demonstrates that the retrieval procedure of IVCF is controlled by the clinician and not by the interventional radiologist.

Inferior Vena Cava Filter Evaluation and Management for the Diagnostic Radiologist: A Comprehensive Review Including Inferior Vena Cava Filter-Related Complications and PRESERVE Trial Filters

Inferior vena cava filters are commonly encountered devices on diagnostic imaging that were highlighted in a 2010 Food and Drug Administration safety advisory regarding their complications from long-term implantation. The Predicting the Safety and Effectiveness of Inferior Vena Cava Filters (PRESERVE) trial is an ongoing after-market study investigating the safety and utility of commonly utilized filters in practice today. While most of these filters are safe, prompt recognition and management of any filter-associated complication is imperative to prevent or reduce the morbidity and mortality associated with them. This review is aimed at discussing the appropriate utilization and placement of inferior vena cava filters in addition to the recognition of filter-associated complications on cross-sectional imaging. An overview of the PRESRVE trial filters is also provided to understand each filter's propensity for specific complications.

Inferior Vena Cava Filters: Current Indications, Techniques, and Recommendations

The vena cava filter (VCF) is intended to prevent the progression of deep venous thrombosis to pulmonary embolism. Recently, the indications for VCF placement have expanded, likely due in part to newer retrievable inferior vena caval filters and minimally invasive techniques. This article reviews the available VCFs, the indications for use, the techniques for placement, and possible outcomes and complications.

Bidirectional Pull-Back Technique for Retrieval of Strut-Embedded Cylinder-Shaped Filters in Inferior Vena Cava

BACKGROUND IVC filters have been widely accepted as an effective method to prevent pulmonary embolism (PE) in patients with deep venous thrombosis (DVT). However, the placement of IVC filters is associated with significant complications and filter retrieval can be challenging when the filter struts are embedded into the caval wall. MATERIAL AND METHODS Over 26 months, we reviewed the safety and efficacy of the bidirectional pull-back technique for removing strut-embedded IVC filters in 15 consecutive patients. Retrieval procedural data such as in-dwell time, retrieval time, and fluoroscopy time were recorded. Clinical outcomes and procedure-related complications were evaluated by venography or enhanced computed tomography. Histologic tissue was analyzed to reveal the pathologic effects of chronic filter implantation. All patients underwent routine clinical follow-up at a mean time of 12 months (range, 8-14 months). RESULTS Technical success of filter retrieval was achieved in 100%, with mean implantation of 46.6 days (range, 27-66 days). Filter types were as follows: OptEase (n=11) and Aegisy (n=4). The mean retrieval time and fluoroscopy time were 21.43±5.42 min and 7.63±2.67 min, respectively. Immediate postprocedure venography showed no procedure-related complications. Thirteen patients discontinued previously prescribed lifelong anticoagulation. There were no long-term complications during follow-up. CONCLUSIONS The bidirectional pull-back technique is safe and efficient for filter retrieval. This complex technique can be particularly useful in selected patients to remove strut-embedded cylindrical-shaped IVC filters previously considered irretrievable.

The Successful Removal of Two Retrievable Inferior Vena Cava (IVC) Filters after 67 Days in a Patient with a Double IVC

We herein present a case in which two retrievable inferior vena cava (IVC) filters, which were implanted to treat deep-vein thrombosis caused by the compression of a double IVC, were successfully removed on the 67th day after placement. The filters were individually placed in both the left and right IVCs. With a prevalence of only 0.2%, a double IVC is an extremely rare anatomical variation. The long-term effects of IVC filters are unknown, and the placement of a filter potentially introduces the risk of complications. Thus, if the patient's clinical condition allows, the endovascular retrieval of the filter should be considered within a few months after implantation.

Inferior Vena Cava Filter-Related Thrombus/Deep Vein Thrombosis: Data and Management

Recurrent deep venous thrombosis and inferior vena cava (IVC) thrombosis are well-described complications following IVC filter placement. IVC thrombosis ranges in severity of clinical presentation, but can lead to significant morbidity and mortality with incidence rates depending on patient population and type of filter used. Endovascular therapies such as catheter-directed thrombolysis, mechanical thrombectomy, balloon venoplasty, and stenting are safe and effective in restoration of venous patency.

A Critical Review of Available Retrievable Inferior Vena Cava Filters and Future Directions

Inferior vena cava filters have been placed in patients for decades for protection against pulmonary embolism. The widespread use of filters has dramatically increased owing at least in part to the approval of retrievable vena cava filters. Retrievable filters have the potential to protect against pulmonary embolism and then be retrieved once no longer needed to avoid potential long-term complications. There are several retrievable vena cava filters available for use. This article discusses the different filter designs as well as the published data on these available filters. When selecting a filter for use, it is important to consider the potential short-term complications and the filters' window for retrieval. Understanding potential long-term complications is also critical, as these devices are approved for permanent placement and many filters are not retrieved. Finally, this article will address research into new designs that may be the future of vena cava filtration.

Evidence-Based Evaluation of Inferior Vena Cava Filter Complications Based on Filter Type

Many inferior vena cava (IVC) filter types, along with their specific risks and complications, are not recognized. The purpose of this study was to evaluate the various FDA-approved IVC filter types to determine device-specific risks, as a way to help identify patients who may benefit from ongoing follow-up versus prompt filter retrieval. An evidence-based electronic search (FDA Premarket Notification, MEDLINE, FDA MAUDE) was performed to identify all IVC filter types and device-specific complications from 1980 to 2014. Twenty-three IVC filter types (14 retrievable, 9 permanent) were identified. The devices were categorized as follows: conical (n = 14), conical with umbrella (n = 1), conical with cylindrical element (n = 2), biconical with cylindrical element (n = 2), helical (n = 1), spiral (n = 1), and complex (n = 1). Purely conical filters were associated with the highest reported risks of penetration (90-100%). Filters with cylindrical or umbrella elements were associated with the highest reported risk of IVC thrombosis (30-50%). Conical Bard filters were associated with the highest reported risks of fracture (40%). The various FDA-approved IVC filter types were evaluated for device-specific complications based on best current evidence. This information can be used to guide and optimize clinical management in patients with indwelling IVC filters.

The CIRSE Retrievable IVC Filter Registry: Retrieval Success Rates in Practice

CIRSE established a registry of retrievable filter use with the primary aim of determining the success of IVC Filter retrieval and associated complications. Secondary endpoints included filter indications, imaging strategies before retrieval, filter dwell times, and anticoagulation status. A web-based electronic registry was hosted between 01/12/2010 and 30/06/2012. Data entry occurred at the date of IVC filter retrieval and included items such as filter type, indication for filter insertion, access route, dwell time, retrieval success, complications, reasons for failed retrieval, and anticoagulation status. 671 filter retrievals were entered (male:female 333:295, mean age 55, median 57). Retrieval data were not entered in 43/671 leaving 628 patients for analysis. The 4 commonest retrievable filters used were the Celect in 182 patients, the OPTEASE in 161, ALN in 120, and Gunther Tulip in 98. Filters were inserted for absolute indications 40%, relative indications in 31%, and prophylactic in 24%, with 5% missing. Mean filter dwell time was 90 days. Filters were successfully retrieved in 576/628 patients (92%). The mean dwell time for successful retrievals was 85 days versus 145 days for unsuccessful retrievals (p = 0.001). Major complications occurred in 2 patients (0.03%). In summary, the CIRSE retrievable filter registry demonstrates a retrieval rate of 92% across a range of filter types, with a low major complication rate, reflecting current practice. There is an increase in trend of retrievable filter use for relative and prophylactic indications.

Penetration of an inferior vena cava filter into the aorta

Transvenous placement of inferior vena cava (IVC) filters is commonly performed in selected patients with deep venous thrombosis and pulmonary embolism. However, filter placement is sometimes associated with serious complications. A common complication is asymptomatic perforation of the IVC and penetration of adjacent organs by the filter. Here, we report a case of an 83-year-old man whose prophylactic IVC filter penetrated the aorta. The patient was closely followed without surgical intervention for more than a year, and no additional complications were observed.

[Vena cava filter. Which indications remain in the era of differentiated anticoagulation?]

CLINICAL/METHODICAL ISSUE

Venous thromboembolism (VTE) is the third most common disease of the cardiovascular system. It is associated with a 30-day lethality in the range of 6  % in deep vein thrombosis and 12  % in pulmonary embolism (PE). There are various guidelines with sometimes controversial recommendations regarding the use of inferior vena cava (IVC) filters.

STANDARD RADIOLOGICAL METHODS

Implantation of IVC filters is a standard therapy in selected patients with an estimated 259,000 filters implanted in 2012.

METHODICAL INNOVATIONS

Optionally retrievable filters are increasingly being used in clinical routine practice. Future developments will include biodegradable and drug-eluting filters.

PERFORMANCE

When compared to anticoagulation as the reference therapy of VTE, IVC filters will significantly reduce the frequency of symptomatic PE; however, there is no advantage in overall survival for either therapy.

ACHIEVEMENTS

Despite different guidelines in clinical routine practice the use of IVC filters appears to depend on the individual clinical experience and assessment of the interventionalist.

PRACTICAL RECOMMENDATIONS

Nowadays retrievable filters should be used although there are relevant differences between the various devices. As a matter of principle all IVC filters should be removed as soon as adequate anticoagulation can be established.

[Temporary vena caval filters: report on cohort of 72 patients in Grenoble, France]

Patients with a contra-indication for anticoagulation can benefit from temporary vena caval filters for protection against pulmonary embolism or recurrence. The filter can be removed secondarily, once the contra-indication is overcome, enabling better long-term outcome by reducing the risk of thrombotic and mechanic complications inherent in these devices. However, it has been shown in several studies that effective withdrawal rates were low and could be improved by the establishment of protocols and registries. We report a retrospective study of withdrawal in 72 patients in whom an ALN® vena caval filter was implanted at the Grenoble University Hospital over a period of three years with an intention for secondary retrieval. Seventy percent of the indications were related to the coexistence of thrombotic and hemorrhagic conditions. Fifty-five percent of filters were removed, the remaining 45% shared involved patients who died before retrieval (11%), those lost to follow-up (4%), technical failure of retrieval (6%), withdrawal technically unfeasible (3%), retrieval refused by patients (6%) and medical indications for continuing filtration (15%). Despite an effective follow-up of these patients and 91% success rate of withdrawal, nearly one out of two filters remains in place. A long-term follow-up of these patients is needed to learn more about the outcome of these filters.

Retrievable vena cava filters: a clinical review

Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism (PE), is a major cause of morbidity and mortality. Parenteral anticoagulant treatment with full-dose unfractioned heparin, low-molecular-weight-heparin, or fondaparinux, followed by oral treatment with the vitamin K antagonists, is recommended for the majority of patients. However, in the presence of contraindications to anticoagulant treatment, bleeding complications during antithrombotic treatment, or VTE recurrences despite optimal anticoagulation, interruption of the inferior vena cava with a filter is a potential option aimed to prevent life-threatening PE. Currently, the vast majority of filters implanted worldwide are of the permanent type, but their use is associated with a number of long term complications. Non-permanent filters represent an important alternative, and in particular retrievable filters are an attractive option because they may be either left in place permanently or safely retrieved after a quite long period when they become unnecessary. In this review, we summarize the currently available literature regarding retrievable vena cava filters and we discuss current evidences on their efficacy and safety. Moreover, the appropriate indications for their use in daily clinical practice are reviewed.

Systematic review of the use of retrievable inferior vena cava filters

PURPOSE

To review the available literature on retrievable inferior vena cava (IVC) filters to examine the effectiveness and risks of these devices.

MATERIALS AND METHODS

Investigators searched MEDLINE for clinical trials evaluating retrievable filters and reviewed the complications reported to the Manufacturer and User Facility Device Experience (MAUDE) database of the U.S. Food and Drug Administration (FDA).

RESULTS

Eligibility criteria were met by 37 studies comprising 6,834 patients. All of the trials had limitations, and no studies were randomized. There were 11 prospective clinical trials; the rest were retrospective studies. Despite the limitations of the evidence, the IVC filters seemed to be effective in preventing pulmonary embolism (PE); the rate of PE after IVC placement was 1.7%. The mean retrieval rate was 34%. Most of the filters became permanent devices. Multiple complications associated with the use of IVC filters were described in the reviewed literature or were reported to the MAUDE database; most of these were associated with long-term use (> 30 days). At the present time, the objective comparison data of different filter designs do not support superiority of any particular design.

CONCLUSIONS

In high-risk patients for whom anticoagulation is not feasible, retrievable IVC filters seem to be effective in preventing PE. Long-term complications are a serious concern with the use of these filters. The evidence of the effectiveness and the risks was limited by the small number of prospective studies.

Interventional treatment of venous thromboembolism: a review

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is the third most common cardiovascular disease after coronary artery disease and cerebrovascular disease and is responsible for significant morbidity and mortality in the general population. Full dose anticoagulation is the standard therapy for VTE, both for the acute and the long-term phase. The latest guidelines of the American College of Chest Physicians recommend treatment with a full-dose of unfractioned heparin (UFH), low-molecular-weight-heparin (LMWH), fondaparinux, vitamin K antagonist (VKA) or thrombolysis for most patients with objectively confirmed VTE. Catheter-guided thrombolysis and trombosuction are interventional approaches that should be used only in selected populations; interruption of the inferior vena cava (IVC) with a filter can be performed to prevent life-threatening PE in patients with VTE and contraindications to anticoagulant treatment, bleeding complications during antithrombotic treatment, or VTE recurrences despite optimal anticoagulation. In this review we summarize the currently available literature regarding interventional approaches for VTE treatment (vena cava filters, catheter-guided thrombolysis, thrombosuction) and we discuss current evidences on their efficacy and safety. Moreover, the appropriate indications for their use in daily clinical practice are reviewed.