Technical and Financial Feasibility of an Inferior Vena Cava Filter Retrieval Program at a Level One Trauma Center

Removal of inferior vena cava filter by open surgery after failure of endovenous retrieval

Background

The permanent placement of inferior vena cava (IVC) filters may lead to numerous complications and their removal is recommended once the risk of pulmonary embolism is reduced. Removal of IVC filters by endovenous means is preferred. But failure of endovenous removal happens when recycling hooks penetrate the vein wall and filters are left in place for too long time. In these scenarios, open surgery may be effective for removal of IVC filters. We aimed to describe the surgical approach, outcomes, and 6-month follow-up of the removal of IVC filter by open surgery, after the failure of removal via the endovenous method.

Methods

A total of 1,285 patients with retrievable IVC filters were admitted from July 2019 to June 2021, including 1,176 (91.5%) endovenous filter removals, and 24 (1.9%) open surgical IVC filter removals after the failure by endovenous method, of whom 21 (1.6%) were followed-up and eligible for analysis of the study. Patient characteristics, filter type, filter removal rate, IVC patency rate, and complications were retrospectively analyzed.

Results

Twenty-one patients were left with IVC filters for 26 (10, 37) months, of which 17 (81.0%) patients had non-conical filters and 4 (19.0%) had conical filters; all 21 filters were successfully removed, with a 100% removal rate, no deaths, no serious complications, and no symptomatic pulmonary embolism. At the 3rd month follow-up after surgery and 3rd month follow-up after discontinuation of anticoagulation therapy, only 1 case (4.8%) had IVC occlusion, but without any occurrence of new lower limb deep venous thrombosis and silent pulmonary embolism.

Conclusion

Open surgery can be used for the removal of IVC filters after failure of removal by endovenous method or when accompanied by complications without symptoms of pulmonary embolism. Open surgical approach can be used as an adjunctive clinical intervention for the removal of such filters.

Case report: Endoluminal removal of a retrievable conical inferior vena cava filter with a ruptured retraction hook attached to the wall

We report the case of a patient who underwent endovascular retrieval of a conical inferior vena cava (IVC) filter with a ruptured retraction hook that was attached to the IVC wall. A 21-year-old woman with a Celect (Cook) filter, implanted 1,522 days prior, requested retrieval. Preoperative ultrasound and CT examinations showed that the filter was inclined, the retraction hook was attached to the IVC wall, and one of the filter’s pedicles was broken. The inferior vena cava was patent, with no thrombus. Old superficial femoral vein thrombosis could be seen in the right lower extremity. The filter retrieval equipment (Gunther Tulip, Cook) failed to capture the retraction hook. By means of a pigtail catheter (with a partly removed catheter tip) and loach guidewire, we applied a modified loop-snare technique to successfully cut the proliferative tissue near the tip of the retraction hook, by which the hook re-entered the inferior vena cava. Although the snare successfully captured the retraction hook and retrieved the filter, the broken pedicle was retained in the inferior vena cava. We used forceps to capture and pull it to the distal end. In the end, the inferior vena cava became patent, with no contrast agent spillage or residual, and no symptomatic pulmonary embolization. A simultaneous occurrence of oblique adherence and fracture is rarely found in the same filter; however, by using the modified loop-snare technique and biopsy forceps technique, we successfully retrieved the filter and broken pedicle. Our case provides a practical auxiliary technique for regular clinical practice.

Costs and complications of hospital admissions for inferior vena cava filter malfunction

OBJECTIVE

Inferior vena cava filter (IVCF) malfunction can result from penetration, fracture, or migration of the device necessitating retrieval. Endovascular and open retrieval of IVCF have been described in institutional series without comparison. This study examines national hospital admissions for IVCF malfunction and compares the outcomes of open and endovascular retrieval.

METHODS

The National Inpatient Sample database (2016-2017) was reviewed for admissions with International Classification of Diseases, Tenth Revision (ICD-10) codes specific for IVCF malfunction. All ICD-10 procedural codes were reviewed, and patients were divided based on open or endovascular IVCF retrieval. Patient characteristics, outcomes, and costs of hospitalization were compared between the two groups.

RESULTS

There were 665 patients admitted with a diagnosis of IVCF malfunction. Open IVCF retrieval was performed in 100 patients and endovascular removal in 90 patients. Of those undergoing open surgery, 45 patients (45%) required median sternotomy and 55 (55%) required abdominal surgeries. Most patients were white females with a mean age of 54.4 years (range, 49.3-59.6 years) with a history of deep venous thrombosis (55.3%) or pulmonary embolism (31.6%). Most patients with IVCF malfunction were treated in large (81.6%) or urban teaching (94.7%) hospitals situated most commonly in the South (42.1%) and Northeast (29.0%) with no difference in characteristics of the patients or the centers between the two groups. Patients undergoing open IVCF retrieval were more likely to undergo surgery on an elective basis compared with endovascular IVCF retrieval (75.0% vs 11.1%; P < .001). Open IVCF retrieval was associated with a higher likelihood of thromboembolic complication compared with endovascular retrieval (20% vs 0%; P = .04). There was a trend toward higher infectious complications and overall complications with endovascular removal, but this difference did not reach statistical significance. Open retrieval was associated with a mortality of 5.0% compared with no inpatient mortality with endovascular retrieval (P = .33). The mean hospital length of stay was no difference between the two groups. Open retrieval was associated with significantly higher hospital costs than endovascular retrieval ($34,276 vs $19,758; P = .05).

CONCLUSIONS

Filter removal for patients with IVCF malfunction is associated with significant morbidity and cost, regardless of modality of retrieval. The introduction of specific ICD-10 codes for IVCF malfunction allows researchers to study these events. The development of effective tools for outpatient retrieval of malfunctioning IVCF could decrease related hospitalization and have potential savings for the healthcare system.

Asymptomatic patients with unsuccessful percutaneous inferior vena cava filter retrieval rarely develop complications despite strut penetrations through the caval wall

OBJECTIVE

We established a program for retrieval of inferior vena cava (IVC) filters within our hospital system. When percutaneous retrieval fails, we only recommend open surgical removal for symptoms and other complications. We examined our outcomes with conservative management of unsuccessful percutaneous retrieval and open surgical removal for symptomatic/complicated IVC filters.

METHODS

All patients with history of IVC filter placement who were referred to us for retrieval between 2010 and 2016 were evaluated. Before retrieval, patients were evaluated for risk of future venous thromboembolic events and ongoing need for IVC filtration. Asymptomatic patients with unsuccessful percutaneous filter retrieval were recommended to have annual follow-up with plain abdominal radiographs and to take daily low-dose aspirin. Patients with symptoms referable to the indwelling filter and those with complications were offered open surgical removal.

RESULTS

There were 213 patients with a history of IVC filter placement who underwent 220 percutaneous attempts for retrieving 214 IVC filters (four patients had two attempts, one patient had three attempts). Technical success in percutaneously retrieving the filter was 180 of 214 (84.1%) at a median of 5.5 months (interquartile range [IQR], 3.5-9.2) from implant. The median filter dwell time was significantly longer in unsuccessful compared with successful retrieval attempts (8.3 months [IQR, 4.3-15.1 months] vs 5.5 months [IQR, 3.2-8.7 months]; P = .011). Of the 34 filters in 33 patients that could not be retrieved percutaneously, all had either significant filter barb penetration through the caval wall or a tilt angle of greater than 15°. The majority of patients (67%) remained asymptomatic without any further complications over a mean follow-up of 24 months (IQR, 12-50 months). No asymptomatic patients developed symptoms or complications over the follow-up period. Two of the five patients who were symptomatic underwent open surgical removal via minilaparotomy. An additional six patients who failed percutaneous retrieval at other institutions were referred to us for open surgical removal owing to symptoms or complications. Technical success for all open surgical removal of IVC filters was 100%. All patients had resolution of their symptoms after percutaneous or open surgical removal.

CONCLUSIONS

Asymptomatic patients with unsuccessful percutaneous IVC filter retrieval seem to have low complications in midterm follow-up despite significant filter strut penetration. Without symptoms or other complications, such patients do not require referral for open surgical filter removal. Symptomatic patients can expect low morbidity and resolution of symptoms after percutaneous or open surgical removal. Further studies are needed to determine the cost-effectiveness of routinely removing asymptomatic IVC filters.

Randomized Controlled Study of an Absorbable Vena Cava Filter in a Porcine Model

PURPOSE

To compare the safety and efficacy of an absorbable inferior vena cava (IVC) filter and a benchmark IVC filter in a porcine model.

MATERIALS AND METHODS

A randomized controlled Good Laboratory Practice study was performed in Domestic Yorkshire cross swine. Sixteen swine were implanted with an absorbable IVC filter (test device; Adient Medical, Pearland, Texas); 8 were implanted with a benchmark metal IVC filter (control device; Cook Medical, Bloomington, Indiana). All animals underwent rotational digital subtraction pulmonary angiography and cavography (anteroposterior and lateral) before filter deployment and 5 and 32 weeks after deployment. Terminal procedures and necropsy were performed at 32 weeks. The IVC, heart, lungs, liver, and kidneys were harvested at necropsy. The reported randomized controlled GLP animal study was conducted at Synchrony Labs, Durham, North Carolina.

RESULTS

One animal died early in the test cohort of a recurring hemorrhage at the femoral access site resulting from a filter placement complication. All other animals remained clinically healthy throughout the study. No pulmonary embolism was detected at the 5- and 32-week follow-up visits. The absorbable filter subjects experienced less caval wall perforation (0% vs 100%) and thrombosis (0% vs 75%). The control device routinely perforated the IVC and occasionally produced collateral trauma to adjacent tissues (psoas muscle and aorta). The veins implanted with the absorbable filter were macroscopically indistinguishable from normal adjacent veins at 32 weeks except for the presence of radiopaque markers. Nontarget tissues showed no device-related changes.

CONCLUSIONS

Implantation of the absorbable IVC filter in swine proved safe with no pulmonary emboli detected. There was complete to near-complete resorption of the filter polymer by 32 weeks with restoration of the normal appearance and structure of the IVC.

The law of unintended consequences: current design challenges in inferior vena cava filters

INTRODUCTION

Venous thromboembolic disease (VTD) encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE) is a commonly encountered condition with potentially fatal sequelae. When unable to be adequately anticoagulated, patients require a mechanical means to prevent PE. This review discusses the history of inferior vena cava interruption and the development of inferior vena cava filters (IVCF). Areas covered: Milestone innovations in the mechanical treatment of VTD, their successes and shortcomings are discussed. The unforeseen complications that have occurred with implantation of IVCF have a profound impact on the present utilization of retrievable filters. Particular attention is dedicated to the evidence for safe and effective use of IVCF and the challenges presented to further improvement of these technologies. Expert commentary: While evidence suggests that IVCF are effective in preventing PE, the recent 'de-volution' from permanent to retrievable design has unleashed an epidemic device-related complications. Retrievable filter design is reliant on a 'Goldilocks' premise: make the device stable (so it doesn't migrate), but not too stable (so you can still retrieve it). Efforts must be aimed at optimizing utilization using decision support tools, meticulous follow up after deployment, and conversion from retrievable to permanent devices if the patient requires lifelong mechanical prophylaxis.

Vena Cava Filter Retrieval Rates and Factors Associated With Retrieval in a Large US Cohort

Background

Retrieval of vena cava filters (VCFs) is important for safety as complications increase with longer dwell times. This study assessed VCF retrieval rates and factors associated with retrieval in a national cohort.

Methods and Results

VCFs were identified by procedural codes from an administrative claims database. Patients were identified who had a VCF placement during a hospitalization from a national commercial administrative claims database. Indications for VCF placement were identified as pulmonary embolism with or without deep vein thrombosis, deep vein thrombosis only, or prophylactic. Patient demographic and clinical characteristics were included in proportional hazard regression models to find associations with early (90‐day) and 1‐year VCF retrieval. Initiation of anticoagulation and the correlation between time‐to‐retrieval and time‐to‐initiation of anticoagulation were observed. Of 54 766 patients receiving a VCF, 36.9% had pulmonary embolism, 43.9% had deep vein thrombosis only, and 19.2% had no apparent venous thromboembolism present. Over the 1 year of follow‐up, the cumulative incidence of VCF retrieval was 18.4%. Retrieval increased over time from a low of 14.0% in 2010 up to ≈24% in 2014. In adjusted time‐to‐event models, increasing age, differing regions, and some comorbidities were associated with poorer retrieval rates. Initiation of anticoagulation was poorly correlated with retrieval, with anticoagulation preceding retrieval by a median of 51 days while those without retrieval had a median of 278 days of exposure to anticoagulation.

Conclusions

VCF retrieval increased over the study period but remained suboptimal and was weakly correlated with anticoagulation initiation.

Indications and Outcomes of Open Inferior Vena Cava Filter Removal

BACKGROUND

Despite recommendations for retrieval of inferior vena cava (IVC) filters, most are not removed in a timely manner. Longer IVC filter dwell times are associated with caval wall perforation and tilting that make percutaneous retrieval more difficult. Open IVC filter removal is generally reserved for patients with symptoms referable to the filter, such as chronic back and abdominal pain. We present our management algorithm and review of cases of open IVC filter removal.

METHODS

Patients referred for management of implanted IVC filters from May 2010 to May 2016 were included. Demographic and imaging were reviewed for cases requiring open surgical removal.

RESULTS

There were 221 percutaneous retrieval attempts in 218 patients. Successful retrieval occurred in 196 (89%) attempts. There were 7 patients who had open surgical IVC filter removal after failure of percutaneous retrieval. One patient had 2 filters and another had 3 filters. Except for 1 case with complications during the percutaneous retrieval procedure, the remaining patients all suffered from back or abdominal pain. All had significant filter strut penetration through the caval wall into adjacent structures. Postoperatively, all patients had relief of pain. There were no deaths and 1 patient had a minor ileus that spontaneously resolved.

CONCLUSIONS

Patients who fail percutaneous IVC filter retrieval can expect low morbidity and prompt resolution of symptoms after open surgical removal via minilaparotomy.

Risk Factors Associated with Symptomatic Pulmonary Embolism of Catheter Directed Thrombolysis for Lower Extremity Deep Venous Thrombosis

OBJECTIVE

The aim was to study the risk factors associated with symptomatic pulmonary embolism (PE) in patients with deep venous thrombosis (DVT) in the lower limbs treated by catheter directed thrombolysis (CDT) without inferior vena cava filter (IVCF) placement.

METHODS

A total 266 patients with acute/subacute ilio-femoral, ilio-femoropopliteal, and femoropopliteal thrombosis confirmed by computed tomography venography or ultrasound Doppler were studied. All patients were treated with CDT. CTPA (computed tomography pulmonary angiography) examination was performed in all patients before thrombolysis. Patients with clinically suspected symptomatic PE were confirmed by repeated CTPA after treatment. The major outcome of this study was the occurrence of symptomatic PE events during CDT.

RESULTS

During CDT, the incidence of symptomatic PE events was 4.9% (13/266). Patients with silent PE had a higher risk of developing symptomatic PE (10/110, 9.1%) than those who had no prior PE (3/156, 1.9%); multivariate analysis confirmed this difference (OR 4.018, 95% CI 1.048-15.402). It was also found that patients with previous heart disease had a higher risk of developing symptomatic PE (11/90, 12.2%) than those with no prior heart disease (2/176, 1.1%). Multivariate analysis confirmed that previous heart disease increased the risk of developing symptomatic PE (OR 10.407, 95% CI 2.228-48.617). One patient who suffered from heart failure and silent PE before CDT died of symptomatic PE (1/13, 7.7%).

CONCLUSION

The risk of developing symptomatic PE is most markedly increased in patients with previous silent PE and heart disease. Selective rather than routine IVCF placement is an appropriate approach.