Techniques Used for Difficult Retrievals of the Günther Tulip Inferior Vena Cava Filter: Experience in 32 Patients

Retrievable Inferior Vena Cava Filters-Use, Removal, and Removal Techniques

The use of retrievable inferior vena cava filters is on the rise, but there is an inadequate number of these filters being removed even if their use as a prophylactic for venous thromboembolism is no longer indicated. Complications with retrievable filters that remain in the patient for an extended duration include examples such as filter tilt and embedding into the caval wall. This raises concerns for whether the filter is properly functioning and for consequent sequelae, including recurrent thrombosis, stenosis, or inferior vena cava perforation. With these complications, there are also challenges to retrieving these filters via the standard techniques and thus more advanced techniques are required. Both standard and advanced techniques, their uses, and possible risks of these methods are also discussed.

Classification System for Inferior Vena Cava (IVC) Appearance Following Percutaneous IVC Filter Retrieval

OBJECTIVE

There is no classification system for describing inferior vena cava (IVC) injuries. The objective of this study was to develop a standardized grading system for venographic appearance of the IVC following percutaneous IVC filter retrieval.

METHODS

A classification system for the appearance of the IVC on cavograms following percutaneous IVC filter removal was developed consisting of two grading elements; luminal characteristics and extravasation. Luminal narrowing from 0% up to 50% from any cause is grade 1; narrowing between 50 and 99% is grade 2; occlusion is grade 3; and avulsion is grade 4. Absence of extravasation is grade A, contained extravasation is grade B, and free extravasation is grade C. This system was then applied retrospectively to pre- and post-IVC filter retrieval cavograms performed at a single institution from October 2004 through February 2019.

RESULTS

546 retrieval attempts were identified with 509 (93.2%) filters successfully retrieved. 449 cases (88.2%) had both pre-retrieval and post-retrieval imaging appropriate for application of the proposed classification system. Inter-rater reliability was 0.972 for luminal characteristics, 0.967 for extravasation, and 0.969 overall. Consensus grading demonstrated a distribution of 97.3% grade 1, 1.3% grade 2, 1.3% grade 3, and 0.0% grade 4 for post-retrieval luminal characteristics. For extravasation classification, 96.4% of the cases were classified as grade A, 2.7% grade B, and 0.9% grade C.

CONCLUSION

A classification system was developed for describing IVC appearance after IVC filter retrieval, and retrospectively validated using a single center dataset.

Variability in the perception and application of force used in IVC filter retrievals among interventional radiologists

INTRODUCTION

A long dwell time is associated with higher inferior vena cava (IVC) filter retrieval complication rates. Manufacturers advise that "excessive force should not be used" during filter retrieval; however, the term "excessive" is subjective and is likely to lead to variability amongst operators. The aims of this study were to 1) ascertain what interventional radiologists consider to be excessive force during filter retrieval and 2) to understand the variability in interventional radiologists' perception of force.

METHODS

The authors recruited interventional radiologists to perform a benchtop simulated filter retrieval. Participants were invited to pull on a modified force tester attached to a Gunther Tulip filter retrieval set (GTRS). The participants were asked to pull as if they were retrieving an IVC filter and stop when they felt it was clinically unsafe to apply greater force. They were then asked to replicate forces of 10N and 50N, respectively. Each of the three tasks was completed three times. Data were obtained on the clinical experience of the participants with specific questions focusing on their filter retrieval practices.

RESULTS

The range of maximum forces applied during filter retrieval varied between 0.8 and 79.8N. When asked to replicate 10N and 50N, for attempt-1, the median forces produced were 23.5N and 38.1N, respectively. A trend analysis showed that those who overestimate 10N are more likely to apply a greater overall maximum force (r_s = 0.622; P < 0.001).

CONCLUSION

There is wide variation in what interventional radiologists consider to be the maximum safe force to apply during IVC filter retrieval.

IMPLICATIONS FOR PRACTICE

Manufacturers and operators should consider methods in which only a safe range of forces can be applied during an IVC filter retrieval. Operators may wish to undertake 'personal' force calibration as part of training in interventional radiology.

Contemporary management of chronic indwelling inferior vena cava filters

OBJECTIVE

Despite increasing retrieval rates of the inferior vena cava (IVC) filter, less than one-third are removed within the recommended timeline. Prolonged filter dwell times may increase the technical difficulty of retrieval and filter-related complications. We sought to evaluate the contemporary outcomes of patients with chronic indwelling IVC filters at a tertiary care center.

METHODS

A retrospective analysis was performed from August 2015 through August 2019 of all patients who were referred for removal of a prolonged IVC filter with a dwell time >1 year. Descriptive analysis was used to evaluate patients' characteristics and procedural outcomes, which were reviewed through electronic medical records. Data were expressed as median with interquartile range (IQR) or number and percentage, as appropriate.

RESULTS

A total of 47 patients were identified with a median filter dwell time of 10.0 years (IQR, 6-13 years); 34 patients underwent IVC filter removal, and 13 patients refused retrieval. The median age of patients was 54.9 years (IQR, 42.5-64.0 years); the majority were female (57%) and white (53%). The most common indication for filter placement was high risk despite anticoagulation (49%), followed by venous thromboembolism prophylaxis (21%). The majority of patients were symptomatic (72%). If symptomatic, the most common reason for retrieval was IVC penetration (94%), and the chief complaint was pain (56%). Retrieval success was 97%, with a median length of stay of 0 days. The majority of retrievals were performed through an endovascular approach (97%). There was one postprocedural complication (3%).

CONCLUSIONS

Despite prolonged dwell times, IVC filter retrieval can be performed safely and effectively in carefully selected patients at a tertiary referral center.

A Single-Institutional Comparative Analysis of Advanced Versus Standard Snare Removal of Inferior Vena Cava Filters

PURPOSE

To investigate differences in procedure time, radiation exposure, and periprocedural complications associated with advanced inferior vena cava (IVC) filter retrieval compared with standard snare retrieval.

MATERIALS AND METHODS

A total of 378 patients underwent standard or advanced IVC filter retrieval over a 5-year period. Technical success, retrieval techniques, fluoroscopy time, radiation dose, and complications were analyzed. All retrieval procedures with techniques other than a "snare-and-sheath" method were categorized as advanced, including failed standard attempts requiring intraprocedural conversion to advanced techniques.

RESULTS

A total of 462 filter retrieval attempts were made in 378 patients (57% female). Success rates for standard and advanced retrieval attempts were 86.8% (317 of 365) and 91.8% (89 of 97), respectively. The rate of periprocedural complications was significantly higher in the advanced retrieval group (P = .006). Complication rates for standard and advanced retrievals were 0.6% (2 of 318; all minor) and 5.2% (5 of 97; 3 minor [3.1%] and 2 major [2.1%]), respectively. The 2 major complications during advanced retrievals included filter fracture and embolization. Average fluoroscopy time for advanced retrievals was significantly higher than for standard retrievals (23.1 min vs 4.3 min; P < .001). Average radiation dose for advanced retrievals was also significantly higher than for standard retrievals (557.2 mGy vs 156.9 mGy; P < .001). Use of general anesthesia was also significantly more common in advanced retrievals compared with standard retrievals (6.2% vs 0.9%; P = .002).

CONCLUSIONS

Advanced filter retrieval results in a similarly high rate of technical success compared with standard snare retrieval but is associated with greater fluoroscopy time, anesthesia requirements, and radiation exposure.

A Modified Loop Snare Technique for Difficult Retrievals of Inferior Vena Cava Filter and Migrated Coil

The aim of this study was to evaluate the safety and efficacy of a modified loop snare technique for retrieval of difficult inferior vena cava (IVC) filters and migrated coils.A retrospective review of Günther Tulip filter retrievals between January 2014 and February 2017 was performed. A total of 316 IVC filter retrievals were attempted. In 25 cases, the standard technique had failed and our modified loop snare technique was subsequently attempted in 21 of these patients.The retrievals were successful in 20 cases (mean dwell time, 42.6 days, range, 14-102 days). The dwell time of the one failure was 46 days. The retrieval rate increased from 92.1% with the standard technique to 98.4% with the combination of the standard and modified loop snare technique. Unsuccessful retrieval was due to migration and endothelialization of the filter. This technique can also be used to remove migrated coils which cannot be captured by standard techniques. There were no complications from the retrievals.Tilt and endothelialization of filters are the main factors resulting in unsuccessful retrievals with the standard technique. In the present study, we describe an alternative technique for difficult IVC filter retrievals, which can also be used to capture migrated coils and occluders in the aorta and heart.

Single-session inferior vena cava filter removal, recanalization, and endovenous reconstruction for chronic iliocaval thrombosis

OBJECTIVE

The objective of this study was to demonstrate the safety and efficacy of treatment of inferior vena cava filter (IVCF)-related chronic iliocaval thrombosis with single-session IVCF retrieval and iliocaval recanalization, thereby optimizing stent deployment and avoiding adverse events (AEs) related to stent placement across an obstructed filter.

METHODS

From January 2015 to April 2018, a cohort of 25 consecutive patients presented for treatment of IVCF-related chronic iliocaval thrombosis with filter retrieval, followed by recanalization with stent placement and adjunctive iliofemoral thrombectomy as needed. Inclusion criteria included computed tomography (CT) imaging and clinical presentations consistent with chronic (>30 days) IVCF-related chronic thrombosis. A retrospective analysis of technical success, clinical success as measured with the Venous Clinical Severity Score, use of advanced filter retrieval techniques, and AEs was performed. Primary patency was evaluated with CT at 1 to 3 months and 1 year. Data analysis was performed using a paired t-test.

RESULTS

There were 25 patients (median age, 58.0 years; standard deviation, 15.6 years) with eight types of IVCF encountered; all were treated in a single session. Technical success was achieved in all patients. Mean improvement in the Venous Clinical Severity Score was 1.4 (95% confidence interval, 1.0-1.7; P < .01) in the venous edema subscore and 0.6 (95% confidence interval, 0.2-1.0; P < .01) in the pain subscore. At 1 to 3 months, iliocaval stent patency was maintained in 96% of patients; unilateral iliac vein stent thrombus was seen in one patient. One-year follow-up was available in eight patients, with CT imaging demonstrating maintained patency. Median filter implantation time was 12.3 months (mean, 41.9 months; range, 0.8-245.1 months; standard deviation, 63.3 months). Advanced IVCF retrieval techniques were required for 17 procedures. One major AE and minor AE occurred; no patients died in the study period.

CONCLUSIONS

Single-session iliocaval recanalization with IVCF retrieval has high rates of technical and clinical success in patients with IVCF-related chronic iliocaval thrombosis.

Is external compression on the IVC a risk factor for IVC filter abutment? A single center experience of 141 infrarenal celect filter insertions

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Tilt of the IVC filter is the major problem for the filter retrieval rate.

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External compression on the IVC wall can cause filter tilting.

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Identifying external compression factors are necessary before insertion of IVC filter.

Objectives

To investigate risk factors for inferior vena cava (IVC) filter abutment, including external compression on the IVC wall, using venous phase computed tomography (CT).

Methods

One-hundred-forty-one cases of Celect IVC filter insertion between January 2009 and April 2017 were retrospectively reviewed. On pre-procedural CT, IVC diameter and morphological classifications were measured. Filter tilt angle, IVC angle, vertical position, and filter tip abutment to the IVC wall were analyzed on post-procedural CT. IVC compression was examined by pre- and post-procedural CT analysis. Multiple logistic regression analysis was conducted to find factors related to IVC filter abutment.

Results

Of 141 IVC filter insertion cases, 52 were classified in the filter tip abutment group and 89 in the non-abutting group. IVC tilt angle (11.7 ± 5.5° vs. 6.4 ± 5.4°), presence of external compression (14/52, 27% vs. 9/89, 9%), and IVC morphology were different between the groups (p < 0.05). In multiple logistic regression analysis, filter-tilt angle over 9.25° and external compression on the IVC were found to be independent predictors of filter abutment (odds ratios: 4.56, 10.18, respectively).

Conclusion

IVC filter tilt, external compression on IVC wall, and IVC morphology were significantly different between the filter tip abutment and non-abutment groups. External compression and filter tilt over 9.25° were risk factors for filter tip abutment in multiple logistic regression analysis. By identifying these factors, we may be able to reduce filter tilting by preventing the filter from being deployed in a dangerous area.

Retrieval characteristics of the Bard Denali and Argon Option inferior vena cava filters

OBJECTIVE

The purpose of this study was to compare the retrieval characteristics of the Option Elite (Argon Medical, Plano, Tex) and Denali (Bard, Tempe, Ariz) retrievable inferior vena cava filters (IVCFs), two filters that share a similar conical design.

METHODS

A single-center, retrospective study reviewed all Option and Denali IVCF removals during a 36-month period. Attempted retrievals were classified as advanced if the routine "snare and sheath" technique was initially unsuccessful despite multiple attempts or an alternative endovascular maneuver or access site was used. Patient and filter characteristics were documented.

RESULTS

In our study, 63 Option and 45 Denali IVCFs were retrieved, with an average dwell time of 128.73 and 99.3 days, respectively. Significantly higher median fluoroscopy times were experienced in retrieving the Option filter compared with the Denali filter (12.18 vs 6.85 minutes; P = .046). Use of adjunctive techniques was also higher in comparing the Option filter with the Denali filter (19.0% vs 8.7%; P = .079). No significant difference was noted between these groups in regard to gender, age, or history of malignant disease.

CONCLUSIONS

Option IVCF retrieval procedures required significantly longer retrieval fluoroscopy time compared with Denali IVCFs. Although procedure time was not analyzed in this study, as a surrogate, the increased fluoroscopy time may also have an impact on procedural direct costs and throughput.

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.

Novel and Advanced Techniques for Complex IVC Filter Retrieval

OPINION STATEMENT

Inferior vena cava (IVC) filter placement is indicated for the treatment of venous thromboembolism (VTE) in patients with a contraindication to or a failure of anticoagulation. With the advent of retrievable IVC filters and their ease of placement, an increasing number of such filters are being inserted for prophylaxis in patients at high risk for VTE. Available data show that only a small number of these filters are retrieved within the recommended period, if at all, prompting the FDA to issue a statement on the need for their timely removal. With prolonged dwell times, advanced techniques may be needed for filter retrieval in up to 60% of the cases. In this article, we review standard and advanced IVC filter retrieval techniques including single-access, dual-access, and dissection techniques. Complicated filter retrievals carry a non-negligible risk for complications such as filter fragmentation and resultant embolization of filter components, venous pseudoaneurysms or stenoses, and breach of the integrity of the caval wall. Careful pre-retrieval assessment of IVC filter position, any significant degree of filter tilting or of hook, and/or strut epithelialization and caval wall penetration by filter components should be considered using dedicated cross-sectional imaging for procedural planning. In complex cases, the risk for retrieval complications should be carefully weighed against the risks of leaving the filter permanently indwelling. The decision to remove an embedded IVC filter using advanced techniques should be individualized to each patient and made with caution, based on the patient's age and existing comorbidities.

Why Temporary Filters Are Not Removed: Clinical Predictors in 1,000 Consecutive Cases

BACKGROUND

Compared to permanent inferior vena cava (IVC) filters, higher complication rates occur with long-term use of temporary IVC filters. We aimed to identify patient clinical factors at the time of placement that could predict failure to remove a temporary IVC filter.

METHODS

A retrospective review was performed of both vascular surgery and interventional radiology prospective databases between December 2008 and December 2013. We analyzed a total number of 1,024 consecutive, temporary IVC filters stratified by whether retrieval was attempted or made permanent. Univariate, multivariate, and prediction modeling analyses with internal validation were performed on abstracted data, which included risk factors, treatment modalities, and indications for IVC filter placement.

RESULTS

Of 1,024 temporary IVC filters, removal was attempted in 60% and no attempt at removal (kept permanent) in 40%. Of the 619 with attempted removal, the overall successful retrieval rate was 95%. The majority of filters were not attempted to be removed because of persistent filter indications (360 cases). Risk factors associated with IVC filter permanence included male sex, older age, history, or indication of venous thromboembolism (VTE) with inability to anticoagulate, malignancy, and neurologic condition. Risk factors most predictive of permanence in the multivariate model were malignancy (odds ratio [OR]: 3.0, P < 0.001) or neurologic disorder (OR: 2.69, P = 0.0005). Validation revealed our model had a sensitivity of 60.4% and specificity of 69.9%.

CONCLUSIONS

Our study shows that patients who are more likely to have a temporary IVC filter kept permanent are more likely to be older males with a history of malignancy, neurologic condition, or VTE. These factors are also predictive of permanence and can be used in our predictive model to provide insight into the significant preoperative risk factors that should play into the decision-making process.

Inferior vena cava filter retrievals, standard and novel techniques

The placement of an inferior vena cava (IVC) filter is a well-established management strategy for patients with venous thromboembolism (VTE) disease in whom anticoagulant therapy is either contraindicated or has failed. IVC filters may also be placed for VTE prophylaxis in certain circumstances. There has been a tremendous growth in placement of retrievable IVC filters in the past decade yet the majority of the devices are not removed. Unretrieved IVC filters have several well-known complications that increase in frequency as the filter dwell time increases. These complications include caval wall penetration, filter fracture or migration, caval thrombosis and an increased risk for lower extremity deep vein thrombosis (DVT). Difficulty is sometimes encountered when attempting to retrieve indwelling filters, mainly because of either abnormal filter positioning or endothelization of filter components that are in contact with the IVC wall, thereby causing the filter to become embedded. The length of time that a filter remains indwelling also impacts the retrieval rate, as increased dwell times are associated with more difficult retrievals. Several techniques for difficult retrievals have been described in the medical literature. These techniques range from modifications of standard retrieval techniques to much more complex interventions. Complications related to complex retrievals are more common than those associated with standard retrieval techniques. The risks of complex filter retrievals should be compared with those of life-long anticoagulation associated with an unretrieved filter, and should be individualized. This article summarizes current techniques for IVC filter retrieval from a clinical point of view, with an emphasis on advanced retrieval techniques.

Günther Tulip inferior vena cava filter retrieval using a bidirectional loop-snare technique

Many advanced techniques have been reported in the literature for difficult Günther Tulip filter removal. This report describes a bidirectional loop-snare technique in the setting of a fibrin scar formation around the filter leg anchors. The bidirectional loop-snare technique allows for maximal axial tension and alignment for stripping fibrin scar from the filter legs, a commonly encountered complication of prolonged dwell times.

Efficacy and Retrievability of Aegisy Vena Cava Filter: A Single Center Experience in 213 Patients

BACKGROUND

The aim of this study was to retrospectively evaluate the safety, efficacy, and retrievability of the Aegisy vena cava filter (LifeTech Scientific Co. Ltd, Shenzhen, China).

METHODS

Data from all patients who underwent Aegisy vena cava filter placement for pulmonary embolism (PE) prophylaxis during catheter-directed thrombolysis (CDT) or aspiration thrombectomy for the proximal deep venous thrombosis (DVT) were included and analyzed.

RESULTS

From October 2006 to September 2015, a total of 213 patients were included in this study. All the filters were successfully placed without any difficulty. Filter removal was attempted in 112 (52.6%) patients after a median duration of 12 days (range 9-15) of placement, and were successful in 107 (95.5%) patients. Venography was performed pre- and post-filter removal, severe tilt was seen in 5 (4.5%, 5/112) patients, and neither filter migration nor deformity was seen in any of the patients. No procedure-related complication was observed in any of the patients. A total of 47 (22.1%) patients underwent thorax or pulmonary computed tomography for cancer or other reasons before the filters were retrieved, and no segmental PE was seen. Also, no symptomatic PE breakthrough was seen in any of the patients after the filter placement.

CONCLUSIONS

Aegisy vena cava filter is a safe and effective device for PE prophylaxis during CDT or aspiration thrombectomy for the proximal DVT. Although only half patients presented for removal, the retrievability of Aegisy vena cava filter is high.

IVC filter retrieval in adolescents: experience in a tertiary pediatric center

BACKGROUND

Inferior vena cava (IVC) filters are commonly implanted with the intent to prevent life-threatening pulmonary embolism in at-risk patients with contraindications to anticoagulation. Various studies have reported increases in the rate of venous thromboembolism within the pediatric population. The utility and safety of IVC filters in children has not yet been fully defined.

OBJECTIVE

To describe the technique and adjunctive maneuvers of IVC filter removal in children, demonstrate its technical success and identify complications.

MATERIALS AND METHODS

A retrospective 10-year review was performed of 20 children (13 male, 7 female), mean age: 15.1 years (range: 12-19 years), who underwent IVC filter retrieval. Eleven of 20 (55%) were placed in our institution. Electronic medical records were reviewed for filter characteristics, retrieval technique, technical success and complications.

RESULTS

The technical success rate was 100%. Placement indications included: deep venous thrombosis with a contraindication to anticoagulation (10/20, 50%), free-floating thrombus (4/20, 20%), post-trauma pulmonary embolism prophylaxis (3/20, 15%) and pre-thrombolysis pulmonary patient (1/20, 5%). The mean implantation period was 63 days (range: 20-270 days). Standard retrieval was performed in 17/20 patients (85%). Adjunctive techniques were performed in 3/20 patients (15%) and included the double-snare technique, balloon assistance and endobronchial forceps retrieval. Median procedure time was 60 min (range: 45-240 min). Pre-retrieval cavogram demonstrated filter tilt in 5/20 patients (25%) with a mean angle of 17° (range: 8-40). Pre-retrieval CT demonstrated strut wall penetration and tip embedment in one patient each. There were two procedure-related complications: IVC mural dissection noted on venography in one patient and snare catheter fracture requiring retrieval in one patient. There were no early or late complications.

CONCLUSION

In children, IVC filter retrieval can be performed safely but may be challenging, especially in cases of filter tilt or embedding. Adjunctive techniques may increase filter retrieval rates.

Retrievable inferior vena cava filters can always be removed using "fall-back" techniques

OBJECTIVE

Retrievable inferior vena cava filters (IVCFs) left in place for a prolonged period can lead to complications including filter migration, fracture, and caval thrombosis. "Fall-back" techniques for IVCF retrieval that can be used when standard snaring is unsuccessful have been recently described. The purpose of this study was to analyze how incorporation of these new techniques affected the outcomes of IVCF retrievals at our institution during the past 5 years.

METHODS

Data were collected of all patients undergoing IVCF removal by vascular surgeons at a tertiary academic medical center between 2009 and 2013, including demographics and procedural and filter characteristics. A standard technique of snaring the retrieval hook was attempted first in all cases; if this was unsuccessful, a number of fall-back techniques were employed, including the use of endoscopic graspers, 18F sheaths, and snaring a second wire below the collar of the filter to collapse it into the sheath.

RESULTS

IVCF retrieval was attempted in 275 patients; 3 were excluded intraoperatively because of thrombus in the filter. Most filters (97%) were Günther Tulips (Cook Medical, Bloomington, Ind); 70% had been placed prophylactically before bariatric surgery. A total of 268 filters (98.5%) were retrieved successfully, 213 (79%) by standard snaring and 55 (21%) with fall-back techniques. In patients undergoing fall-back techniques, technical success was achieved 100% of the time. The median time since insertion was significantly longer in the fall-back group (173 days vs 83 days; P < .0001). Four intraoperative complications occurred; fractured wires embolized to the right atrium or pulmonary artery and were successfully removed endovascularly. The majority of the procedures (80%) were performed under sedation in both groups.

CONCLUSIONS

Incorporation of fall-back techniques may allow 100% technically successful and safe removal of retrievable IVCFs and is especially useful in removing filters with prolonged dwell time.

Retrievable Filter Update: The Denali Vena Cava Filter

Over the past decade, there has been a gradual evolution of the retrievable inferior vena cava (IVC) filter, as the indications for caval filtration have expanded since the first such filters came into use. However, the particular design of retrievable or optional filters has introduced a subset of both symptomatic and asymptomatic device failures that have prompted a reassessment in the approach to patient selection as well as a new lexicon of technical considerations when considering retrieval. The Denali Vena Cava Filter (Bard Peripheral Vascular, Inc., Tempe, AZ) represents one of the latest filters to come to market that specifically addresses the various issues of its predecessors. While the body of published experience with this filter is still relatively sparse, the incidence of filter tilt, strut perforation, strut fracture, and filter migration appears acceptably low and the filters remain relatively easy to retrieve even after long dwell times.

Troubleshooting OptEase inferior vena cava filter retrieval

For treatment of deep vein thrombosis and prevention of pulmonary thromboembolism, a retrievable inferior vena cava filter is commonly utilized as an effective bridge to anticoagulation. However, we have experienced difficulties in retrieving inferior vena cava filters. Endovascular retrieval assisted by disposable biopsy forceps is an appropriate approach because it provides a less-invasive low-cost way to remove a migrated filter. We suggest this troubleshooting technique to deal with filter hook migration into the caval wall.

Successful cases of difficult inferior vena cava filter retrieval with the use of biopsy forceps: Biopsy forceps technique

Objectives:

For treatment and prevention of deep vein thrombosis(DVT) and pulmonary embolism(PE), retrievable inferior vena cava(IVC) filters have commonly been used as an effective bridge to anticoagulation. However, we experienced unexpected difficulty in endovascular retrieval of some IVC filters. Most problems were due to endovascular treatment devices issues, filter intimal migration, filter disintegration, filter-associated thrombosis, and right atrium/ventricle migration.

Methods:

Disposable biopsy forceps was used to engage the filter hook and reform the shape of the filter struts. Endovascular retrieval assisted by use of the biopsy forceps via a similar vein was effective and provided a less-invasive, low cost method for removal of problematic IVC filters.

Results:

We described easily performed methods that uses disposable biopsy forceps for the retrieval of IVC filters that are difficult to remove because of filter hook migration into the caval wall.

Conclusion:

We developed an easily performed method that uses intestine biopsy forceps for the retrieval of IVC filter that are difficult to remove.

Inferior vena cava filtration in the management of venous thromboembolism: filtering the data

Venous thromboembolism (VTE) is a common cause of morbidity and mortality. This is especially true for hospitalized patients. Pulmonary embolism (PE) is the leading preventable cause of in-hospital mortality. The preferred method of both treatment and prophylaxis for VTE is anticoagulation. However, in a subset of patients, anticoagulation therapy is contraindicated or ineffective, and these patients often receive an inferior vena cava (IVC) filter. The sole purpose of an IVC filter is prevention of clinically significant PE. IVC filter usage has increased every year, most recently due to the availability of retrievable devices and a relaxation of thresholds for placement. Much of this recent growth has occurred in the trauma patient population given the high potential for VTE and frequent contraindication to anticoagulation. Retrievable filters, which strive to offer the benefits of permanent filters without time-sensitive complications, come with a new set of challenges including methods for filter follow-up and retrieval.

Introducer curving technique for the prevention of tilting of transfemoral Günther Tulip inferior vena cava filter

Objective

To determine whether the introducer curving technique is useful in decreasing the degree of tilting of transfemoral Tulip filters.

Materials and Methods

The study sample group consisted of 108 patients with deep vein thrombosis who were enrolled and planned to undergo thrombolysis, and who accepted transfemoral Tulip filter insertion procedure. The patients were randomly divided into Group C and Group T. The introducer curving technique was Adopted in Group T. The post-implantation filter tilting angle (ACF) was measured in an anteroposterior projection. The retrieval hook adhering to the vascular wall was measured via tangential cavogram during retrieval.

Results

The overall average ACF was 5.8 ± 4.14 degrees. In Group C, the average ACF was 7.1 ± 4.52 degrees. In Group T, the average ACF was 4.4 ± 3.20 degrees. The groups displayed a statistically significant difference (t = 3.573, p = 0.001) in ACF. Additionally, the difference of ACF between the left and right approaches turned out to be statistically significant (7.1 ± 4.59 vs. 5.1 ± 3.82, t = 2.301, p = 0.023). The proportion of severe tilt (ACF ≥ 10°) in Group T was significantly lower than that in Group C (9.3% vs. 24.1%, χ² = 4.267, p = 0.039). Between the groups, the difference in the rate of the retrieval hook adhering to the vascular wall was also statistically significant (2.9% vs. 24.2%, χ² = 5.030, p = 0.025).

Conclusion

The introducer curving technique appears to minimize the incidence and extent of transfemoral Tulip filter tilting.

Optional inferior vena cava filters in the trauma patient

Trauma patients are at exceedingly high risk of development of venous thromboembolism (VTE) including deep venous thrombosis and pulmonary embolism (PE). The epidemiology of VTE in trauma patients is reviewed. PE is thought to be the third major cause of death after trauma in those patients who survive longer than 24 hours after onset of injury. In fact, patients recovering from trauma have the highest rate of VTE among all subgroups of hospitalized patients. Various prophylactic and surveillance methods have been evaluated and found helpful in certain situations, but VTE complications can occur despite such measures. Therapeutic and prophylactic uses of inferior vena cava (IVC) filters in trauma patients are reviewed. Prophylactic IVC filter use is revealed to be a controversial subject with valid arguments on both sides of the issue. With the lack of prospective randomized trials of IVC filter use in trauma, it is impossible to make evidence-based recommendations. Unfortunately, two sets of guidelines are available for insertion of filters in trauma patients, with conflicting recommendations. The introduction of retrievable IVC filters seems to offer a unique solution for VTE protection in the trauma patient population, which often consists of younger members of our population. Lastly, current generations of FDA-approved retrieval filters are discussed.