Removal of the OptEase Retrievable Vena Cava Filter Is Not Feasible after Extended Time Periods Because of Filter Protrusion Through the Vena Cava

Case Report: Pericardial Tamponade and Hemothorax After Superior Vena Cava Filter Removal

A 67-year-old male patient was admitted to receive surgical treatment because of lumbar spinal stenosis. Ultrasonography showed a thrombus in the middle and lower segment of the left internal jugular vein. Superior vena cava filter implantation was performed and removed on day 7 after its implantation. The patient suddenly had dyspnea, and his blood pressure decreased 9 h after filter removal. Examinations showed pericardial tamponade and hemothorax. In addition, aortic dissection occurred approximately 20 days after superior vena cava filter removal. This case aimed to provide information to clinicians about the complications of the implantation and removal of superior vena cava filter implantation. The safety and possible complications of superior vena cava filter implantation and removal should be evaluated to identify their actual clinical benefit and cost-effectiveness ratio.

Radiofrequency catheter ablation of atrial fibrillation through an implanted inferior vena cava filter

Pulmonary vein isolation (PVI), which creates electrical blocks between pulmonary veins and left atrium, is an established way of catheter ablation for atrial fibrillation (AF). PVI is usually performed via the femoral vein access, using two or three long preshaped sheaths, followed by atrial-septal puncture to approach the left atrium. Here, we treated an AF patient with a permanently implanted inferior vena cava filter (IVC-F) due to deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE). The patient had symptomatic paroxysmal AF for over a decade, which was not controlled under antiarrhythmic drugs including beta-blockers. Therefore, we recommended PVI to treat the AF. However, as the IVC-F was an obstacle to perform conventional PVI, we changed the combination of vascular access sites and devices to perform it safely. Notably, insertions of a single steerable sheath through IVC-F and an intracardiac ultrasound catheter from the right internal jugular vein were useful for the successful completion of the procedure. <Learning objective: Pulmonary vein isolation through an implanted inferior vena cava filter (IVC-F) for an atrial fibrillation patient with IVC-F can be completed by changing the combination of vascular access sites and devices. Notably, insertions of a single "steerable" sheath through IVC-F from the femoral vein and an intracardiac ultrasound catheter from the internal jugular vein are useful for the successful completion of the procedure. Precise evaluation and careful preparation including contrast-enhanced computed tomography are mandatory for this unusual procedure.>.

Nuclear Factor-κB is Activated in Filter-Implanted Vena Cava

BACKGROUND

Implantation of a retrievable vena cava filter (VCF) is an effective method for preventing pulmonary embolism. Retrieval of filters, however, may be difficult due to intimal hyperplasia and inflammation in the cava wall. The transcription factor nuclear factor-kappaB (NF-κB) plays an important role in regulation of numerous genes participating in the inflammatory and proliferative responses of cells. The present study was to determine whether VCF implantation resulted in activation of NF-κB in the venous neointima.

METHODS

Filters were placed in vena cava (VC) in four swine for 30 days and then removed. Intimal specimens adhering to the filter struts were analyzed with reference to normal VC tissues. Immunohistochemical analyses were used to assess the NF-κB subunits p65 and p50 and the phosphorylated inhibitor of κB-α (phosphor-IκB-α) in the tissues. NF-κB DNA-binding activity was measured with enzyme-linked immunosorbent assay.

RESULTS

As compared to normal VC tissues, the intimal tissues contained higher percentages of cell nucleus-located p65 and p50, and NF-κB DNA-binding activity. Elevated immunoreactivities of p65, p50 and phosphor-IκB-α were also present in the intima.

CONCLUSION

The present study demonstrates for the first time that VCF implantation caused NF-κB activation in neointima. We further demonstrate the activation is at least partly due to phosphorylation of IκB-α. Our data suggest that NF-κB activation would significantly contribute to development of intimal hyperplasia and inflammation in filter-inserted vena cava walls. NF-κB might be a therapeutic target for inhibiting filter-induced neointima and improving filter retrieval.

Clinical course and predictive factors for complication of inferior vena cava filters

RATIONALE

The use of inferior vena cava (IVC) filters is associated with various complications. We aimed to elucidate the clinical course and predictive factors for complications of IVC filters, especially IVC penetration

METHODS

A retrospective observational study was performed in 45 adult patients with retrievable IVC filters and follow-up computed tomography (CT) between January 2003 and December 2012. Primary outcomes were the prevalence and predictive factors of IVC penetration. Secondary outcome was other complications of IVC filters.

RESULTS

IVC penetration following filter placement occurred in 87.6% of patients, and 57.8% of those involved significant penetration. Embedding of filter tips, suggestive of lateral tilting, was observed in 51.1%. Both Vertebral body erosions and aortic penetrations were seen in 4.4%, but they were asymptomatic. Longer indwelling duration of the IVC filter was significantly associated with a higher grade of IVC penetration, and the risk of significant IVC penetration increased in patients with the filter indwelling time of more than 20 days and an IVC diameter of less than 24.2mm.

CONCLUSIONS

In patients with a retrievable IVC filter, IVC penetration on CT was common, and significant IVC penetration was associated with a longer indwelling time of the IVC filter and a lesser IVC diameter.

Form And Function Of Vena Cava Filters: How Do Optional Filters Measure Up?

The function of vena cava filters, preventing pulmonary embolism while maintaining caval patency, is associated with the design. Several characteristics have been reported. This report evaluates retrievable filter designs in comparison with previously marketed designs with respect to efficacy and safety. Three inferior vena cava (IVC) filters (Gunther Tulip, Bard Recovery, and the Cordis OptEase) were compared on the basis of design characteristics associated with function, shape, number of trapping levels, and fixation. Adverse events reported in the literature and to the US Food and Drug Administration Manufacturers and User Facility Device Experience Database (MAUDE) were summarized. The major differences among device types include the fixation, the volume and number of trapping levels, and the amount of metal in the IVC. The MAUDE registry reported adverse events that had been hypothesized from the analysis of in vitro and in vivo testing. The Recovery and OptEase filters had the highest number of clinically important reports. From 12 to 57% were retrieved between 3 days and 11 months. Adaptations made to facilitate retrieval led to unacceptable sequelae. The small number removed, the length of time they are left in place, and the risks associated with retrieval suggest that optional filters may not be equivalent to approved permanent devices.

Practice Patterns and Outcomes of Retrievable Vena Cava Filters in Trauma Patients: An AAST Multicenter Study

BACKGROUND

The purpose of this study is to describe practice patterns and outcomes of posttraumatic retrievable inferior vena caval filters (R-IVCF).

METHODS

A retrospective review of R-IVCFs placed during 2004 at 21 participating centers with follow up to July 1, 2005 was performed. Primary outcomes included major complications (migration, pulmonary embolism [PE], and symptomatic caval occlusion) and reasons for failure to retrieve.

RESULTS

Of 446 patients (69% male, 92% blunt trauma) receiving R-IVCFs, 76% for prophylactic indications and 79% were placed by interventional radiology. Excluding 33 deaths, 152 were Gunter-Tulip (G-T), 224 Recovery (R), and 37 Optease (Opt). Placement occurred 6 +/- 8 days after admission and retrieval at 50 +/- 61 days. Follow up after discharge (5.7 +/- 4.3 months) was reported in 51%. Only 22% of R-IVCFs were retrieved. Of 115 patients in whom retrieval was attempted, retrieval failed as a result of technical issues in 15 patients (10% of G-T, 14% of R, 27% of Opt) and because of significant residual thrombus within the filter in 10 patients (6% of G-T, 4% of R, 46% Opt). The primary reason R-IVCFs were not removed was because of loss to follow up (31%), which was sixfold higher (6% to 44%, p = 0.001) when the service placing the R-IVCF was not directly responsible for follow up. Complications did not correlate with mechanism, injury severity, service placing the R-IVCF, trauma volume, use of anticoagulation, age, or sex. Three cases of migration were recorded (all among R, 1.3%), two breakthrough PE (G-T 0.6% and R 0.4%) and six symptomatic caval occlusions (G-T 0, R 1%, Opt 11%) (p < 0.05 Opt versus both G-T and R).

CONCLUSION

Most R-IVCFs are not retrieved. The service placing the R-IVCF should be responsible for follow up. The Optease was associated with the greatest incidence of residual thrombus and symptomatic caval occlusion. The practice patterns of R-IVCF placement and retrieval should be re-examined.

Extended interval for retrieval of vena cava filters is safe and may maximize protection against pulmonary embolism

BACKGROUND

Retrieval of optional vena cava filters (VCF) has been demonstrated to be safe and feasible in injured patients in 4 recent studies. However, 2 pulmonary emboli PE were reported in these studies with mean implant durations less than 19 days. In light of these occurrences, we changed our practice for VCF retrieval when patients had recovered from their injuries and at least 30 days after their discharge, or had been stable on therapeutic anticoagulation for deep venous thrombosis (DVT) or PE for at least 2 weeks. The aim of the current study was to assess the safety of this approach.

METHODS

A review of prospectively collected data on optional VCF over a 16-month period. The filters were inserted prophylactically per an institutional practice guideline or for the presence of DVT or PE with a contraindication and/or complication to anticoagulation. All patients underwent duplex imaging of the lower extremities and had pre- and post- retrieval cavagrams. Demographics, duration of implantation, and complications were recorded.

RESULTS

Eighty-three patients had optional VCF inserted since the change in our clinical practice. Indications included prophylaxis for high-risk trauma patients (n = 58), DVT or PE with acute contraindication to therapeutic anticoagulation (n = 22), or complications of anticoagulation (n = 3). Two patients developed lower extremity DVT after filter insertion and 1 patient developed a vena cava thrombosis. Retrieval was successful in 47 of 54 cases (87%) attempted. Median implantation duration was 142 days (range 17-475). A filter strut fracture occurred during retrieval without further consequences. No post-insertion or post-retrieval PE occurred in this study.

CONCLUSION

Extended intervals for retrieval of VCF are safe and may maximize protection against pulmonary embolism.

Inferior Vena Cava Filters in Venous Thromboembolism

Vena cava filters have been used for the prevention of pulmonary embolism in patients with venous thromboembolism since the 1930s. Historically, vena cava filters were used in patients with either a contraindication to or a complication of systemic anticoagulation or in those with recurrent pulmonary embolism despite adequate anticoagulation. However, indications for placement have broadened even in the absence of support from randomized controlled trials as the deployment procedure became less complex. With more recently available optional retrievable filters, physicians have another valuable tool to use for the treatment of venous thromboembolism in patients who are not candidates for systemic anticoagulation or, perhaps, more importantly, have only a temporary indication for filtration. As with permanent filters, there is a clinical need for robust clinical studies to establish appropriate indications and define long-term outcomes because there are only case series to guide the current usage of such filters.

Accelerated migration and proliferation of smooth muscle cells cultured from neointima induced by a vena cava filter

Formation of a neointima is associated with grafted artery or vein, angioplasty, and stent and inferior vena cava filter (IVCF) implantation. Contributing to the neointima is a population of vascular smooth muscle cells (SMC) that migrates from media and subsequently proliferates within intima. The purpose of this present study was to culture SMC from normal vessel wall and from neointima and to compare migration and growth of these cells. Neointima was stimulated in the vena cava of pigs by placement of an IVCF for 30 days. Tissue was taken from the thickened wall between the struts and from a normal segment of the IVCF. After removal of the endothelium and adventitia, explants were placed in culture dishes and were observed for the migration of cells. Immunoassay for smooth muscle alpha-actin was used to identify cell origin. Proliferation was determined by cell counting. The cell cycle regulator cyclin D1 was detected by Western blot analysis. SMC phenotype was confirmed by positive immunostaining for smooth muscle alpha-actin. Cells migrated from the neointimal explants (NI-SMC) more rapidly than cells from explants of normal media (NM-SMC). Proliferation of NI-SMC was also more rapid than NM-SMC with or without exogenous mitogens. NI-SMC expressed more cyclin D1 than NM-SMC. Injury to the vena cava triggered neointima formation characterized by the expansion of a population of SMC with increased migration and replication compared with SMC from normal regions of the vessel.