Initial experience using the rigid forceps technique to remove wall-embedded IVC filters

Predictors of endobronchial forceps utilization for inferior vena cava filter retrieval: when snare retrieval fails

BACKGROUND

Endobronchial forceps are commonly used for complex IVC filter removal and after initial attempts at IVC filter retrieval with a snare have failed. Currently, there are no clear guidelines to help distinguish cases where primary removal should be attempted with standard snare technique or whether attempts at removal should directly be started with forceps. This study is aimed to identify clinical and imaging predictors of snare failure which necessitate conversion to endobronchial forceps.

METHODS

Retrospective analysis of 543 patients who underwent IVC filter retrievals were performed at three large quaternary care centers from Jan 2015 to Jan 2022. Patient demographics and IVC filter characteristics on cross-sectional images (degree of tilt, hook embedment, and strut penetration, etc.) were reviewed. Binary multivariate logistic regression was used to identify predictors of IVC filter retrieval where snare retrieval would fail.

RESULTS

Thirty seven percent of the patients (n = 203) necessitated utilization of endobronchial forceps. IVC filter hook embedment (OR:4.55; 95%CI: 1.74-11.87; p = 0.002) and strut penetration (OR: 56.46; 95% CI 20.2-157.7; p = 0.001) were predictors of snare failure. In contrast, total dwell time, BMI, and degree of filter tilt were not associated with snare failure. Intraprocedural conversion from snare to endobronchial forceps was significantly associated with increased contrast volume, radiation dose, and total procedure times (p < 0.05).

CONCLUSION

IVC filter hook embedment and strut penetration were predictors of snare retrieval failure. Intraprocedural conversion from snare to endobronchial forceps increased contrast volume, radiation dose, and total procedure time. When either hook embedment or strut penetration is present on pre-procedural cross-sectional images, IVC filter retrieval should be initiated using endobronchial forceps.

LEVEL OF EVIDENCE

Level 3, large multicenter retrospective cohort.

Inferior vena cava filter retrievals using advanced techniques: a systematic review

This study aimed to assess the safety of complex inferior vena cava (IVC) filter retrieval techniques through a systematic review of published literature. Using PubMed, a systematic review was conducted in line with the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines to identify articles published through April 2020 that reported on complex IVC filter retrieval techniques in >5 patients. Case reports, review papers, and studies that did not report on primary outcomes or variables of interest were excluded. Risk of bias was assessed using a modified Newcastle-Ottawa Quality Assessment scale. Pooled success and complication rates were calculated for the overall number of complex retrieval attempts as well as for each filter type and each complex retrieval method. Sixteen fair-quality and three good-quality studies met the inclusion criteria, with 758 patients (428 female) who had undergone 770 advanced retrieval attempts. The mean age of the patients was 46.5 ± 7.1 years (range: 14.1-90), and the mean dwell time was 602.5 ± 388.6 days (range: 5-7336). Regarding filters, 92.6% (702/758) were retrievable and 7.4% (56/758) were permanent. Indications for complex retrieval included the failure of standard retrieval (89.2%; 676/758) and tilting or embedding in the caval wall (53.8%; 408/758); 92.6% (713/770) of the advanced retrieval attempts were successful. The pooled success rate was 92.0% (602/654) for retrievable filters and 96.4% (53/55) for permanent filters (P = 0.422). Only 2.8% (21/758) of patients experienced major complications, and the major complication rate was not significantly associated with filter type (P = 0.183). Advanced techniques for IVC filter retrieval appear safe for the retrieval of retrievable filters and certain permanent filters, with a low short-term major complication rate. Further studies on complex retrieval techniques used to remove permanent filters should be conducted to clarify their safety with respect to filter type.

Rigid forceps and excimer laser use for complex inferior cava filter retrieval: a preliminary quantitative analysis of available evidence

Purpose

The present study aims to evaluate the safety and efficacy of advanced inferior vena cava filter (IVCF) retrieval using laser assistance compared with forceps via systematic review and quantitative aggregation of available data.

Methods

Pubmed and Embase were queried from establishment to September 2021. Original studies with a sample size ≥ 5 that reported at least one primary outcome of patients who underwent laser- or forceps-assisted IVCF retrieval were included. Primary outcomes included technical success and complication rates. Baseline characteristics were extracted: age, sex, presence of filter thrombus, strut penetration, previous retrieval attempt, filter dwell time, fluoroscopy time, and filter type. Complications were categorized by type and severity. Categorical data was pooled and evaluated with chi-square or Fisher exact tests.

Results

From the 16 included studies, a total of 673 and 368 patients underwent laser- and forceps-assisted IVCF retrieval, respectively. Successful retrieval was achieved in 98.1 and 93.7% patients from the laser and forceps groups, respectively (p < 0.001). Major complication rates (1.6 vs 2.1%, p = 0.629) and risk of injury to cava or adjacent organs (1.0 vs 1.4%, p = 0.534) were similar between the two groups. A higher proportion of filters from the laser arm were closed-cell design (75.4 vs 68.1%, p = 0.020).

Conclusion

Based on limited available evidence, forceps- and laser-assisted complex IVCF retrievals were equally safe. The use of laser sheath is associated with a higher retrieval rate than forceps alone, though the baseline characteristics of two cohorts were not controlled. Future large-scale case-controlled comparative studies with longer clinical follow-up are warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42155-022-00311-4.

Safety and efficacy of inferior vena cava filter retrieval: a 5-year single center retrospective review from a tertiary care center

Background

Inferior vena cava (IVC) filter retrieval is typically accomplished with standard snare technique. When this fails, more advanced techniques are necessary, especially when removal falls outside a 12-month window. Complications during filter retrieval depend heavily on technique, type of filter, and filter position. In this study we examined safety and efficacy of 536 filter retrievals at a tertiary care center and compared complication rates between standard snare and endobronchial forcep retrieval.

Method

We reviewed 536 cases between August 2015 and August 2020, recording retrieval success rates, patient comorbidities, and complication rates at the time of removal.

Results

Total overall retrieval success was 97.9% (525/536), and complications occurred in approximately 6.0% (32/536) of all cases. Success and complications with standard snare technique alone were 99.4% (345/347) and 1.7% (5 Grade I/II, 1 Grade III) and advanced forcep technique 98.8% (171/173) and 14.5% (22 Grade I/II, 2 Grade III, and 1 Grade IV), respectively. There was no significant difference between the technical success rates of the standard snare technique and forceps techniques (p = 0.60) despite a significantly longer dwell time in patients undergoing forceps retrieval (p < 0.001).

Conclusion

To our knowledge, this is the largest cohort of forceps directed IVC filter retrieval present in the literature. Rates of successful endobronchial forceps and standard snare retrievals in this study are similar to previous reports. Although use of endobronchial forceps may be associated with higher complication rates, this is likely due to prolonged dwell times, filter tilt, and attempted removal of non retrievable filters. Overall, forceps-directed retrieval offers a safe, effective means of removal in difficult cases.

Level of evidence

Level 3, Large Retrospective Study.

An expert spotlight on inferior vena cava filters

Introduction: Inferior vena cava (IVC) filters are mechanical filtration devices designed as an alternative to surgical ligation/plication of the IVC. Their use has been controversial, especially with the introduction of retrievable filters and expanded/prophylactic indications.Areas covered: Authors discuss the types of available IVC filters, indications for placement, evidence on their effectiveness in general and specific patient populations, procedural considerations, off-label use, complications, and filter retrieval. This review is based on manuscripts/abstracts published from 1960 to 2021 on venous thromboembolism and IVC filters.Expert opinion: Despite the limited data on their effectiveness and survival benefit, IVC filters continue to play an important role in the treatment of patients with venous thromboembolism (VTE) who cannot receive standard anticoagulation. There is no role of IVC filters in patients without VTE. While retrievable filters are desirable for short-term use, a dedicated team-based approach, and advanced training are required for their successful removal. Newer devices are promising in improving patient safety . The device manufacturers and regulatory agencies should consider specific approaches to track device-related adverse events. Population-based studies are required to establish optimal patient population who would benefit from these devices. .

Comparative efficacy and safety of the Captus device for inferior vena cava filter retrieval

PURPOSE

Retrievable inferior vena cava filters (IVCF) have been increasingly used for mechanical pulmonary embolism prophylaxis since their development. The Captus Vascular Retrieval System (Avantec Vascular, Sunnyvale, California) is a new device developed for retrieval of IVCF. This study compared the safety and efficacy of the new Captus device against the existing EnSnare Endovascular Snare System (Merit Medical, South Jordan, Utah) for IVCF retrieval.

METHODS

Patients undergoing IVCF retrieval at a single institution between July 2015 and July 2020 were retrospectively identified. All adult patients (>18 years) undergoing filter retrieval with either Captus or Ensnare were included. Technical success and complications were compared by device. A complexity score was assigned to each case to adjust for selection bias. Logistic regression was used to model the association between device type and primary technical success.

RESULTS

99 IVCF retrievals met inclusion criteria, 59 with Captus and 40 with Ensnare. The majority of the cohort consisted of low complexity cases (n = 51, 86% Captus versus n = 31, 78% Ensnare; p = 0.28). Technical success for low and medium complexity retrievals was 88% and 62% with Captus and 96% and 33% with Ensnare. There was no significant association between device type and technical success, adjusting for case complexity (Captus OR 0.55, 95% CI 0.08-2.72, p = 0.49). There were no device-related complications.

CONCLUSION

No statistically significant difference in device technical success or complications between the Ensnare and Captus devices for uncomplicated IVCF retrieval.

PRECIS

The Captus Vascular Retrieval System is a new device for IVC filter retrieval which has similar technical success to the existing EnSnare.

A modified wire-loop snare technique for the retrieval of inferior vena cava filter with embedded hook

Common obstacles to successful retrieval of retrievable inferior vena cave filter include embedded filter hook and severe tilt of the filter. We described a modified wire-loop snare technique using self-made fishhook-like pigtail catheter and 11-F-long sheath to retrieve a severe tilted filter with embedded hook successfully. The modified wire-loop snare technique is simple and effective requiring only standard equipment and single venous access. This technique may be suitable for some types of retrievable filter with embedded hook.

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.

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.

Retrieval of Inferior Vena Cava Filters: Technical Considerations

Placement of retrievable inferior vena cava filters has seen rapid growth since their introduction into clinical practice. When retrieved, these devices offer the notional benefit of temporary protection from pulmonary embolism related to lower extremity deep venous thrombosis, and mitigation of filter-related deep venous thrombosis. When promptly removed after the indication for mechanical prophylaxis is no longer present, standard endovascular retrieval techniques are frequently successful. However, the majority of these devices are left in place for extended periods of time, which has been associated with greater device-related complications when left in situ, and failure of standard techniques when retrieval is attempted. The development of advanced retrieval techniques has had a positive impact on retrieval of these embedded devices. In this article, technical considerations in the retrieval of such devices, with an emphasis on advanced techniques to facilitate retrieval of embedded devices, are discussed.