Laser-Assisted Removal of Embedded Vena Cava Filters: A First-In-Human Escalation Trial in 500 Patients Refractory to High-Force Retrieval

Laparoscopic-assisted retrieval of inferior vena cava filter: A case report and literature review

BACKGROUND

The retrieval of inferior vena cava filters beyond the retrieval window poses challenges, requiring alternative techniques.

OBJECTIVES

To discuss the laparoscopy-assisted retrieval approach for difficult inferior vena cava filters.

RESEARCH DESIGN

Case report.

SUBJECTS

A 57-year-old male with a retrievable inferior vena cava filter placed 8 months prior.

MEASURES

Laparoscopy-assisted retrieval technique utilized after unsuccessful interventional attempts.

RESULTS

Successful retrieval of the filter despite thickened intimal tissue involvement, with no postoperative complications.

CONCLUSIONS

Laparoscopy-assisted retrieval offers a direct visual approach for challenging filter removal, proving minimally invasive, safe, and effective.

Inferior Vena Cava Filter Retrieval: Simple to Complex

Retrievable inferior vena cava filters were designed to provide mechanical prophylaxis from pulmonary embolism with the intent for retrieval once no longer indicated, and have been utilized at a high rate since their introduction. Unfortunately, retrieval rates have historically lagged behind, in part due to significant rates of failed standard retrieval techniques for filters with prolonged dwell time. Refinement in advanced retrieval techniques has now allowed (in experienced centers) for safe removal of filters previously considered irretrievable. An individualized approach is necessary for each potential advanced filter retrieval to determine appropriate course of action. This review will emphasize complex filter retrieval techniques amidst a larger discussion of inferior vena cava filters and their management.

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.

Safety and Success Rates of Excimer Laser Sheath-Assisted Retrieval of Embedded Inferior Vena Cava Filters

IMPORTANCE

Despite historically high rates of use, most inferior vena cava (IVC) filters are not retrieved. The US Food and Drug Administration safety communications recommended retrieval when the IVC filter is no longer indicated out of concern for filter-related complications. However, failure rates are high when using standard techniques for retrieval of long-dwelling filters, and until recently, there have been no devices approved for retrieval of embedded IVC filters.

OBJECTIVE

To evaluate the safety and success of excimer laser sheath-assisted retrieval of embedded IVC filters.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective, multicenter, clinical cohort study of excimer laser sheath-assisted IVC filter retrievals from 7 US sites was conducted between March 1, 2012, and February 28, 2021, among 265 patients who underwent IVC filter retrieval using the laser. Patients were substratified between a high-volume single center and a multicenter data set. A blinded physician committee adjudicated reported complications and their association with use of the laser.

EXPOSURES

Retrieval of IVC filters using excimer laser sheath.

MAIN OUTCOMES AND MEASURES

The primary safety end point was device-related major complication rate (Society of Interventional Radiology categories C to F, which included any adverse event associated with morbidity or disability that increases the level of care, results in hospital admission, or substantially lengthens the hospital stay). The primary success end point was technical success of IVC filter retrieval. The primary end points were compared with literature-derived, meta-analysis-suggested target performance goals.

RESULTS

The single-center experience included 139 participants (mean [SD] age, 52 [16] years; 78 female participants [56.1%]), and the multicenter experience included 126 participants (mean [SD] age, 52 [16] years; 75 female participants [59.5%]). The device-related major complication rate was 2.9% (4 of 139; 95% CI, 0.8%-7.2%; P = .001) for the single-center experience and 4.0% (5 of 126; 95% CI, 1.3%-9.0%; P = .01) for the multicenter experience, both of which were significantly lower than the primary safety performance goal (10%). No major complications were considered to be definitively associated with use of the laser. The technical success rate was 95.7% (133 of 139; 95% CI, 90.8%-98.4%; P = .007) for the single-center experience and 95.2% (120 of 126; 95% CI, 89.9%-98.2%; P = .02) for the multicenter experience, both of which were significantly higher than the primary performance goal (89.4%).

CONCLUSIONS AND RELEVANCE

This cohort study demonstrated high technical success and low complication rates of excimer laser sheath-assisted retrieval of embedded IVC filters in centers with variable case volume and experience, which suggests a wide applicability of the technique with proper training. The excimer laser sheath offers physicians a valuable tool for retrieval of challenging embedded IVC filters.

Effectiveness and Safety of Laser-Assisted Removal of Inferior Vena Cava (IVC) Filters in a Single Tertiary Care Center

INTRODUCTION

Laser sheath-assisted removal of inferior vena cava (IVC) filters with long dwelling time is a technique that utilizes laser-tipped sheaths. The laser light only penetrates vascular tissue by one hundred microns, causing the target tissues to disintegrate into particles less than 5 microns in size. This approach reduces the energy used during difficult retrieval procedures, allowing permanent filters to be removed in less fluoroscopic and procedural time overall.

MATERIALS AND METHODS

The radiology information system and electronic health records were used in this retrospective cohort study to retrieve the data. A total of nine consecutive patients who underwent laser-assisted filter removal utilizing GlideLightTM were included in the study between January 2016 and January 2017. The study took place at King Abdulaziz Medical City in Riyadh. In this study, five patients were male and four were female with ages ranging from 19 to 57 years with a median age of 31.

RESULTS

During the period of the study, a total of nine patients had their IVC filters removed using a laser. The success rate was 100%. The indications were trauma (n=4) followed by deep vein thrombosis (DVT) (n=3) and one patient indication was prolonged immobilization. The dwelling time ranged from seven to 70 months, with a dwelling median of 19 months.

CONCLUSION

A laser sheath might be necessary for closed-cell filters in order to improve the likelihood of a successful and secure retrieval. Technical efficiency, filter type, the necessity of applying a laser sheath based on an open versus closed filter design, dwell times, and unfavorable results. As a result, after typical procedures failed to successfully retrieve IVC filters with long dwell durations, laser-assisted filter removal is thought to be practical and safe.

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.

Complex filter removal using forceps from combined transfemoral and transjugular approach unhooking the filter apex using forceps and dual access: Two case reports

Modern inferior vena cava filters (IVCFs) are intended to be retrieved once a thrombotic process or risk of pulmonary embolism has resolved independent of administration of anticoagulation. IVCF removal can be challenging with the risk of complications including venous perforation, filter migration, and device fracture. IVCF removal has been described using the nomenclature of routine versus advanced retrieval. Routine retrieval is defined as accessing the filter hook with a loop snare device before advancing a sheath over the filter. Advanced retrieval techniques are employed when routine retrieval fails and can refer to a variety of approaches, including filter realignment with loop snare, stiff wire-displacement, use of a wire and snare with dual access, angioplasty balloon advanced over a guidewire, single access sling approach, the sandwich technique, the endobronchial forceps dissection and removal, photothermic ablation with excimer laser, and the filter eversion technique among others. Successful routine retrieval of IVCF has been reported at 74% and IVCF retrieval with advanced techniques has a success rate of nearly 95%. The complication rate with advanced techniques is higher when compared with routine techniques (5.3% vs. 0.4%; p < .05) and, as expected, requires fluoroscopic time. We report two cases of advanced filter retrieval using endobronchial forceps simultaneously or sequentially through the transfemoral and trans-jugular approach.

Ibero-American Society of Interventionism (SIDI) and the Spanish Society of Vascular and Interventional Radiology (SERVEI) Standard of Practice (SOP) for the Management of Inferior Vena Cava Filters in the Treatment of Acute Venous Thromboembolism

Objectives: to present an interventional radiology standard of practice on the use of inferior vena cava filters (IVCFs) in patients with or at risk to develop venous thromboembolism (VTE) from the Iberoamerican Interventional Society (SIDI) and Spanish Vascular and Interventional Radiology Society (SERVEI). Methods: a group of twenty-two interventional radiologist experts, from the SIDI and SERVEI societies, attended online meetings to develop a current clinical practice guideline on the proper indication for the placement and retrieval of IVCFs. A broad review was undertaken to determine the participation of interventional radiologists in the current guidelines and a consensus on inferior vena cava filters. Twenty-two experts from both societies worked on a common draft and received a questionnaire where they had to assess, for IVCF placement, the absolute, relative, and prophylactic indications. The experts voted on the different indications and reasoned their decision. Results: a total of two-hundred-thirty-three articles were reviewed. Interventional radiologists participated in the development of just two of the eight guidelines. The threshold for inclusion was 100% agreement. Three absolute and four relative indications for the IVCF placement were identified. No indications for the prophylactic filter placement reached the threshold. Conclusion: interventional radiologists are highly involved in the management of IVCFs but have limited participation in the development of multidisciplinary clinical practice guidelines.

Laser-Assisted Removal of Embedded Vena Cava Filters: A First-In-Human Escalation Trial in 500 Patients Refractory to High-Force Retrieval

Background

Many patients are subject to potential risks and filter‐related morbidity when standard retrieval methods fail. We evaluated the safety and efficacy of the laser sheath technique for removing embedded inferior vena cava filters.

Methods and Results

Over an 8.5‐year period, 500 patients were prospectively enrolled in an institutional review board–approved study. There were 225 men and 275 women (mean age, 49 years; range, 15–90 years). Indications for retrieval included symptomatic acute inferior vena cava thrombosis, chronic inferior vena cava occlusion, and/or pain from filter penetration. Retrieval was also offered to prevent risks from prolonged implantation and potentially to eliminate need for lifelong anticoagulation. After retrieval failed using 3X standard retrieval force (6–7 lb via digital gauge), treatment escalation was attempted using laser sheath powered by 308‐nm XeCl excimer laser system (CVX‐300; Spectranetics). We hypothesized that the laser‐assisted technique would allow retrieval of >95% of embedded filters with <5% risk of major complications and with lower force. Primary outcome was successful retrieval. Primary safety outcome was any major procedure‐related complication. Laser‐assisted retrieval was successful in 99.4% of cases (497/500) (95% CI, 98.3%–99.9%) and significantly >95% (P<0.0001). The mean filter dwell time was 1528 days (range, 37–10 047; >27.5 years]), among retrievable‐type (n=414) and permanent‐type (n=86) filters. The average force during failed attempts without laser was 6.4 versus 3.6 lb during laser‐assisted retrievals (P<0.0001). The major complication rate was 2.0% (10/500) (95% CI, 1.0%–3.6%), significantly <5% (P<0.0005), 0.6% (3/500) (95% CI, 0%–1.3%) from laser, and all were successfully treated. Successful retrieval allowed cessation of anticoagulation in 98.7% (77/78) (95% CI, 93.1%–100.0%) and alleviated filter‐related morbidity in 98.5% (138/140) (95% CI, 96.5%–100.0%).

Conclusions

The excimer laser sheath technique is safe and effective for removing embedded inferior vena cava filters refractory to high‐force retrieval. This technique may allow cessation of filter‐related anticoagulation and can be used to prevent and alleviate filter‐related morbidity.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01158482.