Clinical Experience With Retrievable Günther Tulip Vena Cava Filters

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.

Rates and predictors of plans for inferior vena cava filter retrieval in hospitalized patients

BACKGROUND

Use of inferior vena cava (IVC) filters has been increasing over time. However, because of the increased risk of deep vein thrombosis with permanent filters, placement of retrievable filters has been recommended. Little is known about the factors associated with planned retrieval of IVC filters.

OBJECTIVE

To describe rates and predictors of plans to retrieve IVC filters in hospitalized patients.

DESIGN

We identified all IVC filter placements from 2001-2006 at an academic medical center and reviewed medical charts to obtain data about patient characteristics, filter retrieval plans, and retrieval success rates. Multivariable logistic regression was used to identify independent predictors of planned filter retrieval in patients with retrievable filters.

RESULTS

Out of 240 patients who underwent placement of retrievable IVC filters, only 73 (30.4%) had documented plans for filter retrieval. Factors associated with lower rates of planned filter retrieval included a history of cancer [adjusted odds ratio (OR) and 95% confidence interval 0.2 (0.1-0.5)] and not being discharged on anticoagulants [OR 0.1 (0.1-0.3)]. In addition, 36 (21.6%) of patients without retrieval plans had no contraindications to retrieval. Of the 62 patients who underwent attempted filter retrieval, 25.8% of filters could not be successfully removed.

CONCLUSIONS

Only 30.4% of patients who underwent placement of a retrievable IVC filter had documented plans for filter removal. Although most patients had justifiable reasons for filter retention, 21.6% of patients had no clear contraindications to filter removal. Efforts to improve rates of filter retrieval in appropriate patients may help reduce the long-term complications of IVC filters.

Complications related to deep venous thrombosis prophylaxis in trauma: a systematic review of the literature

Deep venous thrombosis prophylaxis is essential to the appropriate management of multisystem trauma patients. Without thromboprophylaxis, the rate of venous thrombosis and subsequent pulmonary embolism is substantial. Three prophylactic modalities are common: pharmacologic anticoagulation, mechanical compression devices, and inferior vena cava filtration. A systematic review was completed using PRISMA guidelines to evaluate the potential complications of DVT prophylactic options. Level one evidence currently supports the use of low molecular weight heparins for thromboprophylaxis in the trauma patient. Unfortunately, multiple techniques are not infrequently required for complex multisystem trauma patients. Each modality has potential complications. The risks of heparin include bleeding and heparin induced thrombocytopenia. Mechanical compression devices can result in local soft tissue injury, bleeding and patient non-compliance. Inferior vena cava filters migrate, cause inferior vena cava occlusion, and penetrate the vessel wall. While the use of these techniques can be life saving, they must be appropriately utilized.

Retrievable vena cava filters: a clinical review

Vena cava filters were developed as a method of preventing pulmonary embolism (PE) in patients with venous thromboembolism (VTE) at risk for bleeding from therapeutic anticoagulation. However, the long-term complications of filter placement, such as caval thrombosis, have mitigated some of the benefits, particularly in those patients with only a temporary contraindication to anticoagulation. Retrievable filters were designed to avoid the long-term risks of a permanent filter while still providing short-term protection against PE. As a result, their use has expanded from patients with known thrombosis to those without VTE who are at high risk for developing PE. In this review, we discuss the different types of retrievable filters, indications for their placement, complications that can occur during and after placement, and their use as prophylaxis in surgical patients. Although the use of retrievable filters in patients with known VTE is clear, further studies are needed to establish their prophylactic efficacy in the surgical patient. Until this evidence is available, we recommend that retrievable filters should be used only in patients with acute VTE who are at risk for recurrent thromboembolism and have a transient risk for bleeding.

Analysis of tilt of the Günther Tulip filter

PURPOSE

To determine the frequency, dimensions, predictors, and sequelae of Günther Tulip filter (GTF) tilt measured at the time of intended retrieval.

MATERIALS AND METHODS

Retrospective review of all medical records and posteroanterior cavograms of 175 patients who underwent both placement and retrieval of the GTF between August 2003 and July 2007 was performed to assess the frequency, dimensions, predictors, and sequelae of tilt.

RESULTS

Tilt occurred at the first retrieval attempt in 159 of the 175 patients (91%). The average degree of tilt was 7.1 degrees (range, 0 degrees-30 degrees), with 87 of the 159 filters with tilt (55%) having a rightward tilt. Compared with the femoral approach, filters placed with a jugular approach demonstrated 4.2 degrees (range of the standard deviation, 3.1 degrees-5.3 degrees) greater tilt at the first retrieval attempt (95% confidence interval=2.6 degrees, 5.7 degrees; P<.001, two-sided Student t test), a greater frequency of tilt of at least 14 degrees (P=.002, two-sided Fisher exact test), and greater rightward tilt predominance (P=.046, one-sided Fisher exact test). Tilt magnitude at the first retrieval attempt correlated positively with the inferior vena cava diameter 40 mm caudal to the renal vein confluence (R=.183, P=.018, Pearson correlation). Within its limitations, this study detected no new cases of pulmonary embolism, caval perforation, or GTF migration. The success rates at the first attempt at retrieval and the cumulative GTF retrieval success rates were 93% (176 of 190 filters) and 97% (181 of 190 filters), respectively. All 29 GTFs with tilt of at least 14 degrees were placed and successfully retrieved by means of a jugular approach with minimal clinical and technical sequelae.

CONCLUSIONS

Frequent GTF tilt detected at the first retrieval attempt can reach at least 14 degrees and is associated with minimal sequelae. Insertion approach and caval diameter are significant factors in GTF tilt.

Loop-Snare Technique for Difficult Inferior Vena Cava Filter Retrievals

Retrievable inferior vena cava (IVC) filters are generally retrieved without difficulties. However, when filters are tilted against the IVC wall, engaging the tip or hook of the filter can be difficult with the use of standard techniques. This report describes an alternative method of successful IVC filter retrieval by creating a wire loop between the filter legs, including the tip of the filter. This loop snare was successfully applied in eight cases after filter retrieval failed with the Recovery Cone or simple snare technique.

Venographic Findings at Retrieval of Inferior Vena Cava Filters

OBJECTIVE

The purpose of this study was to evaluate inferior venacavograms at the time of inferior vena cava (IVC) filters for clot within filter, IVC stenosis, or IVC injuries.

CONCLUSION

Abnormal venographic findings at filter retrieval include clot in the filter, IVC stenosis, and minor IVC injury after filter retrieval. Most abnormalities decrease or resolve over time.

Estimation of Trapped Thrombus Volumes in Retrievable Inferior Vena Cava Filters: A Visual Scale

PURPOSE

To establish a visual, objective scale for estimating trapped thrombus volumes in five types of retrievable inferior vena cava filters.

MATERIAL AND METHODS

Silicone-based radiopaque polymer volumes of 0.25, 0.5, 1.0, 1.5, 2.0, 3.0, and 4.0 mL were created. Both sphere and cone shapes were used. Polymer volumes were confirmed by means of the water displacement method. The volumes were then positioned to simulate trapped thrombus in five retrievable filters: Recovery and G2 (Bard Peripheral Vascular, Tempe, Ariz), Günther Tulip and Celect (Cook, Bloomington, Ind), and OptEase (Cordis Endovascular, Warren, NJ). Radiographs were obtained by using conventional parameters. Visual scales of thrombus volume were created for each filter type.

RESULTS

Visual scales for each retrievable filter type were created with simulated thrombi in typical trapping positions.

CONCLUSION

The authors developed a visual, objective scale for estimating trapped thrombus volume in five types of retrievable IVC filters. This could facilitate standardized reporting of thrombus volumes in studies of optional vena cava filters.

Günther Tulip Filter Retrievability Multicenter Study Including CT Follow-up: Final Report

PURPOSE

To evaluate the safety and effectiveness of retrieval of the Günther Tulip inferior vena cava (IVC) filter.

MATERIALS AND METHODS

This was a nonrandomized, single-armed, multicenter prospective investigation. Patients at temporary high risk for pulmonary embolism (PE) or deep vein thrombosis (DVT) who did not require a permanent filter were eligible. Forty-one patients received 42 Günther Tulip filters: 22 men and 19 women with a mean age of 47.7 years. Indications for filter placement included prophylaxis, PE, and DVT. Three months after filter retrieval, contrast agent-enhanced computed tomography of the abdomen, jugular vein ultrasonography, and clinical follow-up were performed.

RESULTS

The filter retrieval rate was 57% (23 of 41). Günther Tulip filters were removed at a mean of 11.1 days (range, 2-14 d). The technical and clinical success rates for filter retrieval were both 100%. One placement complication and two protocol deviations occurred. These patients were excluded in terms of retrieval-related outcomes. One case of PE occurred with a filter in place, and one filter migrated to the heart. There were no acute complications caused by filter retrieval. At 3-month follow-up, there was no recurrent PE, DVT, jugular vein occlusion, or IVC stenosis or occlusion.

CONCLUSION

In this multicenter study, retrieval of the Günther Tulip filter was safe and without recurrent thromboembolic events or evidence of IVC or jugular vein damage at 3-month follow-up.

Retrieval of the Günther Tulip and OptEase Filters Using the Recovery Cone Removal System

The Recovery Cone Removal System was evaluated in vitro to determine its feasibility as an alterative retrieval device for the Günther tulip and OptEase inferior vena cava filters. The cone removal system was then used electively in eight patients to determine feasibility and safety in vivo and subsequently in a single patient when wire-snare removal failed. The Recovery Cone Removal System allowed in vitro and in vivo retrieval in all cases without difficulty or complication. The Recovery Cone Removal System offers an alternative to the wire-snare-based retrieval systems for removal of the Günther tulip and OptEase filters.

Clinical experience with Günther temporary inferior vena cava filters

This retrospective study was performed to evaluate the safety and effectiveness of Günther temporary inferior vena cava (IVC) filters. Fifteen Günther temporary filters were placed in 13 patients because of deep vein thrombosis (DVT) with pulmonary embolism (PE) despite DVT prophylaxis (9/13) or temporary contraindications for anticoagulants as well as recent or pending surgery (4/13). No clinical manifestation of PE was observed during the filtration or during the removal. Günther temporary IVC filters are easy and safe to use, and are effective in clot trapping, protecting patients at high risk for PE in whom anticoagulation treatment failed or is contraindicated.

Vena Cava Filters: Uses and Abuses

Currently, there are more than 10 permanent and optional retrievable vena cava filters in use in North America and Europe. Indications for inferior vena cava (IVC) filter placement are intuitive and filters are used in patients who have deep venous thrombosis (DVT) and contraindications to anticoagulation, or in patients who hemorrhage while anticoagulated for DVT. Multiple studies have proposed broadening the use of IVC filters as primary venous thromboembolism (VTE) prophylaxis in certain patient populations. Many permanent IVC filters have been well studied and have superior performance characteristics. On the other hand, optional retrievable IVC filters are attractive in the patient with a well-defined, short-term risk for VTE and contraindications to anticoagulation. Filter retrieval after the patient can be anticoagulated would eliminate the long-term risk of DVT associated with permanent IVC filter placement. Unfortunately, most optional retrievable filters are relatively new and have little to no data on their long-term performance when used as permanent filters, and the percentage of retrievable filters actually removed is less than 50%. The spirited debate concerning which patient should get which filter is just beginning. More prospective, randomized trials evaluating optional retrievable filters are needed to answer these important questions.

Experience with the Recovery Filter as a Retrievable Inferior Vena Cava Filter

PURPOSE

This study evaluates clinical experience with the Recovery filter as a retrievable inferior vena cava (IVC) filter.

MATERIALS AND METHODS

One hundred seven Recovery filters were placed in 106 patients with an initial clinical indication for temporary caval filtration. Patients were followed up to assess filter efficacy, complications, eventual need for filter removal, time to retrieval, and ability to remove the filter.

RESULTS

The patient cohort consisted of 62 men and 44 women with a mean age of 48 years (range, 18-90 y). Mean implantation time was 165 days. Indications for filter placement in patients with deep vein thrombosis (DVT) and/or pulmonary embolism (PE) included contraindication to anticoagulation (n = 33), complications of anticoagulation (n = 8), poor cardiopulmonary reserve (n = 6), large clot burden (n = 3), and PE while receiving anticoagulation (n = 1). Indications for filter placement in patients without proven PE or DVT included immobility after trauma (n = 35); recent intracranial hemorrhage, neurosurgery, or brain tumor (n = 18); and other surgical or invasive procedure (n = 3). Three patients (2.8%) had symptomatic PE after placement of the Recovery filter. No caval thromboses were detected. No symptomatic filter migrations occurred. Recovery filter removal was attempted in 15 of 106 patients (14%) at a mean of 150 days after placement. The Recovery filter was successfully retrieved in 14 of 15 patients (93%); one removal was unsuccessful at 210 days after placement. Ninety-two filters (87%) currently remain in place.

CONCLUSIONS

Although all the filters were placed with the intention of being removed, a large percentage of filters were not retrieved. The Recovery filter was safe and effective in preventing PE when used as a retrievable IVC filter.