A Novel Technique for Inferior Vena Cava Filter Extraction

Successful retrieval of tip-embedded inferior vena cava filter using a modified forceps technique: case report

BACKGROUND

The retrieval of inferior vena cava (IVC) filter is essential for preventing complications associated with the device. Advanced techniques have been developed to improve the success rate of retrieving tip-embedded filters. The forceps technique is frequently used to address this issue.

CASE PRESENTATION

We present a case study of two patients who underwent a successful tip-embedded IVC filter retrieval using a modified forceps technique, which has not been previously reported. This technique involves using a wire loop under the filter tip and a forceps to grasp the filter shoulder. By pulling the wire loop and pushing the forceps in counterforce, the filter tip is straightened and aligned with the vascular sheath. The vascular sheath can then dissect the filter tip out from the caval wall and get inside the sheath to complete the retrieval.

CONCLUSIONS

The modified forceps technique we present here offers a new solution for the complex retrieval of IVC filters.

The development of a novel endovascular grasper for challenging inferior vena cava filter retrieval

OBJECTIVE

Although inferior vena cava (IVC) filters are commonly retrieved using a snare, lateral tilt and fibrosis around struts can complicate the procedure and sometimes require the use of off-label devices. We describe the development of a novel articulating endovascular grasper designed to remove permanent and retrievable IVC filters in any configuration.

METHODS

For in vitro testing, the IVC filters were anchored to the inner wall of a flexible tube in a centered or tilted configuration. A high-contrast backlit camera view simulated the two-dimensional fluoroscopy projection during retrieval. The time from the retrieval device introduction into the camera field to complete filter retrieval was measured in seconds. The control experiment involved temporary IVC filter retrieval with a snare. There were four comparative groups: (1) retrievable filter in centered configuration; (2) retrievable filter in tilted configuration; (3) permanent filter in centered configuration; and (4) permanent filter in tilted configuration. Every experiment was repeated five times, with median retrieval time compared with the control group. For in vivo testing in a porcine model, six tilted infrarenal IVC filters were retrieved with grasper via right jugular approach. Comparison analysis between animal and patient procedures was performed for the following variables: total procedure time, the retrieval time, and fluoroscopy time.

RESULTS

The in vitro experiments showed comparable retrieval times between the experimental groups 1, 2, and 4 and the control. However, grasper removal of a centered permanent filter (group 3) required significantly less time than in the control (29 vs 79 seconds; P = .009). In the animal model, all IVC filters were retrieved using the grasper with no adverse events. The total procedure time (21.2 vs 43.5 minutes; P = .01) and the fluoroscopy time (4.3 vs 10 minutes; P = .044) were significantly shorter in the animal model compared with the patient group. Moreover, in the patient group, 16.7% of retrievals required advanced endovascular techniques, and one IVC filter could not be retrieved (success rate = 91.7%), whereas all the IVC filters were successfully retrieved in the animal model without the use of additional tools.

CONCLUSIONS

The novel endovascular grasper is effective in retrieving different types of IVC filters in different configurations and compared favorably with the snare in the in vitro model. In vivo experiments demonstrated more effective retrieval when compared with matched patient retrievals.

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.

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.

Retroperitoneal Laparoscopic-Assisted Retrieval of Wall-Penetrating Inferior Vena Cava Filter After Endovascular Techniques Failed: An Initial Clinical Outcome

BACKGROUND

Inferior vena cava (IVC) filters are commonly used in China to prevent pulmonary embolisms in patients with deep vein thrombosis. However, IVC filter removal is complicated when the filter has penetrated the IVC wall and endovascular techniques usually fail. The purpose of this study was to evaluate the effectiveness and safety of retroperitoneal laparoscopic-assisted retrieval of wall-penetrating IVC filters after endovascular techniques have failed.

PATIENTS AND METHODS

We retrospectively evaluated a series of 8 patients who underwent retroperitoneal laparoscopic-assisted retrieval of a wall-penetrating IVC filter between December 2017 and November 2019. All patients had experienced at least 1 failure with endovascular retrieval before the study. The filters were slanted and the proximal retrieval hooks penetrated the posterior lateral IVC wall in all patients on computed tomography. Demographic information, operation parameters, and complications were recorded and analyzed. All patients were followed up for at least 12 months.

RESULTS

The procedure was successful in all patients. The median surgery time was 53.6 ± 12.7 min and the average blood loss was 45.0 ± 13.5 ml. No serious complication occurred during the patients' hospitalization, which was an average of 6.4 days. The median follow-up time was 15.1 months, and no patient had deep vein thrombosis recurrence.

CONCLUSIONS

Retroperitoneal laparoscopic-assisted retrieval is a feasible and effective technique, particularly when proximal retrieval hooks penetrate the posterior lateral wall of the IVC after endovascular techniques have failed. To some extent, the development of this technique at our institution has increased the success rate of filter removal and improved patient satisfaction.

Endobronchial Forceps-Assisted and Excimer Laser-Assisted Inferior Vena Cava Filter Removal: The Data, Where We Are, and How It Is Done

The recognition of inferior vena cava filter related complications has motivated increased attentiveness in clinical follow-up of patients with inferior vena cava filters and has led to development of multiple approaches for retrieving filters that are challenging or impossible to remove using conventional techniques. Endobronchial forceps and excimer lasers are tools for designed to aid in complex inferior vena cava filter removals. This article discusses endobronchial forceps-assisted and excimer laser-assisted inferior vena cava filter retrievals.

Tine after tine: a varied approach to the removal of a long-standing IVC filter

Inferior vena cava filters are important tools used to help prevent life-threatening pulmonary embolisms in hospitalized patients with contraindications to pharmacological prophylactic anticoagulation. This is a case report of a patient who had an inferior vena cava filter placed after a traumatic subdural hematoma. He made a complete recovery but was lost to follow-up until he presented 1825 days after filter deployment with abdominal pain discovered to be from penetration of the filter tines outside the lumen and into adjacent structures. We describe a case complicated by fibrotic tine entrapment with penetration to surrounding structures and discuss the technical approach used to free and eventually remove the long-standing filter.