Factors Associated with Advanced Inferior Vena Cava Filter Removals: A Single-Center Retrospective Study of 203 Patients Over 7 Years

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.

Clinical outcomes of retrievable inferior vena cava filters for venous thromboembolic diseases

Aim: To identify literature evidence assessing retrievable inferior vena cava filter (rIVCF) for venous thromboembolic diseases. Methods: A systematic literature search was conducted to identify relevant references from the mainstay English and Chinese bibliographic databases (search period: January 2003 to October 2019). Results: 80 original studies with 11,413 patients were included in this review. The success rates of deploying the six types of rIVCFs ranged from 98.4 to 100.0%. Denali had the highest retrieval success rate (95.4-97.6%). The incidence rates of fracture and perforation associated with retrieving the six rIVCFs were less than 2%. Conclusion: The approved rIVCF had comparable clinical profiles, except that Denali was easier to be retrieved than other rIVCF.

Lateral tilt during IVC filter placement does not predict the need for advanced filter retrieval techniques

PURPOSE

We aimed to determine if lateral inferior vena cava (IVC) filter tilt at placement predicts the need for subsequent advanced retrieval techniques.

METHODS

A retrospective chart review was performed of all Gunther Tulip IVC filter placements with subsequent retrievals between February 2015 and October 2017. Chart and imaging review was performed for patient, filter placement, and filter retrieval demographics/characteristics. Degree of agreement between two measurement sets was evaluated with the intraclass correlation (ICC) analysis. Categorical variables were compared with chi-square or Fisher exact test, as appropriate. Kendall rank correlation was used to measure correlation between categorical variables.

RESULTS

There was poor agreement between filter tilt angle at the time of placement and retrieval (ICC coefficient, 0.54). Mean difference ± standard deviation between tilt angle at the time of placement and retrieval was 4.6°±4.3° (p = 0.35). Among patient- or procedure-related factors, a common femoral vein access on placement (regression coefficient, -2.90; p = 0.039) was associated with a lower difference between placement and retrieval filter tilt angles compared to internal jugular vein access. Higher filter tilt angle measured at the time of retrieval (OR: 1.19, p = 0.025), hook embedment (OR: 77.3, p < 0.001), and a longer dwell time (OR: 1.25, p = 0.002) were associated with the need for advanced retrieval techniques. However, in univariate and multivariate analysis filter tilt angle at the time of placement was not associated with the subsequent need for advanced retrieval technique (p = 0.16).

CONCLUSION

Lateral tilt at the time of placement is poorly associated with lateral tilt at the time of retrieval and does not correlate with the need for advanced retrieval technique.

Computational evaluation of inferior vena cava filters through computational fluid dynamics methods

Numerical simulation is growing in its importance toward the design, testing and evaluation of medical devices. Computational fluid dynamics and finite element analysis allow improved calculation of stress, heat transfer, and flow to better understand the medical device environment. Current research focuses not only on improving medical devices, but also on improving the computational tools themselves. As methods and computer technology allow for faster simulation times, iterations and trials can be performed faster to collect more data. Given the adverse events associated with long-term inferior vena cava (IVC) filter placement, IVC filter design and device evaluation are of paramount importance. This work reviews computational methods used to develop, test, and improve IVC filters to ultimately serve the needs of the patient.

Inferior vena cava filter tilting between placement and retrieval is associated with caval diameter and need for complex retrieval techniques

PURPOSE

Inferior vena cava (IVC) filter tilt may lead to apex embedment and need for advanced retrieval techniques. This study assesses factors associated with filter tilt change over time and need for complex retrieval procedures.

MATERIALS AND METHODS

252 consecutive patients underwent retrievable IVC filter placement and removal at a single academic institution over 58 months. 182 (72.2%) patients met inclusion criteria. IVC filters included 168 (92.3%) Gunther Tulip and 14 (7.7%) Option filters. The primary outcome was medial-to-lateral IVC filter tilt change between placement and retrieval. Secondary outcomes included advanced retrieval technique use and multiple retrieval attempts. Independent variables included demographics, IVC diameter, filter hook position relative to the renal veins, and dwell time. Associations were determined using student's t-tests, ANOVA, and linear and logistic regressions.

RESULTS

Mean IVC diameter at placement was 19.2 ± 3.3 mm. Mean filter tilts at placement and retrieval were 6.1 ± 4.9° and 5.2 ± 5.0°, respectively. Mean tilt change was 5.0 ± 5.0°. Larger IVC diameter was associated with greater filter tilt change (p = 0.0004). While IVC diameter did not independently predict retrieval difficulty, greater tilt change and prolonged dwell time were associated with increased advanced retrieval technique use (p = 0.01 and 0.002, respectively). Results were unchanged in a subgroup analysis of patients treated with Gunther Tulip filters.

CONCLUSION

Larger IVC diameter predicts increased filter tilt change, which in turn is associated with challenging retrievals. Attention to IVC diameter during filter placement may anticipate tilt-related complications.

Comparison of Retrievability and Indwelling Complications of Celect and Denali Infrarenal Vena Cava Filters: A Randomized, Controlled Trial

PURPOSE

To compare the Celect and Denali filters in terms of complex filter retrieval and indwelling complications after a 2-month indwelling time.

MATERIALS AND METHODS

In this prospective, randomized trial, 153 subjects were assessed for eligibility between May 2016 and July 2018. A total of 136 participants were randomly assigned to receive either Celect (n = 68) or Denali (n = 68) filter placement in the infrarenal inferior vena cava. Tilt angles at placement and retrieval and rates of overall filter retrieval, indwelling complication, and complex retrieval were compared.

RESULTS

Of 136 participants (mean age, 62 ± 12.8 years, 55 male), 24 (17.6%) were lost to follow-up. The mean indwelling time of filter was 60.4 ± 7 days and there was no significant difference in the baseline characteristics between the two groups. Filter retrieval was successful in all participants (112/112, 100%). Significantly higher rates of filter tilt > 15° (n = 8) and strut penetration (n = 14) were found with the Celect filter than with the Denali filter (1 significant tilt and 1 penetration) (P = 0.033 and 0.001, respectively). No filter fractures were observed and there was no significant difference in tip embedment, filter fracture, filter migration, or mean fluoroscopy times. There were 3 cases of complex retrieval (1 for Denali vs. 2 for Celect, P = 0.500), for which the loop-snare technique was used.

CONCLUSION

Denali filters demonstrated significantly lower rates of tilt angle > 15° and strut penetration. However, there was no significant difference in the complex filter retrieval rate between the Celect and Denali filters.

Role of Inferior Vena Cava Filter Retrieval in Patients on Chronic Anticoagulation Therapy

Purpose of review

Describe the role of inferior vena cava filter (IVCF) retrieval in patients on chronic anticoagulation given the overlap of these treatment options in the management of patients with venous thromboembolic disease.

Recent findings

Despite the increase in IVCF retrievals since the Food and Drug Administration safety communications in 2010 and 2014, retrieval rates remain low. Previous studies have shown that longer filter dwell times are associated with greater risk for filter complications and more difficulty with filter retrievals. Recent findings suggest that complications are more frequent in the first 30 days after placement.

Summary

The decision to retrieve an optional IVCF is individualized and requires diligent follow-up with consistent re-evaluation of the need for the indwelling IVCF, particularly in those on long-term anticoagulation therapy.

Contemporary management of chronic indwelling inferior vena cava filters

OBJECTIVE

Despite increasing retrieval rates of the inferior vena cava (IVC) filter, less than one-third are removed within the recommended timeline. Prolonged filter dwell times may increase the technical difficulty of retrieval and filter-related complications. We sought to evaluate the contemporary outcomes of patients with chronic indwelling IVC filters at a tertiary care center.

METHODS

A retrospective analysis was performed from August 2015 through August 2019 of all patients who were referred for removal of a prolonged IVC filter with a dwell time >1 year. Descriptive analysis was used to evaluate patients' characteristics and procedural outcomes, which were reviewed through electronic medical records. Data were expressed as median with interquartile range (IQR) or number and percentage, as appropriate.

RESULTS

A total of 47 patients were identified with a median filter dwell time of 10.0 years (IQR, 6-13 years); 34 patients underwent IVC filter removal, and 13 patients refused retrieval. The median age of patients was 54.9 years (IQR, 42.5-64.0 years); the majority were female (57%) and white (53%). The most common indication for filter placement was high risk despite anticoagulation (49%), followed by venous thromboembolism prophylaxis (21%). The majority of patients were symptomatic (72%). If symptomatic, the most common reason for retrieval was IVC penetration (94%), and the chief complaint was pain (56%). Retrieval success was 97%, with a median length of stay of 0 days. The majority of retrievals were performed through an endovascular approach (97%). There was one postprocedural complication (3%).

CONCLUSIONS

Despite prolonged dwell times, IVC filter retrieval can be performed safely and effectively in carefully selected patients at a tertiary referral center.

A Single-Institutional Comparative Analysis of Advanced Versus Standard Snare Removal of Inferior Vena Cava Filters

PURPOSE

To investigate differences in procedure time, radiation exposure, and periprocedural complications associated with advanced inferior vena cava (IVC) filter retrieval compared with standard snare retrieval.

MATERIALS AND METHODS

A total of 378 patients underwent standard or advanced IVC filter retrieval over a 5-year period. Technical success, retrieval techniques, fluoroscopy time, radiation dose, and complications were analyzed. All retrieval procedures with techniques other than a "snare-and-sheath" method were categorized as advanced, including failed standard attempts requiring intraprocedural conversion to advanced techniques.

RESULTS

A total of 462 filter retrieval attempts were made in 378 patients (57% female). Success rates for standard and advanced retrieval attempts were 86.8% (317 of 365) and 91.8% (89 of 97), respectively. The rate of periprocedural complications was significantly higher in the advanced retrieval group (P = .006). Complication rates for standard and advanced retrievals were 0.6% (2 of 318; all minor) and 5.2% (5 of 97; 3 minor [3.1%] and 2 major [2.1%]), respectively. The 2 major complications during advanced retrievals included filter fracture and embolization. Average fluoroscopy time for advanced retrievals was significantly higher than for standard retrievals (23.1 min vs 4.3 min; P < .001). Average radiation dose for advanced retrievals was also significantly higher than for standard retrievals (557.2 mGy vs 156.9 mGy; P < .001). Use of general anesthesia was also significantly more common in advanced retrievals compared with standard retrievals (6.2% vs 0.9%; P = .002).

CONCLUSIONS

Advanced filter retrieval results in a similarly high rate of technical success compared with standard snare retrieval but is associated with greater fluoroscopy time, anesthesia requirements, and radiation exposure.

Retrieval characteristics of the Bard Denali and Argon Option inferior vena cava filters

OBJECTIVE

The purpose of this study was to compare the retrieval characteristics of the Option Elite (Argon Medical, Plano, Tex) and Denali (Bard, Tempe, Ariz) retrievable inferior vena cava filters (IVCFs), two filters that share a similar conical design.

METHODS

A single-center, retrospective study reviewed all Option and Denali IVCF removals during a 36-month period. Attempted retrievals were classified as advanced if the routine "snare and sheath" technique was initially unsuccessful despite multiple attempts or an alternative endovascular maneuver or access site was used. Patient and filter characteristics were documented.

RESULTS

In our study, 63 Option and 45 Denali IVCFs were retrieved, with an average dwell time of 128.73 and 99.3 days, respectively. Significantly higher median fluoroscopy times were experienced in retrieving the Option filter compared with the Denali filter (12.18 vs 6.85 minutes; P = .046). Use of adjunctive techniques was also higher in comparing the Option filter with the Denali filter (19.0% vs 8.7%; P = .079). No significant difference was noted between these groups in regard to gender, age, or history of malignant disease.

CONCLUSIONS

Option IVCF retrieval procedures required significantly longer retrieval fluoroscopy time compared with Denali IVCFs. Although procedure time was not analyzed in this study, as a surrogate, the increased fluoroscopy time may also have an impact on procedural direct costs and throughput.

Role of inferior vena cava filters in transplant patients

PURPOSE

This study evaluates the selection, use, and risks of permanent and retrievable inferior vena cava filters (IVCFs) in patients who have undergone organ transplantation.

MATERIALS AND METHODS

Single-center retrospective review of 35 patients who had an IVCF placed following organ transplantation. Patient demographics, IVCF indication, and eligibility for retrieval were reviewed. Computed tomography (CT) studies showing the filter (n=22) were evaluated independently for IVCF adverse effects.

RESULTS

Thirty-two (91%) of 35 patients had retrievable IVCFs placed while three (9%) patients received permanent IVCFs. Filter retrieval was indicated in three of the 32 patients receiving retrievable filters and was performed in two cases. Patients were ineligible for retrieval due to short life expectancy, complications/contraindications to anticoagulation, extended filter dwell time, lost to follow-up, and undetermined therapeutic value of anticoagulation.

CONCLUSION

Current practices of filter placement usually dictate placing a retrievable IVCF in transplant patients. However, transplant patients are unlikely to be eligible for filter retrieval especially in situations of advanced age and comorbidities. Given the low incidence of eligibility for retrieval in this patient population, these results suggest preferential placement of permanent filters may reduce the potential morbidity due to filter-related complications, such as strut perforation, in transplant patients.

Retrievable IVC filters - Friend or foe

Venous thromboembolism is a common condition with widely varied outcomes. Pulmonary embolism is associated with a case-fatality rate of up to 8%, increasing up to 18-fold in massive PE. Pharmacological treatment of VTE with anticoagulant medication (AC) is the first line therapy of choice. Retrievable inferior vena cava filters (IVCF) are indicated as a short-term replacement for AC in certain circumstances. Most of the evidence concerning IVCF pertains to permanent filters and older filter models. Limited evidence for retrievable IVCF results in poor consensus regarding indications, follow-up and retrieval. Complications increase with dwell-time and retrieval success rates decline. Professional bodies advocate strict guideline adherence and robust strategies for filter monitoring to maximise retrieval rate.