Novel and Advanced Techniques for Complex IVC Filter 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.

Perforation of the Heart During Elective Removal of an Inferior Vena Cava Filter

ABSTRACT

A common treatment for venous thromboembolic disease in patients with contraindications to anticoagulation includes placement of an inferior vena cava (IVC) filter. Temporary filters are available to avoid the risk of long-term permanent placement. A woman in her 60s with a history of uterine serous carcinoma presented to the emergency department with cardiac arrest following elective attempted IVC filter removal. Three months prior, a temporary filter was placed because anticoagulation medication was stopped in preparation for a hysterectomy. During the IVC retrieval procedure, which was performed using an intravascular approach from the right jugular vein, the filter was tilted, requiring the use of a different retrieval sheath. During catheter reentry, the patient complained of discomfort in the chest and neck, after which she became hypotensive, lost consciousness, and died. Autopsy revealed 2 cardiac perforations, one in each ventricle. Approximately 600 mL of liquid and clotted blood was within the tense pericardial sac. An IVC filter was found in place, with no adjacent hemorrhage.To our knowledge, this is the first reported fatality due to cardiac perforation by an access sheath during intravascular removal of an IVC filter. This instance also documents the time course of the cardiac perforations to the resultant loss of consciousness.

Case Report: Endoluminal removal of a conical retrievable superior vena cava filter with a retraction hook attached to the wall

We report the case of a 22-year-old male who underwent endoluminal surgery and was implanted an Option Elite filter in the superior vena cava (SVC) while the filter retraction hook was attached to the vessel wall. The patient requested to remove the filter after 155 days. Preoperative ultrasonography and CT examination revealed that the filter retraction hook was very likely to penetrate the SVC wall and its tip was very close to the right pulmonary artery. The SVC was not obstructed, and no thrombus was observed in either upper limb. After the filter retrieval device (ZYLOX, China) failed to capture the filter hook, we introduced a pigtail catheter with its tip partly removed and a loach guidewire, used a modified loop-snare technique to cut the proliferative tissues and free the hook, and finally removed the filter successfully by direct suspension of the guidewire. During this procedure, the patient experienced discomfort, such as chest pain and palpitations, but these symptoms disappeared when procedure completed. Repeated multiangle angiography revealed no contrast medium extravasation, no complications such as pericardial tamponade, pleural effusion, SVC haematoma formation, right pulmonary artery dissecting aneurysm, or intramural haematoma. We initially presented the modified loop-snare technique used to remove a conical superior vena cava filter (SVCF), so this method can be considered a practical and novel auxiliary technique for successful filter retrieval.

Supply Costs in Complex and Routine Inferior Vena Cava Filter Retrieval: 10 Years' Data from a Single Center

PURPOSE

To characterize the medical supply costs associated with inferior vena cava filter retrieval (IVCFR) using endobronchial forceps (EFs), a snare, or Recovery Cone (RC).

MATERIALS AND METHODS

In total, 594 of 845 IVCFRs attempted at a tertiary referral hospital between October 1, 2012, and June 20, 2022 were categorized by intended retrieval strategy informed by, rotational cavography as follows: (a) EF (n = 312) for tilted or tip-embedded/strut-embedded filters and for long-dwelling closed-cell filters and (b) a snare (n = 255) or (c) RC (n = 27) for other well-positioned filters with or mostly without hooks, respectively. List prices of relevant supplies at time of retrieval were obtained or, rarely, estimated using a standard procedure. Contrast use, fluoroscopic time, filter type, dwell time, and patient age and sex were recorded. Mean between-group cost differences were estimated by linear regression, adjusting for date. Additional models evaluated filter type, dwell time, and patient-level effects.

RESULTS

Of the 594 IVCFRs, 591 were successful, whereas 2 EF and 1 snare retrievals failed. Moreover, 4 EF retrievals were successful with a snare and 2 with smaller EF, 12 snare retrievals were successful with EF, 1 RC retrieval was successful with a snare and 2 with EF. Principal model indicated a significantly lower mean cost of EF ($564.70, SE ± 9.75) than that of snare ($811.29, SE ± 10.83; P < .0001) and RC ($1,465.48, SE ± 47.12; P < .0001) retrievals. Adjusted models yielded consistent results. Had all retrievals been attempted with EF, estimated undiscounted full-period supplies savings would be $87,201.51.

CONCLUSIONS

EFs are affordable for complex IVCFR, and extending their use to routine IVCFR could lead to considerable cost savings.

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.

Reengaging patients with forgotten filters through an institutional multidisciplinary approach

OBJECTIVE

The aim of the present study was to evaluate the outcomes of a hospital-wide multidisciplinary initiative to reengage and manage patients with unretrieved chronic indwelling inferior vena cava (IVC) filters placed at a large tertiary care center, who had been lost to follow-up.

METHODS

We performed a retrospective review of outcomes from a completed multidisciplinary quality improvement project. The quality improvement project identified and contacted (via letter) patients with chronic indwelling IVC filters placed at a single tertiary care center from 2008 to 2016 who were alive and without evidence of filter retrieval in the medical records. A total of 316 eligible patients were mailed a letter regarding their chronic indwelling IVC filter and the updated recommendations regarding IVC filter removal. The letter included institutional contact information, and all the patients who responded were offered a clinic visit to discuss potential filter retrieval. In the retrospective review, we assessed the outcomes of the quality improvement project, including the patient response rate, follow-up clinic visits, new imaging studies generated, retrieval rate, procedural success, and complications. The patient demographics and filter characteristics were collected and evaluated for correlations with the response and retrieval rates.

RESULTS

The patient response rate to the letter was 32% (101 of 316). Of the 101 patients who responded, 72 (71%) were seen in clinic and 59 (82%) underwent new imaging studies. Using standard and advanced techniques, 34 of 36 filters after a median dwell time of 9.4 years (range, 3.3-13.3 years) were successfully retrieved (94% success rate). The patients with a documented IVC filter complication were more likely to respond to the letter (odds ratio, 4.34) and undergo IVC filter retrieval (odds ratio, 6.04). No moderate or severe procedural complications occurred during filter retrieval.

CONCLUSIONS

An institutional, multidisciplinary quality initiative successfully identified and reengaged patients with chronic indwelling IVC filters who had been lost to follow-up. The filter retrieval success rate was high and procedural morbidity low. Institution-wide efforts to identify and retrieve chronic indwelling filters are feasible.

Acute venous problems: Integrating medical, surgical, and interventional treatments

"Acute venous problems" refers to a group of disorders that affect the veins and result in sudden and severe symptoms. They can be classified based on the pathological triggering mechanisms, such as thrombosis and/or mechanical compression, and their consequences, including symptoms, signs, and complications. The management and therapeutic approach depend on the severity of the disease, the location, and the involvement of the vein segment. Although summarizing these conditions can be challenging, the objective of this narrative review was to provide an overview of the most common acute venous problems. This will include an exhaustive yet concise and practical description of each condition. The multidisciplinary approach remains one of the major advantages in dealing with these conditions, maximizing the results and the prevention of complications.

Stenting across inferior vena cava filters can be a safe and effective alternative to complex retrieval

OBJECTIVE

Venous stenting for acute and chronic venous disease has been increasingly used as more evidence has accumulated on the efficacy and durability of these interventions for symptomatic patients. Inferior vena cava (IVC) filters that could have been present for years will often be implicated in the obstructive pathology and removal can be challenging. The purpose of the present study was to evaluate whether stenting across an indwelling IVC filter is a safe and effective alternative to removal.

METHODS

Consecutive patients who had undergone iliocaval stenting at our institution from 2007 to 2020 were identified and divided into groups stratified by the presence of an IVC filter. The operative notes, venography findings, and the electronic health records were queried to obtain the operative details, patient characteristics, postoperative outcomes, stent patency, and survival outcomes. The primary end point was iliocaval stent patency. The patients were divided into two groups according to the presence of an IVC filter with or without overstenting. We used the χ2 test and survival analysis as appropriate.

RESULTS

A total of 224 consecutive patients were identified, of whom 71 were found to have undergone iliocaval stenting (age, 48 ± 18 years; 47.9% male; body mass index, 31 ± 9 kg/m2). Of the 71 patients, 15 had had stents placed across an indwelling IVC filter (overstented group) and 56 had not had an IVC filter present (non-overstented group). No differences were found in presentation between the overstented group (acute occlusion, 4 of 15 [26.7%]; chronic occlusion, 8 of 15 [53.3%]; and nonocclusive lesions, 3 of 15 [20%]) and the non-overstented group (acute occlusion, 29 of 56 [52%]; chronic occlusion, 18 of 56 [32%]; nonocclusive lesions, 9 of 56 [16%]; P = .2). Comparisons between the two groups revealed no differences in the baseline characteristics except for age (overstented, 57 ± 15 years; non-overstented, 46 ± 18 years; P = 0.03), preoperative anticoagulation therapy (overstented, 66.6%; non-overstented, 26.9%; P = .01), and bilateral leg symptoms (overstented, 86.7%; non-overstented, 23.2%; P < .001). Primary patency at 30 months was 85.6% in the overstented group and 86.1% in the non-overstented group (P = .78). At follow-up, no adverse events related to filter crushing were reported, and no differences were found in 30-month survival.

CONCLUSIONS

In our single-center, retrospective study of iliocaval stenting, patients who had undergone overstenting across an indwelling IVC filter had had patency rates similar to those whose stents had been placed with no IVC filter in place. Thus, complex IVC filter removal, when not possible or when the risk of operative complications is too high, can be forgone in favor of stenting across the IVC filter, with no implications on midterm patency or adverse events.

Case report: Endoluminal removal of a retrievable conical inferior vena cava filter with a ruptured retraction hook attached to the wall

We report the case of a patient who underwent endovascular retrieval of a conical inferior vena cava (IVC) filter with a ruptured retraction hook that was attached to the IVC wall. A 21-year-old woman with a Celect (Cook) filter, implanted 1,522 days prior, requested retrieval. Preoperative ultrasound and CT examinations showed that the filter was inclined, the retraction hook was attached to the IVC wall, and one of the filter’s pedicles was broken. The inferior vena cava was patent, with no thrombus. Old superficial femoral vein thrombosis could be seen in the right lower extremity. The filter retrieval equipment (Gunther Tulip, Cook) failed to capture the retraction hook. By means of a pigtail catheter (with a partly removed catheter tip) and loach guidewire, we applied a modified loop-snare technique to successfully cut the proliferative tissue near the tip of the retraction hook, by which the hook re-entered the inferior vena cava. Although the snare successfully captured the retraction hook and retrieved the filter, the broken pedicle was retained in the inferior vena cava. We used forceps to capture and pull it to the distal end. In the end, the inferior vena cava became patent, with no contrast agent spillage or residual, and no symptomatic pulmonary embolization. A simultaneous occurrence of oblique adherence and fracture is rarely found in the same filter; however, by using the modified loop-snare technique and biopsy forceps technique, we successfully retrieved the filter and broken pedicle. Our case provides a practical auxiliary technique for regular clinical practice.

Migration of an Inferior Vena Cava (IVC) Filter Into the Intrahepatic IVC: A Case Report

The use of Inferior Vena Cava (IVC) filters is increasing for patients who cannot otherwise receive anticoagulation for a deep vein thrombosis (DVT) or pulmonary embolism (PE). In this case, a 60-year-old man presenting with abdominal pain was found to have migration of his IVC filter into his intrahepatic IVC. Interventional radiology (IR) and vascular surgery were consulted as the migrated IVC filter was felt to be the likely cause of the patient’s pain. Consideration was given to transferring the patient to a liver transplant center to retrieve the migrated filter. When patients with a history of IVC filter placement present to the emergency department, a high index of suspicion for IVC filter complication should be maintained and there should be a low threshold for ordering CT imaging. If a severe IVC filter complication is discovered, patients may ultimately require transfer to a center with hepatic surgery capability for definitive treatment given the complex vasculature involved.

Precision interventional radiology

The recent interest in precision medicine among interventionists has led to the establishment of the concept of precision interventional radiology (PIR). This concept focuses not only on the accuracy of interventional operations using traditional image-guided techniques, but also on the comprehensive evaluation of diseases. The invisible features extracted from CT, MRI, or US improve the accuracy and specificity of diagnosis. The integration of multi-omics and molecule imaging provides more information for interventional operations. The development and application of drugs, embolic materials, and devices broaden the concept of PIR. Integrating medicine and engineering brings new image-guided techniques that increase the efficacy of interventional operations while reducing the complications of interventional treatment. In all, PIR, an important part of precision medicine, emphasizing the whole disease management process, including precision diagnosis, comprehensive evaluation, and interventional therapy, maximizes the benefits of patients with limited damage.

Permanent IVC filter strut penetration into an abdominal aortic aneurysm

An 85-year-old man with a known history of abdominal aortic aneurysm (AAA) presented to a vascular surgery clinic with a severely swollen, tender and erythematous left leg. An urgent CT angiogram demonstrated a left-sided, proximal deep vein thrombosis, and a permanent, Bird's Nest inferior vena cava (IVC) filter (Cook, Inc., Bloomington, Ind.) penetrating his AAA. The patient was treated with a course of apixaban 5 mg two times per day and the decision was made to closely observe his IVC filter and AAA, given his numerous comorbidities and age. This case highlights the unique considerations associated with an approach to permanent IVC filter complications among patients with AAAs.

Procedural complications of inferior vena cava filter retrieval, an illustrated review

Annually, approximately 65,000 inferior vena cava (IVC) filters are placed in the United States (Ahmed et al., J Am Coll Radiol 15:1553-1557, 2018). Approximately 35% of filters are eventually retrieved (Angel et al., J Vasc Interv Radiol 22: 1522-1530 e1523, 2011). Complications during filter retrieval depend heavily on technique and filter position. In this paper, we review risk factors and incidence of complications during IVC filter removal. We also discuss ways these complications could be avoided and the appropriate management if they occur.

Forceps-assisted Removal of Difficult-to-Retrieve Filters: Preliminary Results

BACKGROUND

The aim of this study is to retrospectively evaluate the safety and effectiveness of forceps-assisted removal of difficult-to-retrieve filters.

METHODS

Patients who underwent forceps-assisted removal of difficult-to-retrieve filters (filters that could not be successfully removed with the standard loop-snare technique) between February 2008 and February 2019 were included in this study. Patients underwent forceps-assisted filter removal either immediately after failed loop-snare removal (same procedure) or at a later time (separate procedure). Data regarding success rate, X-ray exposure time, and complications were recorded.

RESULTS

A total of 27 patients (14 men, 13 women; mean age 57.9 ± 12.6 years) were included in this study. The mean indwelling time of the filters was 10.9 ± 10.7 months. All filters were successfully removed. The mean X-ray exposure time was 25.9 ± 12.7 min (range 8-55) for all patients; the mean X-ray exposure times were 10.2 ± 2.3 min (range 8-14) for the 5 patients who underwent forceps-assisted filter removal in a separate procedure and 29.5 ± 11.2 min (range 15-55) for the 22 patients who underwent forceps-assisted filter removal immediately after failure of the loop-snare technique (P < 0.001). Two patients (8.3%) experienced extravasation of contrast material and needed no additional treatment. No major complications occurred.

CONCLUSIONS

Forceps-assisted filter retrieval can be used to safely and effectively remove difficult-to-retrieve filters.

The Clinical Rationale for the Sentry Bioconvertible Inferior Vena Cava Filter for the Prevention of Pulmonary Embolism

The Sentry inferior vena cava (IVC) filter is designed to provide temporary protection against pulmonary embolism (PE) during transient high-risk periods and then to bioconvert after 60 days after implantation. At the time of bioconversion, the device's nitinol arms retract from the filtering position into the caval wall. Subsequently, the stable stent-like nitinol frame is endothelialized. The Sentry bioconvertible IVC filter has been evaluated in a multicenter investigational-device-exemption pivotal trial (NCT01975090) of 129 patients with documented deep vein thrombosis (DVT) or PE, or at temporary risk of developing DVT or PE, and with contraindications to anticoagulation. Successful filter conversion was observed in 95.7% of patients at 6 months (110/115) and 96.4% at 12 months (106/110). Through 12 months, there were no cases of symptomatic PE. The rationale for development of the Sentry bioconvertible device includes the following considerations: (1) the period of highest risk of PE for the vast majority of patients occurs within the first 60 days after an index event, with most of the PEs occurring in the first 30 days; (2) the design of retrievable IVC filters to support their removal after a transitory high-PE-risk period has, in practice, been associated with insecure filter dynamics and time-dependent complications including tilting, fracture, embolization, migration, and IVC perforation; (3) most retrievable IVC filters are placed for temporary protection, but for a variety of reasons they are not removed in any more than half of implanted patients, and when removal is attempted, the procedure is not always successful even with advanced techniques; and (4) analysis of Medicare hospital data suggests that payment for the retrieval procedure does not routinely compensate for expense. The Sentry device is not intended for removal after bioconversion. In initial clinical use, complications have been limited. Long-term results for the Sentry bioconvertible IVC filter are anticipated soon.

Guidewire Loop Dissection Technique for Filter Strut Endothelialization

Complex inferior vena cava (IVC) filter retrieval was usually in need of advanced techniques. Filter strut endothelialization without tilt of the filter was still one of the challenges. Therefore, we would like to describe the guidewire loop dissection technique, which required no extra equipment, to solve problem. A 53-year-old male had IVC filter for 8 months. Venogram showed no tilt of the apex and endothelialization of struts. The hook was snared but the filter cannot be retrieved. A fine guidewire was then advanced and formed a loop between the strut and the caval wall. With traction applied, the guidewire peeled the struts off the caval wall, resulting in the dissection of strut endothelialization. In the end, the filter was retrieved without injuring IVC. This technique was a feasible option for such circumstance.