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.

Management of failed inferior vena cava filter retrieval for complex cases: A case series

The aim of this report is to describe our experience in managing cases of difficult inferior vena cava (IVC) filter retrieval with emphasis on different advanced retrieval techniques. We report three cases of difficult IVC filter retrieval at our institution. We included three patients age ranging from 42 to 72 years. Two of the cases were presenting with the lower limb deep vein thrombosis and one of the cases had pulmonary embolism and they all had Retrievable Celect Platinum IVC filter (Cook Medical, Bloomington, Ind.) inserted preoperatively. One case was managed conservatively after failing IVC filter retrieval using standard retrieval set, meaning the filter was left in place, one was successfully removed with advanced endovascular retrieval techniques, and one failing advanced endovascular retrieval and finally had it removed with open surgery. We reviewed the risk factors contributing to difficult IVC filter retrieval and discussed the different options for managing these cases including conservative management, endovascular treatment, and open surgery for retrievable type of IVC filter which can be placed permanently. Knowledge of these options will help us better understand conditions, leading to difficult IVC retrieval on insertion, hopefully to minimize the occurrence of these cases, and to better manage cases with difficult IVC filter retrieval to decide the best option for each patient after careful consideration and multidisciplinary discussion with surgeons and patients.

Endovascular Rescue of Sheath Perforation During Inferior Vena Cava Filter Retrieval

Introduction

Inferior vena cava (IVC) filter retrieval is generally a straightforward procedure but can be challenging with unique complications. A technique used for endovascular rescue of a patient where sheath perforation by the IVC filter occurred during IVC filter retrieval is described.

Report

A 75 year old man underwent retrieval of an IVC filter that had been in place for 10 months. Using the IVC filter retrieval set from a standard right internal jugular vein approach and the loop-snare technique, the hook and collet were captured, and the filter was collapsed into the retrieval sheath. Approximately halfway through removal of the filter through the sheath, mild resistance was encountered and the tip of the IVC filter was found to have perforated the side of the retrieval sheath. The sheath appeared to have bent slightly in this region, probably weakening the sheath wall and creating angulation, which allowed sheath perforation to occur. From a right common femoral vein approach, an Amplatz wire was used to cannulate the distal end of the perforated sheath. A balloon was then used to pull the perforated sheath with the IVC filter into a larger sheath. After removing the Tuohy-Borst and Luer adapters on the perforated sheath, it was able to be internalised and removed via the femoral vein sheath.

Discussion

The endovascular rescue technique described herein may prove useful to other practitioners encountering similar situations, and the complication shows areas of caution when using the loop-snare retrieval technique.

Costs and complications of hospital admissions for inferior vena cava filter malfunction

OBJECTIVE

Inferior vena cava filter (IVCF) malfunction can result from penetration, fracture, or migration of the device necessitating retrieval. Endovascular and open retrieval of IVCF have been described in institutional series without comparison. This study examines national hospital admissions for IVCF malfunction and compares the outcomes of open and endovascular retrieval.

METHODS

The National Inpatient Sample database (2016-2017) was reviewed for admissions with International Classification of Diseases, Tenth Revision (ICD-10) codes specific for IVCF malfunction. All ICD-10 procedural codes were reviewed, and patients were divided based on open or endovascular IVCF retrieval. Patient characteristics, outcomes, and costs of hospitalization were compared between the two groups.

RESULTS

There were 665 patients admitted with a diagnosis of IVCF malfunction. Open IVCF retrieval was performed in 100 patients and endovascular removal in 90 patients. Of those undergoing open surgery, 45 patients (45%) required median sternotomy and 55 (55%) required abdominal surgeries. Most patients were white females with a mean age of 54.4 years (range, 49.3-59.6 years) with a history of deep venous thrombosis (55.3%) or pulmonary embolism (31.6%). Most patients with IVCF malfunction were treated in large (81.6%) or urban teaching (94.7%) hospitals situated most commonly in the South (42.1%) and Northeast (29.0%) with no difference in characteristics of the patients or the centers between the two groups. Patients undergoing open IVCF retrieval were more likely to undergo surgery on an elective basis compared with endovascular IVCF retrieval (75.0% vs 11.1%; P < .001). Open IVCF retrieval was associated with a higher likelihood of thromboembolic complication compared with endovascular retrieval (20% vs 0%; P = .04). There was a trend toward higher infectious complications and overall complications with endovascular removal, but this difference did not reach statistical significance. Open retrieval was associated with a mortality of 5.0% compared with no inpatient mortality with endovascular retrieval (P = .33). The mean hospital length of stay was no difference between the two groups. Open retrieval was associated with significantly higher hospital costs than endovascular retrieval ($34,276 vs $19,758; P = .05).

CONCLUSIONS

Filter removal for patients with IVCF malfunction is associated with significant morbidity and cost, regardless of modality of retrieval. The introduction of specific ICD-10 codes for IVCF malfunction allows researchers to study these events. The development of effective tools for outpatient retrieval of malfunctioning IVCF could decrease related hospitalization and have potential savings for the healthcare system.

Observations on failed retrieval of optional inferior vena cava filters

PURPOSE

To evaluate causes of failed optional inferior vena cava filter (IVCF) retrievals.

METHODS

Single-center retrospective study.

RESULTS

IVCF retrievals were attempted in 26/211 (12%) patients at a mean 42.9 days. There were 9 failures (all OptEase) due to: inability to snare the hook (n=5), noncollapsible IVCF (n=3), and unusual procedural pain (n=1). Median duration of retrieved IVCFs was 31 days compared to 53 days for failures (P<.05). IVCFs aligned with the IVC's cephalocaudal axis were retrieved in 13/16 cases, while misaligned IVCFs were retrieved 4/10 cases (P<.05).

CONCLUSION

Filter duration and misalignment were significantly associated with retrieval failures.

IVC filter retrieval in adolescents: experience in a tertiary pediatric center

BACKGROUND

Inferior vena cava (IVC) filters are commonly implanted with the intent to prevent life-threatening pulmonary embolism in at-risk patients with contraindications to anticoagulation. Various studies have reported increases in the rate of venous thromboembolism within the pediatric population. The utility and safety of IVC filters in children has not yet been fully defined.

OBJECTIVE

To describe the technique and adjunctive maneuvers of IVC filter removal in children, demonstrate its technical success and identify complications.

MATERIALS AND METHODS

A retrospective 10-year review was performed of 20 children (13 male, 7 female), mean age: 15.1 years (range: 12-19 years), who underwent IVC filter retrieval. Eleven of 20 (55%) were placed in our institution. Electronic medical records were reviewed for filter characteristics, retrieval technique, technical success and complications.

RESULTS

The technical success rate was 100%. Placement indications included: deep venous thrombosis with a contraindication to anticoagulation (10/20, 50%), free-floating thrombus (4/20, 20%), post-trauma pulmonary embolism prophylaxis (3/20, 15%) and pre-thrombolysis pulmonary patient (1/20, 5%). The mean implantation period was 63 days (range: 20-270 days). Standard retrieval was performed in 17/20 patients (85%). Adjunctive techniques were performed in 3/20 patients (15%) and included the double-snare technique, balloon assistance and endobronchial forceps retrieval. Median procedure time was 60 min (range: 45-240 min). Pre-retrieval cavogram demonstrated filter tilt in 5/20 patients (25%) with a mean angle of 17° (range: 8-40). Pre-retrieval CT demonstrated strut wall penetration and tip embedment in one patient each. There were two procedure-related complications: IVC mural dissection noted on venography in one patient and snare catheter fracture requiring retrieval in one patient. There were no early or late complications.

CONCLUSION

In children, IVC filter retrieval can be performed safely but may be challenging, especially in cases of filter tilt or embedding. Adjunctive techniques may increase filter retrieval rates.