Placement and Retrieval of Inferior Vena Cava Filters: A Case-Based Approach [1st ed.] 9783030451493, 9783030451509

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Placement and Retrieval of Inferior Vena Cava Filters A Case-Based Approach Kush R. Desai Osman Ahmed Thuong Van Ha Editors

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Placement and Retrieval of Inferior Vena Cava Filters

Kush R. Desai  •  Osman Ahmed Thuong Van Ha Editors

Placement and Retrieval of Inferior Vena Cava Filters A Case-Based Approach

Editors Kush R. Desai Division of Interventional Radiology Northwestern University Feinberg School of Medicine Chicago, IL USA

Osman Ahmed University of Chicago Chicago, IL USA

Thuong Van Ha University of Chicago Chicago, IL USA

ISBN 978-3-030-45149-3    ISBN 978-3-030-45150-9 (eBook) https://doi.org/10.1007/978-3-030-45150-9 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Contents

1 Current Data and Trends on Inferior Vena Cava Filter Placement and Retrieval����������������������������������������������������������������������������   1 John A. Kaufman 2 IVC Filter Placement: Accepted and Relative Indications��������������������  11 D. Alexander Paratore and Jennifer P. Montgomery 3 Inferior Vena Cava Filter Placement: Anatomical Evaluation and Approach to Variant Anatomy������������������������������������������������������������������  21 Zachary Berman and Jeet Minocha 4 IVC Filter Retrieval: Routine Approach ������������������������������������������������  33 Brian Holly and Mark L. Lessne 5 Complex Filter Retrieval Planning����������������������������������������������������������  39 Andrew C. Gordon, Kush R. Desai, and Robert J. Lewandowski 6 Filter Strut Penetration: Does It Matter?������������������������������������������������  55 Nathan Kafity and Minhaj S. Khaja 7 Retrieval of Filters with Embedded Apices ��������������������������������������������  89 James X. Chen, Scott O. Trerotola, and S. William Stavropoulos 8 Filter Strut Incorporation: Tools for Success and Improved Procedural Safety�������������������������������������������������������������������������������������� 103 Kush R. Desai, Osman Ahmed, Mark Hieromnimon, and Basem Jaber 9 Mechanism and Approach to Fractured Filters�������������������������������������� 113 Michael Hong Jr, Matthew A. Brown, and Robert K. Ryu 10 IVC Filter Migration and Misplacement������������������������������������������������ 131 Mark Hieromnimon, Basem Jaber, Bulent Arslan, Sreekumar Madassery, and Osman Ahmed 11 IVC Filter Retrieval: Unusual Circumstances���������������������������������������� 149 Wes Klejch, Imogen Foster, Steven Zangan, Thuong Van Ha, Alex Lionberg, Q. T. Elizabeth Van Ha, and Rakesh Navuluri

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12 Permanent Inferior Vena Cava Filters: Special Considerations������������ 167 Shelly Bhanot and Kumar Madassery 13 Management of the Acute Thrombus-­Bearing IVC Filter �������������������� 177 Mark L. Lessne and Brian Holly 14 Management of Filter-Related Chronic Iliocaval Occlusion������������������ 189 Ethan T. Klepitsch and Kush R. Desai Index�������������������������������������������������������������������������������������������������������������������� 203

Contributors

Osman Ahmed, MD  University of Chicago, Chicago, IL, USA Bulent  Arslan, MD  Section of Vascular and Interventional Radiology, Rush University Medical Center, Chicago, IL, USA Zachary  Berman, MD  Division of Interventional Radiology, Department of Radiology, UC San Diego, San Diego, CA, USA Shelly Bhanot, MD  Rush University Medical Center, Chicago, IL, USA Matthew  A.  Brown, MD  Division of Interventional Radiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA James  X.  Chen, MD  Charlotte Radiology, Carolinas Medical Center, Charlotte, NC, USA Kush  R.  Desai, MD, FSIR  Division of Interventional Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA Imogen Foster  Department of Radiology, University of Chicago Medical Center, Chicago, IL, USA Andrew C. Gordon, MD, PhD  Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA Thuong Van Ha, MD, FSIR  University of Chicago, Chicago, IL, USA Q. T. Elizabeth Van Ha  Department of Radiology, University of Chicago Medical Center, Chicago, IL, USA Mark Hieromnimon, MD  University of Illinois at Chicago College of Medicine, Chicago, IL, USA Brian Holly, MD  The Johns Hopkins Medical Institute, Baltimore, MD, USA Michael  Hong Jr, MD  Division of Interventional Radiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA Basem  Jaber, MD  Section of Vascular and Interventional Radiology, Rush University Medical Center, Chicago, IL, USA vii

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Contributors

Nathan Kafity, MD  Division of Vascular and Interventional Radiology, University of Michigan Health System, Ann Arbor, MI, USA John  A.  Kaufman, MD, MS  Department of Interventional Radiology, Dotter Interventional Institute, Frederick S. Keller Professor of Interventional Radiology, Oregon Health & Science University, Portland, OR, USA Minhaj S. Khaja, MD, MBA  Division of Vascular and Interventional Radiology, University of Virginia Health System, Charlottesville, VA, USA Wes Klejch, MD  Department of Radiology, University of Chicago Medical Center, Chicago, IL, USA Ethan  T.  Klepitsch, BA  Division of Interventional Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA Mark L. Lessne, MD  Vascular & Interventional Specialists of Charlotte Radiology, Charlotte, NC, USA The Johns Hopkins Medical Institute, Baltimore, MD, USA Robert J. Lewandowski, MD  Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA Department of Medicine-Hematology/Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA Department of Surgery-Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA Alex  Lionberg, MD  Department of Radiology, University of Chicago Medical Center, Chicago, IL, USA Sreekumar  Madassery, MD  Section of Vascular and Interventional Radiology, Rush University Medical Center, Chicago, IL, USA Kumar Madassery, MD  Rush University Medical Center, Chicago, IL, USA Jeet  Minocha, MD  Division of Interventional Radiology, Department of Radiology, UC San Diego, San Diego, CA, USA Jennifer P. Montgomery, MD, PhD  Section of Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA Rakesh Navuluri, MD  Department of Radiology, University of Chicago Medical Center, Chicago, IL, USA D.  Alexander  Paratore, DO  Section of Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, OH, USA Robert K. Ryu, MD, FSIR  Division of Interventional Radiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA

Contributors

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S. William Stavropoulos, MD  Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA Scott  O.  Trerotola, MD  Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA Steven  Zangan, MD  Department of Radiology, University of Chicago Medical Center, Chicago, IL, USA

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Current Data and Trends on Inferior Vena Cava Filter Placement and Retrieval John A. Kaufman

Vena cava filters are important yet controversial devices utilized to prevent pulmonary embolism (PE). Originally designed to replace more invasive inferior vena cava (IVC) interruption techniques (such as plication or clip placement), the first filters still required surgical cutdown on the jugular or femoral vein for insertion [1]. Over time, percutaneous placement became the norm, with a simultaneous increase in the overall number of filter insertions and dissemination of the procedure to interventional radiology and interventional cardiology. In the late 1990s, nonpermanent vena cava filters became commercially available, and filter utilization increased even more rapidly [2]. With more widespread use came increased awareness of complications associated with these devices [3]. The current vena cava filter environment is one of doubt and uncertainty, which is reflected in the decreasing utilization [4, 5]. Nevertheless, vena cava filters remain clinically important tools for protecting patients at risk of PE who cannot be managed with conventional strategies (anticoagulation) [6].

History The links between deep vein thrombosis (DVT) and PE, and PE and death, are well established. In 1761, the Italian anatomist Giovanni Morgagni described large blood clots in the pulmonary arteries of patients who had experienced sudden death. The association between deep venous thrombosis and pulmonary embolism was formally recognized by the German pathologist Rudolf Virchow in 1846 when he described “the detachment of larger or smaller fragments from the end of the J. A. Kaufman (*) Department of Interventional Radiology, Dotter Interventional Institute, Frederick S. Keller Professor of Interventional Radiology, Oregon Health & Science University, Portland, OR, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 K. R. Desai et al. (eds.), Placement and Retrieval of Inferior Vena Cava Filters, https://doi.org/10.1007/978-3-030-45150-9_1

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softening thrombus which are carried along the current of blood and driven into remote vessels. This gives rise to the very frequent process on which I have bestowed the name Embolia” [7]. In the classic article by Dalen and Alpert, it was estimated that 11% of patients died within the first hour of the PE event [8]. Of the surviving patients, 8.7% died despite treatment, while 30% died if the diagnosis was missed (and presumably therefore are untreated). The accepted primary therapy for all venous thromboembolism (either deep vein thrombosis (DVT) or PE) is anticoagulation [9]. The overall rate of recurrent PE in adequately treated patients is 1.2–1.4%, and the incidence of fatal recurrent PE may be as low as 0.1% [10]. The strategy of interruption of the vena cava to prevent pulmonary embolism in patients with VTE who cannot be anticoagulated is attributed to Trendelenburg, who performed the first IVC ligation for this indication in 1906 [11]. Placement of an external clip on the IVC was described in 1959, and the first successful intraluminal filter (the Mobin-Uddin “umbrella”) in the early 1970s [12, 13]. The Kimray-Greenfield filter became commercially available shortly after the MobinUddin filter and with the conical design and stainless steel construction became the industry standard [1]. The external diameter of the original Greenfield filter delivery capsule was 24 Fr, requiring surgical access through either the internal jugular or common femoral vein. Percutaneous insertion was first described in 1984, involving serial dilation to 24 Fr and achievement of hemostasis with compression [14]. Smaller diameter devices that could be delivered percutaneously through sheaths were subsequently developed, all of which were intended to remain in place permanently [15]. The materials used to construct the filters included stainless steel, nitinol, elgiloy, and titanium. These devices completely supplanted the 24 Fr Greenfield filter. Retrievable vena cava filters were first approved for this indication in the United States in 2003, although devices were used earlier in both Europe and Canada [16]. The initial devices were believed to become permanently attached to the IVC wall within a few weeks of indwelling time, leading to initial conservative recommendations for the retrieval window [17]. Over time, clinical experience demonstrated that devices could be retrieved safely months and years after placement, and design features were incorporated to permit extend the retrieval window [18]. In 2016, the Food and Drug Administration (FDA) approved the first convertible filter, the B. Braun VenaTech (B. Braun, Bethlehem, PA). This device introduced the concept of a filter that converts to an open stent-like structure after percutaneous removal of an apical constraining cap. In 2017, the FDA approved a bioconvertible device (Sentry, Boston Scientific, Marlborough, MA), a filter that converts to an open configuration after 60 days without the need for an additional procedure [19]. Completely absorbable filters are currently in development and early clinical trial phase [19].

Why Filters Are Inserted Any discussion of filter utilization must begin with revisiting the sole purpose of these devices – to prevent clinically significant PE. Perfect protection from PE is not achievable for a device that must preserve patency of the IVC while capturing

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Table 1.1  FDA-approved indications for IVC filters [20] Pulmonary thromboembolism when anticoagulants are contraindicated Failure of anticoagulant therapy in thromboembolic diseases Emergency treatment following massive pulmonary embolism where anticipated benefits of conventional therapy are reduced Chronic, recurrent pulmonary embolism where anticoagulant therapy has failed or is contraindicated

emboli that might result in hemodynamic compromise. Therefore, small and usually (but not always) clinically insignificant emboli may escape the filter. The FDA-approved indications for vena cava filters are listed in Table 1.1 [20]. These represent the most conservative indications, in which a diagnosis of PE is required in most instances. Of note, interruption of anticoagulation due to a complication of anticoagulation is not specifically approved. Furthermore, prevention of PE in patients who have a diagnosis of DVT only and cannot be anticoagulated is not included. The clinical application of vena cava filters includes a much broader set of indications [21]. These can be roughly divided into patients with or without documented venous thromboembolism (VTE) [22]. There is little debate among clinicians that patients with documented VTE who cannot be anticoagulated should be considered for filters, although there remain great institutional, regional, and international variations in the application of this indication [23]. For example, a major trauma patient with high bleeding risk and a small incidental lower lobe PE on abdominal CT scan in the setting of normal lower extremity venous duplex studies might receive a filter in one institution and be observed in another. The most controversial indication for a vena cava filter is in the patient who does not have but is considered at high risk of developing VTE, yet cannot receive medical prophylaxis or be adequately screened for DVT. This is the “prophylactic” indication, which includes patients with major trauma, undergoing bariatric surgery, or undergoing major orthopedic or spine surgery [24–26]. Trauma patients make up the largest segment in this group and present the additional problems of often being relatively young, with extend life expectancies provided they survive the trauma, and the most variable follow-up. Many believe that filter placement in this group was a major reason for the increase on filter placements between 1990 and 2010 [2]. Regardless of the indication, the type of filter (permanent, retrievable, convertible, and someday absorbable) should not factor into the decision to place the device. The availability of nonpermanent filters does not change the indications for placement, although in practice this has likely led to a relaxation of indications [27]. The decision to place a filter should be careful, deliberate, individualized, and clearly documented in the medical record. The type of filter placed should depend on the expected required duration of high risk of PE. If this is indefinite, a filter that can remain in place as a filter should be used. Conversely, for patients with short-­ term protective needs, an optional (meaning retrievable or convertible) filter should be utilized.

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Trends in Filter Placement Filter utilization is inexplicably variable. As mentioned earlier, the United States places more filters than any other country. Roughly 15% of all patients with VTE receive these devices in the United States, whereas in an international registry less than 1% of patients had filter placement [23, 28]. There are major differences in utilization between regions, states, and even hospitals within cities [29, 30, 31]. For example, teaching hospitals in cities tend to use more filters than rural hospitals or those owned by managed care networks [30]. Although patient mix likely has impact upon the prevalence of VTE within a region or institution, the degree of variability is not explained by these factors alone. The availability of practitioners capable of placing filters and the local medical malpractice environment seem to contribute to a lower threshold for filter placement [29]. The ease of placement of vena cava filters and the ready availability of the skill set among several specialties in the 1990s may have contributed to the increased utilization in patients with VTE as an adjunct to anticoagulation. Filters may be placed as an additional therapy when clinicians are concerned about issues such as the ability to maintain adequate and safe anticoagulation, the assessment that an additional PE while anticoagulated could be lethal due to lack of physiologic reserve, and a high risk of substantial PE from a large volume of lower extremity thrombus. This concept has been studied in two randomized prospective trials, the PREPIC and PREPIC II trials [32, 33]. The former utilized a variety of permanent vena cava filters, and the latter allowed only a single retrievable device. These two studies compared anticoagulation alone to anticoagulation plus a filter in patients with acute VTE [32, 33]. In the PREPIC trial, there was an early (12-day) survival benefit with the addition of a filter, but this was not sustained. At 8 years, patients with filters had more DVT, while patients without filters had more PE, but survival was equivalent in both groups [32]. The PREPIC II trial was underpowered for discrimination between the two groups based on recurrent PE, recurrent lethal PE, and overall mortality due to a lower than expected event rate in the anticoagulation group [33]. However, the study did demonstrate that stable patients who could be anticoagulated were subjected to more procedures without a discernable reduction in PE or death. More recently, overall filter utilization in the United States has decreased, with fewer placements overall and a shift in indications toward patients with established VTE (and presumably away from prophylactic indications) [34, 35]. The explanation for this has not been established with certainty, but filter placement started to decline after 2012. This roughly coincided with FDA advisories to remove nonpermanent filters whenever possible, the rise of large class action lawsuits against filter manufacturers, increased reporting of filter complications, and skepticism about the clinical benefit of the devices [19]. Although it would seem intuitive that interruption of the IVC would decrease the likelihood of PE, especially in patients with DVT, this has not been adequately tested in a prospective randomized manner in patients who cannot be anticoagulated. Rather than attempt such an ethically challenging trial, population-based studies using large databases have been utilized to test this question. Turner et al.

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utilized state-level inpatient data to evaluate the impact of IVC filter placement in patients with VTE who were not anticoagulated [36]. After correcting for immortal time bias (patients who lived long enough to receive a filter had a better chance of surviving than those who died before filter placement), they concluded that filters were associated with an increased hazard ratio of 30-day mortality (1.18; 95% CI, 1.13–1.22; P 28 mm may predispose a filter to migrate as most filters are not approved for placement above this size. As the configuration and size of the IVC is dynamic with respect to hemodynamic status, intravascular blood volume, and cardiac pulsation, migration may occur anytime following placement. Further, caval diameter increases as it extends cephalad, likely increasing the risk for migration in the presented case where a suprarenal filter was placed. Open heart surgery is considered the gold standard for management of cardiac filter migration in ideal patients. This approach allows for direct visualization and repair of any associated complications that may be related to the migration event. An endovascular approach can however be considered for poor surgical candidates and may also allow for safe removal [5, 7]. In the current example, the decision to pursue an endovascular retrieval was made after multidisciplinary discussion between cardiothoracic surgery, vascular surgery, and interventional radiology. A triaxial system with three sheaths (including a steerable sheath) provided adequate support and directionality to engage the filter apex with a snare at the level of the tricuspid valve. Given positioning of the filter apex at the tricuspid valve, the sheaths were slowly advanced forward over the sheath to prevent valvular or papillary muscle damage. Additionally, proper pre-procedure planning with cardiac anesthesia and utilization of a hybrid OR with CT-surgery standby was undertaken in the event a procedural complication necessitated open surgical repair. Pearls 1. IVC filter migration to the heart is a serious, life-threatening condition where patients may present with chest pain, arrythmia, dyspnea, and/or valvular injuries. 2. At present, open surgery should be considered first line with endovascular intervention reserved only in whom surgery is not ideal. Any decision to pursue endovascular retrieval should be made after consultation with cardiothoracic surgery with consideration to appropriate pre-procedural precautions. 3. A directional sheath may be aid in engaging the apex or hook of a filter migrated to the heat given the angular orientation of the cardiac axis relative to the SVC. Pitfalls 1. Endovascular filter retrieval from the right ventricle may result in filter or guidewire entrapment within the papillary muscles or chordae tendineae of the tricuspid valve. Fused intracardiac echocardiography and three-dimensional electroanatomic mapping may be considered as a method to potentially lessen this type of injury by providing direct guidance during retrieval [8].

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2. Cardiac filter migration is a serious life-threatening complication with retrieval from an endovascular approach limited to mostly case reports in the literature. Given the complexity and risks associated with removal, retrieval at experienced centers with appropriate surgical backup and cardiac monitoring expertise is recommended.

Case 3: Filter Misplacement: Azygos Vein Sreekumar Madassery, Basem Jaber, Mark Hieromnimon and Osman Ahmed History:  A 32-year-old female with a history of DVT during her second trimester of pregnancy status post IVC filter placement 9.5 years ago. The patient presents with severe abdominal and right flank along with chronic dyspnea.

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(a)   Pre-procedure sagittal contrast-enhanced CT scan demonstrating a posteriorly tilted Gunther Tulip filter with position just anterior to the spine. The filter position corresponds to the azygos vein. (b) Pre-procedure axial contrast-enhanced CT scan again demonstrating azygos misplacement and multifocal penetration of the primary filter struts into the diaphragmatic crus. (c) Inferior vena cavagram from time of filter placement demonstrates the filter apex extending outside the confines of the IVC and constrained to less than the caliber of the normal IVC at this level

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Filter Type:  Cook® Gunther Tulip Complication:  IVC filter misplacement into the azygos vein. After the initial placement, the patient began experiencing abdominal and flank pain. Three unsuccessful attempts for filter retrieval were made at an outside hospital, and the patient was informed the filter had migrated and it will be permanent. When the original IVC filter placement imaging was reviewed, the initial venogram was not performed from the iliac veins, and the vessel in which the filter was placed appeared to be of small caliber. Intervention/Technique retrieval of filter.

Performed:  Laser-assisted

endobronchial

forceps

Procedure Images Procedure Description Right internal jugular venous access was obtained with ultrasound guidance, and venogram demonstrated patent central veins. Under a steeply oblique view, a 5-Fr angled catheter was advanced into the azygos vein by angling the catheter posteriorly. An azygos venogram was performed, demonstrating patency central to the filter and adjacent intercostal veins. A 10-Fr sheath was advanced over a stiff 0.035″ guidewire with the tip just above the filter hook. A 0.018″ was placed parallel and advanced caudal to the filter within the azygos vein. The sheath was removed over both wires and exchanged for a new 10-Fr sheath over the 0.035″ wire only. Subsequently, the filter hook was captured with a trilobed snare. However, during the retrieval attempts, the filter could not be distorted and the hook of the filter straightened due to excessive traction placed on the filter. The sheath was exchanged for a 16-Fr sheath over the snare still engaged on the filter hook. A 12-Fr laser sheath was activated; however, it was unsuccessful and resulted in inadvertent fracturing of the snare. Attempts at retrieving the filter with both gooseneck snare and subsequently endobronchial forceps were performed but ultimately unsuccessful. The 16-Fr sheath was then exchanged for a 20-Fr sheath, and a 16-Fr laser sheath was then placed coaxially. The forceps were placed through the laser sheath to engage the straightened hook. Utilizing the laser sheath and simultaneous forceps counter tension, the filter was successfully removed. Equipment Used • Boston Scientific® Amplatz Super Stiff Straight Tip 0.035″/180 cm • Boston Scientific® V-18 Control Wire 0.0.018″/200 cm • Cook® Bentson Wire Guide 0.035”/180 cm • Cook® Flexor Check-Flo Introducer Set Ansel 9 Fr × 45 cm • Cook® Flexor Tuohy-Borst Shuttle 7 Fr × 90 cm • Cook® Rosen Curved Wire Guide 0.035″/180 cm • EV3® Amplatz Goose Neck Snare Kit 6 Fr/25 mm • Lymol Medical Rigid Endobronchial Forceps

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(a)  Steep oblique image demonstrates a Gunther Tulip filter projecting just anterior to the spine, compatible with azygos filter placement as seen on prior CT. (b) Endobronchial forceps were used to engage the apex of the filter but could not entirely sheath it. (c) The sheath was subsequently upsized, and a laser sheath was advanced coaxially to dissect the incorporated filter struts. The forceps were used to provide traction

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Gore® Dryseal 20 Fr × 33 cm Gore® Dryseal 18 Fr × 33 cm Gore® Dryseal flex 16 Fr x 33 cm Merit Medical® En Snare Endovascular System 6–20 mm Philips® Glidelight Laser Sheath 16 Fr Terumo® Glidecath Cobra 2 5 Fr × 65 cm Terumo® Glidecath Non-taper Angle 4 Fr × 65 cm Terumo® Glidewire Angled 0.035/180 cm Terumo® Pinnacle Introducer Sheath 5 Fr × 10 cm Terumo® Pinnacle Introducer Sheath 9 Fr × 10 cm

Anesthesia:  General anesthesia was obtained given complexity and potential pain associated with removal. Summary with Procedure Pearls and Pitfalls This case provides an example of operator error during IVC filter placement. Although rarely described in the literature, operator error is a potential source of complication with IVC filters. Prior reports have described filter placement into the gonadal, ovarian, and mesenteric veins [9–11]. A universal factor in all misplacements has been a failure to perform an appropriate vena cavagram and/or misinterpretation of the imaging. In this case, the initial venogram was not performed from the iliac veins, and the small caliber appearance of the vessel in which the filter was placed should have alerted the operator that either the wrong vessel was selected or that the IVC was occluded. Also, the unexpanded appearance of the filter should have raised concern regarding misplacement. To prevent such complications from occurring, thorough evaluation of the patient’s physical and vascular anatomy from prior relevant imaging and confirmation of intracaval positioning with contrast venography prior to deployment is needed. Furthermore, during filter placement, the sheath should not be advanced further without a wire as this may result in inadvertent placement into the gonadal or other parallel oriented veins. In the presented example, misplacement introduced unique challenges of placing a large bore sheath into the azygos vein and dealing with penetration of the filter struts into the crus of the diaphragm. Azygos positioning and penetration into the crus were felt to be the cause of the patient’s flank pain and chronic dyspnea, thus prompting removal. Given these findings and a dwell time over 9 years, nonstandard endovascular techniques to retrieve the misplaced IVC filter were used. These techniques included utilization of both the laser sheath and endobronchial forceps [12]. In this scenario, a large bore sheath (20 Fr) was needed to accommodate the largest available laser sheath (16 Fr) coaxially through it. Although straightening of the filter hook was unintended, in this situation it allowed for the forceps to pass through the laser sheath and engage the hook. Finally, careful pre-procedural planning of the vascular anatomy was undertaken to ensure that the appropriate catheters were used to select the azygos vein and proper oblique imaging was utilized to visualize the vessel of interest. Intra-procedurally, selective venography was performed to

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document azygos catheterization, and live fluoroscopy was utilized during advancement of large bore sheaths to avoid vessel shearing or injury. Pearls 1. In the event of misplacement, pre-procedural imaging with contrast-enhanced CT is helpful to evaluate anatomy and develop a plan prior to attempting retrieval. 2. Misplacement may necessitate utilization of complex retrieval techniques for retrieval as it may be associated with other filter-related complications (i.e., penetration, tilt, etc.). 3. Utilization of oblique imaging can aid in selection of vessels that may overlap or appear parallel to the IVC. Pitfalls 1. Thorough evaluation of a patient’s vascular anatomy with review of any relevant prior cross-sectional imaging along with proper confirmation of intracaval location during contrast venography is required to ensure proper filter deployment and avoid nontarget insertion. 2. Misplacement of filters may introduce unique challenges to filter retrieval specific to the location of placement and nearby critical neurovascular structures or organs. 3. During filter placement, avoid advancing the sheath forward (from jugular approach) to prevent misplacement into the gonadal or other parallel oriented veins.

Case 4: Filter Misplacement: Right Renal Vein Basem Jaber, Mark Hieromnimon, Bulent Arslan and Osman Ahmed History:  A 44-year-old female with a past medical history of multiple sclerosis, neurogenic bladder, hip disarticulation, and right lower extremity below the knee amputation underwent IVC filter placement at an outside institution for symptomatic DVT following orthopedic surgery. Patient presents as transfer for further management of complications that arose during placement. Filter(s) Type:  Argon® Option Elite and B. Braun VenaTech LP Complication:  During filter placement, the operator from the outside institution reported misplacing the Option filter inverted and into the right renal vein. After recognition of this mistake, it was subsequently “corrected” by placement of a permanent suprarenal filter (VenaTech LP) cephalad to the initial filter. Intervention/Technique Performed:  Retrieval of both (misplaced) IVC filters with placement of a new, retrievable, infrarenal IVC filter.

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(a)  Scout radiograph demonstrates two IVC filters that project over the abdomen. The lower filter is an Option Elite and is inverted with its apex projecting caudally toward the feet. Immediately above is a VenaTech LP filter that is oriented appropriately. (b) Venogram from the apex of the Option filter demonstrates opacification of a vessel that drains centrally into the IVC

Procedure Images Procedure Description Right internal jugular and left common femoral venous access was obtained with ultrasound guidance. A 12-French sheath was placed from the jugular access and positioned in the intrahepatic IVC above both filters. A 6-French sheath was placed from the left femoral access. A venogram was performed and demonstrated the Option™ filter within the right renal vein and the VenaTech® LP in the suprarenal IVC. Next, the apex of the VenaTech LP filter was captured with a gooseneck snare. The 12-French sheath was advanced over the snare to the filter base, the hook of the filter snared, and the conical legs of the filter collapsed subsequently. Next, by applying traction to the filter to invert its side rails, the filter was sheathed and removed in its entirety. A 5-French Berenstein catheter was then used to select the right renal vein and subsequently exchanged for a 12–20-mm trilobed snare. The snare was opened below the apex of the filter and retracted to encircle the filter legs. The legs were

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c

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(a)  Initial retrieval of suprarenal filter was pursued. A gooseneck snare was advanced over the apex of the conical portion of the filter. (b) The apex was sheathed to its base and subsequently removed by simultaneous traction on the sheath and snare to invert and further oversheath the side rails. (c) Next, a trilobed snare was carefully opened beneath the hook and apex of the Option Elite filter in the renal vein. (d) The snare was carefully advanced cephalad and used to encircle and constrain the struts of the filter. The initial plan was to snare the filter from a femoral approach with a gooseneck snare (arrow) once traction was applied to the filter to pull it into the IVC; however, the filter was able to be easily sheathed and removed from the jugular snare

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captured, constrained, and retracted cephalad into the IVC. From the femoral access, a gooseneck snare was placed and attempted to engage the filter hook that was now retracted nearly into the IVC. This was not successful, and therefore the decision was made to further collapse the filter legs and sheath it from the jugular access. The filter was sheathed entirely from the jugular access and removed. Both filters were intact and completion venogram demonstrated no complications. Subsequently, an infrarenal Gunther Tulip retrievable IVC filter was placed given an ongoing indication for IVC filtration (acute DVT with contraindication to anticoagulation). Equipment Used • Cook® Flexor 12 Fr × 40 cm • Terumo® Pinnacle 6 Fr sheath • Medtronic® Amplatz Goose Neck Snare – 20 cm loop diameter, 120 cm length • Merit Medical En Snare Endovascular Snare System – 12–20 mm loop diameter, 120 cm length • Cook® Pigtail 5 Fr 65 cm • Boston Scientific® Amplatz Super Stiff guidewire 0.035″/180 cm • Cook® Berenstein catheter 5 Fr 65 cm • Terumo® Glidewire 0.035″/180 cm Anesthesia:  The procedure was performed with moderate sedation. Summary with Procedure Pearls and Pitfalls The provided case is another unfortunate example of IVC filter misplacement. In this scenario however, the filter was misplaced in two ways: position (renal vein) and orientation (inverted). Additionally, this initial error was subsequently managed by inappropriate placement of a permanent filter in a suprarenal position that was not ideal nor indicated given its added potential compromise to renal vein flow. Misplacement of filters outside of the IVC may result in complications unique to the site of implantation. Belenotti et al. described a case of filter fracture and migration to the renal vein that resulted in >80% stenosis of the vein and ultimately required nephrectomy from fibrotic changes [13]. Another report described misplacement of a filter into the right renal vein that resulted in microscopic hematuria secondary to erosion of a filter strut into the urinary collecting system [14]. Furthermore, other studies have also described filter misplacement by placement of filters in an inverted orientation [15, 16]. Failure to perform an appropriate vena cavagram and/or misinterpretation of the imaging is commonly the main cause of IVC filter misplacement. In the presented example, the venogram was performed from the right renal vein, which appeared abnormally vertical due to the patient’s contorted body position. The appearance of the “chronic IVC occlusion,” as initially suspected on placement, actually represented tapered hilar renal vein branches. Further, the inverted placement of the first filter was due to error in back-table preparation of the device, as the Option Elite can

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be placed via jugular or femoral routes depending on how the filter cartridge is inserted onto the sheath. An upside-down filter can be missed if care is not taken to ensure proper orientation during deployment [15]. Finally, the added placement of a permanent suprarenal filter in this patient with temporary indication (i.e., postoperative DVT) was also undesirable as a retrievable infrarenal filter would have allowed for a simpler and safer retrieval when mechanical protection was no longer needed. Pearls 1. Filter misplacement can occur due to position (i.e., non-caval vessel) or orientation. 2. Thorough evaluation of a patient’s vascular anatomy during contrast venography along with review of any prior relevant cross-sectional imaging can help prevent the complication of filter misplacement and/or rule out rare disorders like caval agenesis. 3. Power injection (i.e., 20 ml/sec for 30-ml total volume) in the IVC using a multi-­ sidehole catheter or sheath can help opacify and identify important anatomical landmarks (i.e., renal inflow, renal vein variants, gonadal/lumbar veins, etc.) and confirm accurate filter placement. 4. Femoral venography (if needed) or catheterization of the iliac veins from the jugular approach can help ensure visualization of the IVC. Pitfalls 1. During filter placement, the sheath should never be advanced forward (from a jugular approach) without a guidewire in the IVC as inadvertent selection of the gonadal vein (or another parallel vein) can occur. 2. An abnormal size or orientation of a presumed IVC should prompt further venography or assessment to rule out accidental catheterization of a non-­ caval vein. 3. Filter misplacement can result in complications unique to the site of implantation. Filter retrieval in this situation, including the use of advanced techniques, should be considered to prevent such complications from occurring.

References Case 1: Pulmonary Filter Strut Migration 1. Angel LF, Tapson V, Galgon RE, et al. Systematic review of the use of retrievable inferior vena cava filters. J Vasc Interv Radiol. 2011;22(11):1522–30. 2. Kuo WT, Robertson SW, Odegaard JI, Hofmann LV. Complex retrieval of fractured, embedded, and penetrating inferior vena cava filters: a prospective study with histologic and electron microscopic analysis. J Vasc Interv Radiol. 2013;24(5):622–30. 3. Mehanni S, Higley M, Schenning RC. Expectoration of an inferior vena cava filter strut. BMJ Case Rep. 2016;23:2016.

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Case 2: Cardiac Migration of an IVC Filter 4. Ayad MT, Gillespie DL. Long-term complications of inferior vena cava filters. J Vasc Surg Venous Lymphat Disord. 2019;7(1):139–44. 5. Owens CA, Bui JT, Knuttinen MG, et al. Intracardiac migration of inferior vena cava filters: review of published data. Chest. 2009;136(3):877–87. 6. Janjua M, Omran FM, Kastoon T, Alshami M, Abbas AE. Inferior vena cava filter migration: updated review and case presentation. J Invasive Cardiol. 2009;21(11):606–10. 7. Wakabayashi Y, Takeuchi W, Yamazaki K. Inferior vena cava filter misplacement in the right atrium and migration to the right ventricle followed by successful removal using the endovascular technique: a case report and review of the literature. SAGE Open Med Case Rep. 2015;3:2050313X15595833. 8. Hannawa KK, Good ED, Haft JW, Williams DM. Percutaneous extraction of embolized intracardiac inferior vena cava filter struts using fused intracardiac ultrasound and electroanatomic mapping. J Vasc Interv Radiol. 2015;26:1368–74.

Case 3: Filter Misplacement: Azygous Vein 9. Sharma S, Mukund A, Agarwal S, Srivastava DN. Case of a misplaced IVC filter: a lesson to learn. Cardiovasc Intervent Radiol. 2010;33(4):880–2. 10. Ding PX, Han XW, Liu C, Ren KW. Inferior vena cava filter misplacement in the right ovarian vein and successful removal by loop-snare technique in a patient with inferior vena cava agenesis. J Vasc Surg Cases Innov Tech. 2018;4(4):324–6. 11. Martin MJ, Blair KS, Curry TK, Singh N. Vena cava filters: current concepts and controversies for the surgeon. Curr Probl Surg. 2010;7(47):524–618. 12. Ding PX, Han XW, Liu C, Ren KW. Inferior vena cava filter misplacement in the right ovarian vein and successful removal by loop-snare technique in a patient with inferior vena cava agenesis. J Vasc Surg Cases Innov Tech. 2018;4(4):324–6.

Case 4: Filter Misplacement: Right Renal Vein 13. Bélénotti P, Sarlon-Bartoli G, Bartoli MA, et  al. Vena cava filter migration: an unap preciated complication. About four cases and review of the literature. Ann Vasc Surg. 2011;25(8):1141.e9–14. 14. White S, Lehrfeld T, Schwab C. Misplaced inferior vena caval filter in right renal vein with erosion into renal collecting system. J Endourol. 2009;23(11):1899–901. 15. Kwok PCH, Wong WK, Siu KW, Lai AKH, Chan SCH. Difficult retrieval of a retrievable inferior vena cava filter placed in an inverted orientation. J Vasc Interv Radiol. 2006;17(1):153–5. 16. Cappelli F, Vignini S, Baldereschi GJ. ALN inferior vena cava filter upside down rotation with chest caval migration in an asymptomatic patient. J Invasive Cardiol. 2010;22(8):E153–5.

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Wes Klejch, Imogen Foster, Steven Zangan, Thuong Van Ha, Alex Lionberg, Q. T. Elizabeth Van Ha, and Rakesh Navuluri

Contents Case 1: SVC Filter Placement Wes Klejch, Imogen Foster, Steven Zangan and Thuong Van Ha Case 2: Complex SVC Filter Removal Wes Klejch, Imogen Foster, Steven Zangan and Thuong Van Ha Case 3: Iliac Filter Placement Alex Lionberg, Q. T. Elizabeth Van Ha, Rakesh Navuluri and Thuong Van Ha Case 4: Bilateral Iliac Filter Retrieval Alex Lionberg, Q. T. Elizabeth Van Ha, Rakesh Navuluri and Thuong Van Ha References

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Case 1: SVC Filter Placement Wes Klejch, Imogen Foster, Steven Zangan and Thuong Van Ha History:  A 46-year-old man with history of neurofibromatosis presented with a left axillary mass. There was compression of the left axillary vein by the mass (Fig. 11.1) and thrombus formation for which patient was placed on anticoagulation. Prior to surgery for resection of the axillary mass, the patient underwent preoperative SVC filter placement (Fig. 11.2) and anticoagulation was withheld. Six weeks after surgery, the patient returned for filter retrieval. Filter Type:  Cook® Gunther Tulip W. Klejch · I. Foster · S. Zangan · A. Lionberg · Q. T. E. Van Ha · R. Navuluri Department of Radiology, University of Chicago Medical Center, Chicago, IL, USA T. Van Ha (*) University of Chicago, Chicago, IL, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 K. R. Desai et al. (eds.), Placement and Retrieval of Inferior Vena Cava Filters, https://doi.org/10.1007/978-3-030-45150-9_11

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Fig. 11.1 (a) Coronal (A) and axial (B) non-contrast-enhanced images show a large left axillary mass (arrows) in the region of the axillary vein. (b) Coronal (A) and axial (B) non-contrast-­ enhanced images show a large left axillary mass (arrows) in the region of the axillary vein. (c) T1 (C)- and T2 (D)-weighted MRI images showed the mass in the axillary space. (d) T1 (C)- and T2 (D)-weighted MRI images showed the mass in the axillary space

Complication:  None Intervention Performed:  SVC filter placement Procedure Images Procedure Description Right common femoral venous access was obtained with a micropuncture set, and an 8 French sheath was placed over a stiff guidewire. An angled catheter was advanced into the right and left brachiocephalic veins, and venography was performed to delineate the length and caliber of the SVC. Next, a “jugular” approach Cook Gunther Tulip IVC filter was advanced and placed into the SVC with its apex directed toward the right atrium. Equipment Used • Terumo® Pinnacle sheath 8 Fr × 11 cm • Cook® Gunther Tulip IVC Filter • Boston Scientific® Amplatz Super Stiff Guidewire 0.035″/150 cm • Cook® MPA Catheter 5 Fr

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Fig. 11.2 (a) Venogram with catheter in left innominate vein showed patent left innominate vein and SVC. (b) Venogram with catheter in right innominate vein showed patent right innominate vein and SVC. Innominate veins are important to delineate proper location of SVC for filter placement. (c) Substracted image from SVC venogram showed the filter in the SVC. (d) Unsubtracted image from SVC venogram showed the filter aligned in the SVC

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Anesthesia:  Moderate Sedation Summary with Procedure Pearls and Pitfalls Deep venous thrombosis of the upper extremity can result in pulmonary embolism, but the incidence of clinically significant PE is not well established [1]. Due to this uncertainty and inherent risk of indwelling filters, the use of SVC filters is controversial [2, 3]. In a review of SVC filters, 21 studies were identified with 209 SVC filter placements. The reported in-hospital mortality rate was 43.1%, with eight major filter-related complications (four cardiac tamponades, two aortic perforations, and one recurrent pneumothorax). In the same review, 28 additional publications on 3747 cases of upper extremity DVT showed that the rates of PE and associated mortality were 5.6% and 0.7%, respectively, as compared to a rate of PE from lower extremity DVT at 25.1%. Therefore, the risk of PE from the upper extremity is much lower than that of the lower extremity, and the risk of major complications from SVC filter placement is not trivial [4]. Currently, there are no FDA-approved SVC filters, and their use in this location is considered off-label. The inherent risk of an indwelling SVC filter is considerable. SVC filter retrieval also carries risks that are distinct from IVC filter retrieval. Considerations for SVC filter placement include length of the SVC; filter orientation, which is opposite to IVC filter orientation due to direction of blood flow; and access route, typically from the common femoral vein. SVC filter retrieval carries risks related to the superior extent of the pericardium which, if compromised, can lead to hemopericardium and serious sequelae and life-threatening cardiac tamponade. Pearls 1. SVC filters should be placed with the tip directed inferiorly, due to the direction of blood flow. 2. Approach from common femoral vein allows more room to maneuver and is safer due to the ability to engage the legs to the wall first. 3. Routine retrieval is from the common femoral vein due to filter orientation in conical filter cases. Pitfalls 1. The SVC length should be long enough to accommodate the filter used. Verify the length of the filter and SVC prior to placement.

Case 2: Complex SVC Filter Removal Wes Klejch, Imogen Foster, Steven Zangan and Thuong Van Ha History:  A 31-year-old female presented with shortness of breath following orthotopic liver transplantation. Duplex ultrasound examination demonstrated line-­ related internal jugular vein thrombosis as well as bilateral upper extremity deep

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FIg. 11.3 (a) Contrast enhanced chest CT showed left lung pulmonary embolus (dashed arrow) and (b) right lung pulmonary embolus (dashed arrow)

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Fig. 11.4 (a) Venogram prior to SVC filter placement demonstrating a patent SVC. (b) Post-­ placement radiograph demonstrates appropriate SVC filter placement

vein thrombosis despite therapeutic anticoagulation. CT chest revealed bilateral pulmonary emboli (Fig. 11.3a, b). An IVC filter was placed in the SVC (Fig. 11.4a, b). The patient was discharged on therapeutic anticoagulation and 10 months later returned for filter retrieval. Filter Type:  Cook® Celect Complication:  Tilted and embedded SVC filter apex. Intervention/Technique Performed:  Forceps-assisted SVC filter retrieval.

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Procedure Images Procedure Description The first attempt at retrieval was unsuccessful due to incorporation of the filter tip into the lateral wall of the SVC secondary to filter tilt. After initial attempts to snare the tip of the filter were not successful, the wire-loop snare technique was attempted. A 16 French sheath was placed in the right common femoral vein, and a reverse curve catheter was used to loop and snare an exchange length Glidewire around the apex of the filter (Fig. 11.5). Traction on the wire resulted in patient’s complaint of pain, and because the hook could not be separated from the SVC wall, the procedure was terminated. Two weeks later, the patient returned for forceps-assisted retrieval under general anesthesia. A 16 Fr sheath was placed in the right internal jugular vein, and a 10 F Flexor sheath was placed in the right common femoral vein, through which the Cook filter retrieval set was placed. The forceps were introduced via the right jugular sheath to dissect the neointimal tissue from the filter apex and free the hook. Next, the forceps were used to center the filter while simultaneously snaring it from below (Fig. 11.6). The filter was then retrieved into the femoral sheath. Completion

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Fig. 11.5 (a) As the filter appeared tilted and was refractory to standard snare removal, an initial attempt using a wire-loop technique was performed. (b) After formation of the wire loop however, the sheath was unable to be advanced over the hook and apex. The procedure was terminated due to severe pain

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Fig. 11.6 (a) During repeat attempt, a venogram demonstrated the femoral sheath below the apex of the SVC filter. The hook of the filter appeared embedded and the SVC appears narrowed at this level. (b) Rigid forceps were advanced from a right jugular approach and used to engage the apex of the filter and dissect the embedded tissue (arrow). (c) Following successful dissection, the forceps were then used to direct the filter tip from the wall toward the snare, and the snare was used to engage the filter hook. (d) Once snared, the filter was sheathed and removed. (e) Completion venogram demonstrated no extravasation or other evidence of SVC injury. Reflux into a patent left brachiocephalic vein is also noted (arrow)

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Fig. 11.6 (continued)

venogram demonstrated a normal-appearing SVC without evidence of contrast extravasation. Two weeks after the procedure, the patient was followed up in Interventional Radiology Clinic and had no complaints. Ultrasound examination of the right internal jugular and right common femoral vein demonstrated no evidence of stenosis or thrombus. Equipment Used • Boston Scientific® Amplatz Super Stiff Guidewire 0.035″/150 cm • Cook® Filter Retrieval Set • Cook® Simmons-1 catheter 5 Fr x 100 cm

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Cook® Flexor sheath 16 Fr × 70 cm Terumo® Glidewire 0.035″/260 cm Cook® Flexor sheath 10 Fr × 60 cm Lymol Medical Rigid Endobronchial Forceps

Anesthesia:  Initial attempt was performed with moderate sedation. The forceps-­ assisted procedure was performed with general anesthesia due to complexity and proximity of the filter to critical structures. Summary with Procedure Pearls and Pitfalls SVC filter retrieval can be attempted using the conventional snare method. However, since the filter is oriented opposite to the IVC placed filter, route of access in general should be from the common femoral vein. Reports of SVC filter retrieval are limited. A case report of an uneventful Bard Recovery filter retrieval from the SVC was made in 2004 [5]. One report of retrieval of a Gunther Tulip SVC filter described contrast extravasation into the pericardial space immediately after retrieval, thought to be self-limited but ultimately resulting in delayed cardiac tamponade requiring pericardiocentesis 16 days later [6]. Advanced techniques have been described in SVC filter retrieval. One case report described uncomplicated forceps retrieval via right common femoral approach of a tip-embedded Celect superior vena cava filter after 8-month dwell time [7]. Another report of SVC filter retrieval, after 6-year dwell time, described wire-loop snare technique in addition to forceps complicated by a small hemorrhagic pericardial effusion and self-resolving pericarditis [8]. Potential complications of SVC filter retrieval are in part related to disruption of the pericardial reflection, which can extend far cephalad from the cavoatrial junction, resulting in hemopericardium [7]. Appropriate use of SVC filters should be determined on an individualized basis. If a patient has proven PE from upper extremity DVT despite anticoagulation or when anticoagulation is contraindicated, SVC filter placement should be considered. Clinicians should be mindful that retrieval of a filter in the SVC requires caution as a tear in the SVC can cause complications unique to the SVC such as hemopericardium and results in immediate or delayed cardiac tamponade. Pearls 1. Caution should be exercised in complex retrieval of SVC filters as tearing of the pericardium can occur. 2. Similar to complex IVC filter retrieval, a variety of advanced techniques can be employed in complex SVC filter retrieval. 3. Venograms should be performed after retrievals to exclude contrast extravasation as hemopericardium is a risk with potentially significant consequences. Stent grafts should readily be available in the event of such events to repair the SVC. 4. Patients should be closely monitored for potential complications.

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Pitfalls 1. Like IVC filters, SVC filters can tilt and become incorporated into the vein endothelium, complicating retrieval. 2. As has been reported in the literature, serious delayed complications can occur following SVC filter retrieval. Continued follow-up post procedure should be considered.

Case 3: Iliac Filter Placement Alex Lionberg, Q. T. Elizabeth Van Ha, Rakesh Navuluri and Thuong Van Ha History:  A 39-year-old morbidly obese man who underwent intra-op IVC filter placement prior to bariatric surgery. Post procedure, the patient was referred to interventional radiology to manage a significantly tilted filter where it was noted that the inferior vena cava was larger than 3.2  cm. Interventional radiology was consulted for further management (Fig. 11.7).

Fig. 11.7 Intraoperative IVC venogram performed after an immediate preoperative filter placement showed an enlarged inferior vena cava and a tilted IVC filter, with the tip of the filter up against the IVC wall (arrow)

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Filter Type:  Cook® Celect Complication:  Inappropriate filter placement in a megacava. Intervention/Technique Performed:  Filter removal with bilateral iliac filter placement. Procedure Images Procedure Description Right jugular venous access was obtained using a micropuncture set. A filter retrieval set was used to remove the existing tilted filter with the included snare and removed. Bilateral iliac venograms were performed to measure their size and confirm an appropriate area for deploying the filters. Subsequently, two filters were placed in the common iliac veins bilaterally (Fig. 11.8). Six weeks after surgery, the patient was brought back for bilateral iliac vein filter retrieval. This was performed uneventfully from the right internal jugular vein approach, as the angles from the IVC to the common iliac veins were gradual and did not require special technique or maneuvering. Equipment Used • Boston Scientific® Amplatz Super Stiff Guidewire 0.035″/150 cm • Cook® Filter Retrieval Set • Cook® Celect Filter (×2) • Cook® Pigtail Catheter 5 Fr x 65 cm Anesthesia:  Moderate sedation with midazolam and fentanyl. Summary with Procedure Pearls and Pitfalls There are certain situations where placement of filters in the IVC is contraindicated and necessitates other locations, mainly in the common iliac veins. Megacava, generally described as an inferior vena cava with diameter equal to or larger than 3 cm, presents a particular challenge to IVC filter placement and retrieval. The incidence of megacava varies from 2% to 12% [9]. Commercially available retrievable filters are not sized to fit in an IVC with a diameter larger than 2.8–3.2 cm. Placing a filter in an IVC larger than the recommended diameter can result in significant tilting (such as this case), filter migration, and decreased filtration efficacy. The Bird’s Nest IVC filter (Cook, Bloomington, IN) is approved for IVC diameters up to 40 mm but can be associated with IVC thrombosis due to its coil-like configuration and cannot be retrieved. One suggested way of dealing with a megacava is to place filters in the bilateral common iliac veins, which tend to be smaller in diameter, using the available retrievable filters [10]. The use of retrievable filters also allows for their removal at the appropriate time.

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Fig. 11.8 (a) Iliac venograms showed patent common iliac veins bilaterally (arrows) and diameters (< 28 mm) appropriate for commercially available IVC filters. (b) The preexisting filter was snared (arrow) and subsequently removed. (c) Spot image showing bilateral iliac filters in position

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In the largest study to date, a cohort of ten patients who underwent bilateral iliac vein retrievable filter placement was analyzed, with a mean indwelling time of 40  days. No complications were reported with placement, during the indwelling period, or during retrieval [11]. Nine of the patients had megacava. One had normal caval diameter, but iliac filters were placed due to concerns of intraoperative manipulation of a large retroperitoneal tumor. Pearls 1. Placement of filters in an IVC too large for its recommended coverage size can result in unwanted complications, such as tilting in this case. 2. The use of IVC filters in the iliac veins is considered off-label. Pitfalls 1. With a significantly tilted filter, when the tip of the filter is in contact with the IVC wall, incorporation of the tip into the wall can lead to complicated retrieval. 2. Other potential complications with a tilter filter include decreased filtration efficacy and filter migration.

Case 4: Bilateral Iliac Filter Retrieval Alex Lionberg, Q. T. Elizabeth Van Ha, Rakesh Navuluri and Thuong Van Ha History A 74-year-old female with DVT with contraindication to anticoagulation due to history of falls and recent cervical discectomy presented for IVC filter placement. Initial venogram demonstrated a duplicated IVC. The right-sided IVC was of normal caliber, and the left-sided IVC measured less than 1 cm. Suprarenal IVC venogram demonstrated a caval diameter larger than 3 cm. Bilateral iliac vein filters were placed (Fig. 11.9). She subsequently presented for iliac filter retrieval. Filter Type:  Cook® Celect (×2) Complication:  None. Angulation of iliac veins however makes standard retrieval more difficult. Intervention/Technique Performed:  Directional snare-assisted retrieval of bilateral iliac filters. Procedure Images Procedure Description Right internal jugular venous access was obtained. A retrieval set was used to successfully snare and remove the right iliac filter in standard fashion. However, due to

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Fig. 11.9 (a) Pre-placement venogram demonstrated a duplicated IVC with a small left IVC (arrow) draining into the left renal vein. Note the interiliac vein (dashed arrow). The suprarenal IVC was abnormally large in diameter. (b) Bilateral iliac filters were placed

the more angulated left iliac vein with respect to the IVC, routine retrieval was not possible on the left, as the snare could not reach the filter tip. A modified snare technique uses a trimmed 7 Fr, 90-degree angled pigtail catheter, through which a trilobed snare was placed for directional maneuvering of the snare (Fig. 11.10). This technique allowed for angulation of the system, with subsequent snaring of the filter tip and filter removal. Equipment Used • Boston Scientific® Amplatz Super Stiff Guidewire 0.035″/150 cm • Cook® Filter Retrieval Set • Cordis® 90° angled pigtail catheter 7 Fr/100 cm • Merit Medical EN Snare® – 120 cm snare length, 12–20 mm working diameter Anesthesia:  Moderate sedation was used for both placement and retrieval procedures. Summary with Procedure Pearls and Pitfalls Indications for an iliac filter include duplicated IVC and when IVC placement is contraindicated, such as anticipated extensive manipulation of the IVC during future intra-abdominal or retroperitoneal surgeries. Cases of duplicated IVC require protective filtration for each IVC. The incidence of duplicated IVC is reported to be between 0.2% and 3% [12]. Various case reports have espoused the use of dual

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Fig. 11.10 (a) The right common iliac vein with a slight angle, allowing for routine retrieval with a conventional snare retrieval set (arrow). (b) The left common iliac vein angle to the IVC did not allow for the regular snare set approach. A filter hook and a modified snare were used with a trimmed 7 French, 90-degree pigtail catheter. The angled catheter navigates the bend (arrow) and allows the snare to reach the filter tip. (c) Photograph of a trilobed snare through a trimmed 7 French, 90-degree pigtail catheter. The distal tip of the 7 French catheter is cut off and discarded, allowing the angle of the trimmed catheter to direct the snare in the appropriate orientation

filters in this circumstance, one filter for each IVC [13–15]. An alternative technique is to place a filter in the suprarenal IVC, thereby providing protection for both IVCs after the left IVC joins the left renal vein and then converges with the right IVC [16]. In this scenario however, suprarenal filter placement was not possible due to megacava. The other option would have been to place filters in both IVCs; however, the left IVC was deemed too small for this. A right IVC filter placement in conjunction with a left iliac filter placement would also have been a consideration, though there is potential for clot to embolize to the lungs via the unfiltered right iliac system, through the interiliac vein, and up the left IVC in this patient.

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Pearls 1. Retrieval of filters placed in the iliac vein can be routine except for the angulation from the IVC to the iliac vein, especially on the left side, and some planning is required to facilitate this situation. 2. When the angle of the iliac vein from the IVC is particularly acute, such as in this case, a modified angled snare system can be helpful. Pitfalls 1. Be aware of megacava in the suprarenal IVC as the IVC increases in diameter as it extends cephalad.

References Case 1: SVC Filter Placement 1. Hingorani A, Ascher E, Markevich N, et al. Risk factors for mortality in patients with upper extremity and internal jugular deep venous thrombosis. J Vasc Surg. 2005;41:476–8. 2. Spence LD, Gironta MG, Malde HM, Mickolick CT, Geisinger MA, Dolmatch BL.  Acute upper extremity deep vein thrombosis: safety and effectiveness of superior vena caval filters. Radiology. 1999;210:53–8. 3. Usoh F, Hingorani A, Ascher E, et al. Long-term follow-up for superior vena cava filter placement. Ann Vasc Surg. 2009;23:350–4. 4. Owens CA, Bui JT, Knuttinen MG, Gaba RC, Carillo TC. Pulmonary embolism from upper extremity deep vein thrombosis and the role of superior vena cava filters: a review of the literature. J Vasc Interv Radiol. 2010;21:779–87.

Case 2. Complex SVC Filter Removal 5. Rajan DK, Sniderman KW, Rubin BB. Retrieval of the Bard Recovery filter from the superior vena cava. J Vasc Interv Radiol. 2004;15:1169–70. 6. Dalvie PS, Gutta NB, JC MD. Delayed cardiac tamponade following injury during retrieval of a superior vena cava filter. J Vasc Interv Radiol. 2015;26:929–31. 7. Bayer O, Schummer C, Richter K, Frober R, Schummer W. Implication of the anatomy of the pericardial reflection on positioning of central venous catheters. J Cardiothorac Vasc Anesth. 2006;20:777–80. 8. Yan Y, Galfione M, Stavropoulos SW, Trerotola SO. Forceps retrieval of a tip-embedded superior vena cava filter. J Vas Interv Radiol. 2013;24:592–5.

Case 3. Iliac Filter Placement 9. Prince MR, Novelline RA, Athanasoulis CA, Simon M. The diameter of the inferior vena cava and its implications for the use of vena caval filters. Radiology. 1983;149:687–9. 10. Baron HC, Klapholz A, Nagy AA, Wayne M. Bilateral iliac vein filter deployment in a patient with megacava. Ann Vasc Surg. 1999;13:634–6. 11. Van Ha TG, Dillon P, Funaki B, et al. Use of retrievable filters in alternative common iliac vein location in high-risk surgical patients. J Vasc Interv Radiol. 2011;22:325–9.

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Case 4. Bilateral Iliac Filter Retrieval 12. Mayo J, Gray R, St Louis E, et al. Anomalies of the inferior vena cava. AJR Am J Roentgenol. 1983;140(2):339–45. 13. Rohrer M, Cutler B. Placement of two Greenfield filters in a duplicated vena cava. Surgery. 1988;104:572–4. 14. Sartori MT, Zampieri P, Andres AL, Prandoni P, Motta R, Miotto D. Double vena cava filter insertion in congenital duplicated inferior vena cava. Haematologica. 2006;91:42–3. 15. Hashmi ZA, Smaroff GC. Dual inferior vena cava: Two inferior vena cava filters. Ann Thorac Surg. 2007;84:661–3. 16. Mano A, Tatsumi T, Sakai H, et al. A case of deep venous thrombosis with a double inferior vena cava effectively treated by suprarenal filter implantation. Jpn Heart J. 2004;45:1063–9.

Permanent Inferior Vena Cava Filters: Special Considerations

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Shelly Bhanot and Kumar Madassery

Pulmonary emboli (PE) are the sequelae of a thromboembolic phenomenon within the venous system. They usually originate from a lower extremity deep vein thrombosis (DVT) which travels to the lungs, the consequences of which can be life-­threatening. Inferior vena cava filters (IVCFs) are used as filtration devices in the IVC to protect against venous thromboembolism (VTE) traveling to the heart and lungs. These devices simultaneously mechanically obstruct thrombi while maintaining blood flow through the IVC. Anticoagulation is the gold standard treatment of thromboembolic disease, and IVCFs neither treat nor prevent VTE [1–3]. Historically, IVC filtration methods began with surgical IVC plication. This was followed by open surgical permanent filter placement such as the MobinUddin umbrella filter and eventually into large sheath percutaneous conical metal filters. In the 1990s, filters with proximal hooks to assist in subsequent percutaneous removal were introduced. IVCFs largely fall into two primary categories, retrievable IVCF (rIVCF) and permanent (pIVCF). Both filter types are currently placed percutaneously into the IVC and using deployment devices. They anchor onto the wall of the IVC using hooks, barbs, or radial force [4]. All rIVCFs are FDA-approved for pIVCF use [5]. In fact, 18–33% of rIVCFs that are placed are kept in place long term as pIVCFs secondary to ongoing increased risk for PE over time [6]. IVCFs simply help prevent the occurrence of PE. For some patients with contraindications to anticoagulation or chronic pathologies such as cancer which cause recurrent VTE/PE, pIVC becomes necessary. However, for decades, the long-term negative consequences of keeping these foreign bodies in were not known. Over time, the deleterious effects after their short-term benefits were discovered,

S. Bhanot · K. Madassery (*) Rush University Medical Center, Chicago, IL, USA © Springer Nature Switzerland AG 2020 K. R. Desai et al. (eds.), Placement and Retrieval of Inferior Vena Cava Filters, https://doi.org/10.1007/978-3-030-45150-9_12

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including filter migration, fracture, symptomatic pain, occlusion of the venous system, and increased PEs. Given these complications, medicolegal concerns have focused on removal of all filters if clinically appropriate. Additionally, there has been appreciable controversy regarding the placement of rIVCFs versus pIVCFs. Different parameters govern the decision to use a retrievable or a permanent filter. In general, pIVCFs are indicated when longterm VTE/PE protection is required for a patient or for patients with short (less than 3–6 months) life expectancy. rIVCF usage has significantly increased given the fact they are able to be used as pIVCF; however, it has been shown that rIVCFs have higher complication rates than pIVCFs [3]. Adverse event rates have also been shown to increase the longer rIVCFs dwell within the IVC [7]. With only 41% of rIVCFs being retrieved after placement from factors like loss of follow-up or conversion to permanent placement, pIVCFs continue to remain an important consideration for PE prevention. Examples of pIVCF currently in use include Vena Tech LP (B.  Braun IS, Bethlehem, PA), TrapEase (Cordis, Bridgewater, NJ), Bird’s Nest (Cook Group, Bloomington, IN), Simon Nitinol (Bard Peripheral Vascular Inc., Tempe AZ), and the titanium Greenfield (Boston Scientific, Watertown, MA). For the purpose of this chapter, we will be focusing on pIVCFs. As with all IVCFs, complications can be divided into three main categories: placement (venous access and filter deployment), delayed complications, and complications with filter retrieval. A landmark trial PREPIC (Prévention du Risque d’Embolie Pulmonaire par Interruption Cave) published in 1998 evaluated 8-year follow-up after pIVCF placement in 396 patients. This study showed that while there were reduced rates of PE in patients with pIVCFs, it was shown that there were increased rates of recurrent DVTs [8]. Additionally, another study found that the most common complication from pIVCFs is filter placement [9]. Filters are typically placed with the tip of the filter at or just below the level of the renal veins (infrarenal). This location has shown the maximal clinical significance in terms of IVCF efficacy [10]. The incidence of complications from IVCF malpositioning varies from 4% to 11% [11]. Late complications from poor IVCF placement include filter fracture, filter migration, IVC thrombosis, and recurrent PE. Majority of filter placement complications are found incidentally on imaging done for other clinical reasons. In the event that a major complication is found after filter placement, unique techniques are employed to retrieve the filter. Planning of pIVCF removals first requires good clinical evaluation and determination of why filter removal has been pursued. Increasingly, it is common to have referrals from physicians, other endovascular specialists, and patient self-referrals and, unfortunately, from law firms. Historically, the general understanding was that a permanent filter equated to it is not removed. Although many pIVCFs were placed due to presumed long-term protection needs, referrals for potential removals are increasing as the awareness that advanced filter removal specialists can remove

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these without major complications has evolved. Some patients may have symptomatic issues related to filter penetration, and others may be referred due to sequelae of caval occlusion due to these long-term indwelling constructs. A portion of these will need iliocaval reconstruction during the complex filter removal. The safe removal of these filters has been increasingly demonstrated considering these filters have higher rates of IVC wall embedment and difficulty in removal. Detailed discussions must be had with patients and their families regarding potential for complications that may necessitate angioplasty, stenting, or possibly bleeding. Currently, there is a paucity of high-volume data in the literature specific to pIVCF removals aside from case reports or a few case series. Pre-procedural imaging is also recommended for these pIVCF cases. This typically involves a computed tomography (CT) venogram, allowing detailed evaluation of the filter position, penetration/fracture/migration of the filter and its components, thrombus presence, and iliocaval patency (Case 2). Others may opt for magnetic resonance (MR) imaging. Some operators also choose to have a recent vascular duplex venous ultrasound of the lower extremities depending on patient symptomatology. Imaging evaluation can significantly help equipment planning and provide more complete information to the patient and their family regarding expectations. For many operators, deep sedation or general anesthesia is utilized as chronically embedded filters can induce significant pain during removals. However, there are operators globally who choose to perform or at least attempt the procedure under moderate sedation. The pIVCFs, particularly the polygonal types such as the TrapEase and VenaTech, have higher degrees of difficulty in removal due to the extensive wall contact that is made. While this construct helps keep them centrally positioned in the IVC, this also makes for much more fibrin scarring that needs addressing. Due to this, chronically indwelling pIVCFs may require excimer laser use to deal with the extensive scarring. It is prudent to plan for large sheaths (give name, size, and company) in order to accommodate the multiple advanced maneuvers that may be needed, such as endobronchial forceps (brand and company), laser sheath (brand and company), and other adjunctive techniques. For the TrapEase, many times dual sheaths from above (internal jugular) and from below (femoral vein) may be required to secure both cone ends and simultaneous sheathing (as shown in Case 1 for a similarly shaped filter). Strong sheaths are beneficial for the force required to disengage the rigid leg hooks from the IVC walls when attempting to remove the Greenfield filter. Otherwise, escalation of the many techniques mentioned throughout this book is commonly utilized for successful retrieval. As some pIVCFs and complex rIVCF removals can take a significant amount of time and manipulation of the IVC with numerous equipment, it is prudent to consider dosing systemic heparin as to prevent caval thrombosis. Post-removal venograms may demonstrate residual hard thrombus or potentially stenosis left behind.

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If there is concern, it would be beneficial to consider venoplasty with stenting if absolutely necessary. It is almost always prudent to have a low threshold to continue or start short-term anticoagulation in these patients to prevent eventual thrombosis. Many operators chose to continue anticoagulation that patient may be on for the procedure. However, this should be individualized to each patient and operator experience. When in doubt, it is safer to discontinue or adjust bleeding parameters. Additionally, it is ideal to have a fail-safe to ensure all filter components have been removed. This includes taking spot abdominal and chest images along with evaluating and knowing the specific construct of each filter that is removed. In rare cases, if the filter cannot be removed, there is a symptomatic need to recanalize an occluded iliocaval system. In these cases, some do choose to stent across the filter which has demonstrated acceptable patency [12, 13]. The following cases illustrate varying advanced approaches utilized when dealing with complex permanent IVCF removals. Case 1 A 46-year-old female with no significant past medical history presented to the Interventional Radiology Clinic for consultation regarding an IVC filter which was incidentally found for epigastric and back pain workup. As patient was unaware of filter presence, she recalled an motor vehicle accident when she was a teenager, 28 years ago. After obtaining her records, she found that a permanent IVC filter was placed during her trauma stay at an outside facility. She has no history of leg swelling, DVT, or PE. CT scan during her symptomatic workup demonstrated a Greenfield filter with strut penetration outside of the vena cava, with legs penetrating toward the spine and one strut potentially penetrating the abdominal aorta. Patient was adamant regarding having this filter removed. Risks and benefits were thoroughly discussed.

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Discussion Patient recovered post filter removal without complication and minimal pain. In clinic follow-up, patient reported resolution of back pain and improvement of epigastric pain after GI consultation and management. Her potential May-Thurner compression findings were not further evaluated or treated; however, she is aware to look for any potential sequelae in the future.

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Case 2 A 44-year-old male with history of VTE including multiple DVT and PE episodes and IVC filter placed 12 years ago. Patient was mismanaged and suboptimally compliant with anticoagulation medications. Patient reports occasional vague back pain and desires strongly to have filter removed. Patient was sent to hematology service for proper medication evaluation and management. Once jointly determined it was safe to do so, plan for filter removal was made.

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Discussion This case demonstrates the importance of pre-procedural imaging. Specifically, the suggested likelihood of tip embedment into the IVC wall was confirmed with the imaging. Several complex IVC filter removal techniques that have been described elsewhere may be utilized in these cases. While venograms are not necessary for straightforward removals, it is recommended in complex removals. Case 3 A 57-year-old female with history of hypertension and coronary arterial disease, and VTE who had a VenaTech LP IVC filter placed out of state during motor vehicle accident approximately 15 years ago. Patient was sent from OSH physicians after failed attempted removals. Patient has had no lower extremity swelling and is no longer on anticoagulation. Patient desires filter to be removed.

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Discussion This case demonstrates additional improvisation needed compared to previously described advanced techniques. Utilization of tip deflecting sheath from caudal direction can help push off the filter cone from the IVC wall while simultaneously attempting to grasp the filter from above. Riding a snare over forceps that has hold of the tip can assist in improved sheathing.

Conclusion Permanent IVC filter removals require similar advanced filter removal techniques that have been discussed in the literature and elsewhere in this book. The most important considerations are why the filter should be removed, the pre-procedural imaging that is recommended, and a detailed documented discussion with patient and family members. At times, as demonstrated above, improvisation of advanced techniques may be necessary. In general, large sheaths, endobronchial forceps, and possible excimer laser will be required along with recommendation of deep/general anesthesia. It has been demonstrated here and in limited case series that permanent IVC filter can be removed safely by experienced operators.

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References 1. Ray CE Jr, Mitchell E, Zipser S, Kao EY, Brown CF, Moneta GL. Outcomes with retrievable inferior vena cava filters: a multicenter study. J Vasc Interv Radiol. 2006;17(10):1595–604. 2. Ghatan CE, Ryu R. Permanent versus retrievable inferior vena cava filters: rethinking the “one-­ filter-­for-all” approach to mechanical thromboembolic prophylaxis. Semin Intervent Radiol. 2016;33(2):75–8. 3. Eifler AC, Lewandowski RJ, Gupta R, et al. Optional or permanent: clinical factors that optimize inferior vena cava filter utilization. J Vasc Interv Radiol. 2013;24(1):35–40. 4. Haas SK.  Venous thromboembolic risk and its prevention in hospitalized medical patients. Semin Thromb Hemost. 2002;28(6):577–84. 5. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6, Suppl):381S–453S. 6. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3, Suppl):338S–400S. 7. Division of Industry and Consumer Education (DICE). FaDA Removing Retrievable Inferior Vena Cava Filters: FDA Safety Communication; 2014. Available at: http://www.fda.gov/ MedicalDevices/Safety/AlertsandNotices/ucm396377.htm. Accessed June 14, 2019. 8. Decousus H, Leizorovicz A, Parent F, et  al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d’Embolie Pulmonaire par Interruption Cave Study Group. N Engl J Med. 1998;338(7):409–15. 9. Andreoli JM, Lewandowski RJ, Vogelzang RL, Ryu RK. Comparison of complication rates associated with permanent and retrievable inferior vena cava filters: a review of the MAUDE database. J Vasc Interv Radiol. 2014;25:1181. 10. Van Ha TG.  Complications of inferior vena caval filters. Semin Intervent Radiol. 2006;23(2):150–5. 11. Haga M, Hosaka A, Miyahara T, Hoshina K, Shigematsu K, Watanabe T. Penetration of an inferior vena cava filter into the aorta. Ann Vasc Dis. 2014;7(4):413–6. 12. Neglen P, Oglesbee M, Olivier J, Raju S. Stenting of chronically obstructed inferior vena cava filters. J Vasc Surg. 2011;54(1):153–61. 13. Chick JFB, Jo A, Meadows JM, Abramowitz SD, Khaja MS, Cooper KJ, Williams DM. Endovascular Iliocaval stent reconstruction for inferior vena cava filter-associated iliocaval thrombosis: approach, technical success, safety, and two-year outcomes in 120 patients. J Vasc Interv Radiol. 2017;28(7):933–9.

Management of the Acute Thrombus-­ Bearing IVC Filter

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Mark L. Lessne and Brian Holly

Introduction While anticoagulation is the mainstay for the treatment of venous thromboembolism (VTE), for patients who have failed or cannot tolerate anticoagulation therapy, caval filtration is an effective means for decreasing the risk of pulmonary embolism (PE). The first intracaval prosthesis was described by Mobin-Uddin et al. and obviated the need for open surgical caval ligation; however, this technique was plagued by thrombotic occlusion of the inferior vena cava (IVC) in the majority of patients [1]. Since then, rheologic refinements in percutaneous caval filter designs, aimed at maintaining caval flow, have mitigated—though not eliminated—the risks of caval thrombosis. Current evidence suggests IVC thrombus may occur in up to 40% of patients following filter placement but may vary based on filter type with some reports indicating increased thrombus rates following placement of retrievable and biconical filters [2–7]. However, IVC thrombus is a general term that can imply minimal thrombus within the filter or total caval thrombosis. Clinical presentation can be likewise disparate, ranging from asymptomatic to limb and life-threatening phlegmasia. The Prévention du Risque d’Embolie Pulmonaire par Interruption Cave (PREPIC) study was a randomized, controlled trial comparing patients without caval filters with those who received a permanent-type IVC filter. At 8-year follow-­up, the no-filter group reported 27.5% deep venous thrombosis (DVT) rate, while the filter group had 35.7% DVT (P = 0.042), though rates of post-thrombotic syndrome (PTS) were similar between groups [5]. The etiology of filter-bearing caval thrombus is controversial with some purporting these thrombi are trapped clot that otherwise would have

M. L. Lessne (*) Vascular & Interventional Specialists of Charlotte Radiology, Charlotte, NC, USA The Johns Hopkins Medical Institute, Baltimore, MD, USA B. Holly The Johns Hopkins Medical Institute, Baltimore, MD, USA © Springer Nature Switzerland AG 2020 K. R. Desai et al. (eds.), Placement and Retrieval of Inferior Vena Cava Filters, https://doi.org/10.1007/978-3-030-45150-9_13

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resulted in pulmonary emboli in the absence of filtration; others maintain the presence of a filter may disturb flow sufficiently to promote DVT. For the interventionalist offering IVC filter placement, it is essential to be familiar with not only the signs, symptoms, and treatment of filter-related caval thrombosis but also the clinical decision-making regarding removal of an asymptomatic but thrombus-bearing IVC filter.

Indications for Treatment Asymptomatic Caval Thrombus Asymptomatic caval thrombus detected incidentally on cross-sectional imaging performed for unrelated reasons or on pre-retrieval cavagram occurs in as many as one out of four patients [2]. When IVC clot is encountered, even in asymptomatic patients, anticoagulation is recommended, when possible, to mitigate the risks of propagation of thrombus. Of course, for many patients with IVC filters, anticoagulation may have been contraindicated, complicating the appropriate therapeutic course. However, in the setting of significant IVC thrombosis, this contraindication should be reevaluated; in fact, for many patients, the contraindication to anticoagulation is ephemeral and may have resolved, or the risk-benefit profile of anticoagulation in the setting of a more extensive thrombus may have shifted [8]. A commonly encountered scenario is caval thrombus detected during the retrieval procedure on pre-retrieval cavagram. Thrombus may be acute or chronic or—as is frequently the case—of indeterminate age. The presence of clot can increase the technical difficulty of filter removal and, if thrombus is nonadherent and mobile, can result in PE with catastrophic consequences. The classic teaching is that significant thrombus within a filter—historically and arbitrarily defined as 25% of the volume of the filter cone—should be considered a contraindication to filter removal. Visual scales have been published to help assess this 25% threshold [7]. Practically, clot burden is only a single data point used when determining whether filter removal is prudent: patient’s age, comorbidities—especially cardiopulmonary status, which affects how well or poorly a patient could tolerate a trapped thrombus inadvertently embolizing to the lungs—and the condition of the IVC filter must be factored into the retrieval decision. Furthermore, in some patients of advanced age and significant comorbidities, the decision to leave the filter in situ may be the most prudent option. For most patients in whom filter retrieval is still desired, a 6-week course of anticoagulation with repeat imaging or retrieval attempt (preceded by pre-­retrieval cavagram) often confirms regression or stability of the thrombus, allowing filter removal.

Symptomatic Caval Thrombosis Patients may also present with significant symptoms of venous outflow obstruction. Pain in the lower back, buttocks, or legs accompanied by abdominal and bilateral lower extremity swelling is indicative of significant caval DVT.  If

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Fig. 13.1  Massive DVT resulting in phlegmasia cerulea dolens [11]

thrombus extends into or above the juxtarenal IVC, renal or hepatic vein outflow may be compromised resulting in renal or hepatic failure [9, 10]. Extensive, occlusive caval thrombosis, especially in the setting of iliac and infrainguinal DVT, can result in phlegmasia cerulea dolens (PCD), with potential for venous gangrene, compartment syndrome, arterial compromise, and limb loss (Fig.  13.1). PCD has a 40% reported mortality rate, which may be inevitable despite reperfusion [11]. When evaluating a patient with suspected IVC thrombosis, evaluation must include an assessment of symptom severity based on physical examination and laboratory findings. On examination, degree of abdominal and lower extremity swelling and dilation of superficial abdominal or axillae and chest (in the case of concomitant iliac vein DVT) varicosities may be appreciated, though these are not consistent findings. Discoloration of the lower extremities and decreased range of motion may be present. Fever is a nonspecific finding of DVT. Blood work is generally aimed at evaluation of renal function and coagulation profiles [9]. For patients in whom significant caval thrombosis is suspected, cross-sectional imaging with computed tomography (CT) or magnetic resonance imaging (MRI) usually confirms the diagnosis and delineates the extent of clot burden. Contrast-­ enhanced imaging is first line for evaluation of the deep veins in the abdomen and pelvis. For patients in whom contrast cannot be used, non-contrast imaging, especially with non-gadolinium based MR venography techniques, can be equally useful but requires radiological expertise to perform and interpret. CT or MR venography can also be extended to image the infrainguinal lower extremities, although duplex ultrasound is frequently used to assess these vein segments for thrombotic involvement. In addition to anticoagulation, patients should be evaluated for a clot removal procedure. Open surgical thrombectomy has largely fallen out of favor replaced by percutaneous, endovascular techniques. Recently, the ATTRACT trial evaluated the role of pharmacomechanical catheter-directed thrombolysis (PCDT) in patients with acute, proximal DVT and demonstrated a lack of benefit for intervention [12]. However, it is important to note that this trial specifically evaluated patients with femoral, common femoral, and iliac vein DVT and should not be generalized to patients with caval thrombus. If severe symptoms of DVT are present, the patient must be evaluated for thrombectomy and/or thrombolytic procedures.

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Techniques of Clot Removal Once the decision has been made to proceed with caval thrombectomy and/or thrombolysis, pre-procedure planning is essential to ensure a safe and efficacious outcome. As discussed above, patients with acute thrombosis of a filter-bearing IVC benefit from initiation of anticoagulation if not contraindicated. Clot removal procedures in patients unable to be anticoagulated may have a role to treat severe thrombotic symptoms, including PCD, but risk of rethrombosis is high. Low-dose anticoagulation or antiplatelet agents may be reasonable alternatives in the prevention of recurrent DVT, but generalizing these data to the post-caval thrombectomy setting is fraught with fallacy [13, 14]. Moderate sedation is commonly sufficient for these procedures, though general anesthesia may be required for certain patients. As with all endovascular procedures, appropriate access planning is crucial to successful therapy. The primary goal of thrombectomy is to restore inflow and outflow; therefore, access into a patent peripheral vessel is important to facilitate restoration of flow. Commonly, the patent popliteal or common femoral veins are chosen given their direct inline access to the IVC and ability to accommodate larger sheath sizes required for placement of thrombectomy devices, balloon catheters, and stents. However, the jugular veins or—in the case of popliteal vein thrombosis—posterior tibial vein (PTV) can be used for access. Despite the relatively small size of the PTV, devices as large as 8 French can still be delivered either bareback or through dedicated radial artery sheaths (Fig. 13.2). Once access is secured, the thrombus is crossed using traditional endovascular techniques. Generally, acute thrombus is soft and traversal with any number of types of guidewires being possible; if the thrombus is hard or difficult to cross, a component of chronic thrombus is likely. In these instances, advanced recanalization techniques may be required to achieve wire access, but removal of as much acute thrombus as possible should still be performed prior to treatment of chronic stenosis or occlusion with balloons and stents and before filter removal. Prior to treating acute filter-bearing caval thrombosis, the interventionalist should consider if additional filtration is required cephalad to the thrombosed filter (cephalad in the infrarenal segment if there is adequate length or suprarenal IVC). In general, this is not necessary, though it may be warranted in the setting of free-floating, mobile, or significant clot burden above the IVC filter or in patients with reduced cardiopulmonary reserve. Cephalad filter placement can be performed from the femoral, jugular, or popliteal vein approach, though the latter requires extended length IVC filter deliver systems. Traditionally, caval thrombus removal was restricted to catheter-directed thrombolysis (CDT), whereby a multi-side hole catheter was advanced through the thrombus and used to directly infuse the clot with thrombolytic agents, such as tPA usually at 0.5–2 mg/hour. The catheter is usually left in place for 24–72 hours, and each day the patient returns to the angiography suite for reevaluation. This technique has been used for decades with relative safety and efficacy. However, the slow drip of thrombolytics does not allow for expeditious removal of thrombus and carries a risk of both minor and catastrophic bleeding complications [15].

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These hurdles have led to the increased use of active clot removal with pharmacomechanical thrombectomy (PCDT) devices, either as stand-alone or adjuncts to CDT.  PCDT has been shown to reduce intensive care unit resources, treatment times, and costs while maintaining effectiveness [16, 17]. Even initial PCDT, CDT can still be utilized for residual thrombus recalcitrant to PCDT clearance. Today, the choice of PCDT devices is plentiful with the most commonly used devices briefly introduced below.

 ngioJet Thrombectomy System (Boston Scientific, A Marlborough, MA) AngioJet Thrombectomy System utilizes high-velocity saline jets to fragment thrombus and create a low-pressure zone allowing clot aspiration. The system works in two modes: power pulse mode, whereby thrombolytic-laced saline is infused within the thrombus without aspiration, and rheolytic mode, which employs the

Fig. 13.2  Tibial access to facilitate thrombectomy. (a, b) Acute posterior tibial, popliteal, iliofemoral DVT. (c, d) Restoration of flow through the tibial, popliteal, and femoral veins following PCDT via posterior tibial vein access

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Fig. 13.2 (continued)

traditional aspiration mechanism. Generally, filter-bearing caval occlusions are laced with tPA using the power pulse mode which is allowed to dwell for at least 20–30 min. The catheter is then activated in rheolytic mode until all thrombus is removed, no additional clot clearance is occurring, or the maximum activation time is reached (240–480 seconds per indications for use). “The rapid lysis” technique has been described in which tPA-laced saline is infused into the thrombus but aspirated immediately in usual rheolytic mode; torqueing the thrombectomy catheter or placing the AngioJet catheter through an angled hockey stick-shaped guide catheter can improve wall-to-wall apposition [18].

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Indigo System (Penumbra, Alameda, CA) Penumbra’s Indigo Mechanical Thrombectomy System is an aspiration thrombectomy catheter connected to a pump to provide suction. The design of the catheter minimizes catheter lumen collapse when negative pressure is applied. The largest Indigo catheters are 8 French and can be angled or straight. Some catheters may be used with a separator to mechanically break up thrombus while aspirating.

AngioVac (AngioDynamics, Latham, NY) The AngioVac venous drainage system relies on a 22 French, large bore straight or curved cannula to aspirate thrombus. The system removes a sufficiently large amount of blood during activation that veno-veno extracorporeal bypass and reperfusion are required. When using the cannula in and around the IVC filter, care must be taken to avoid disruption of the filter. Although larger access is required, the device remains percutaneous and access is closed using a purse string suture.

Inari ClotTriever Thrombectomy System (Inari, Irvine, CA) ClotTriever is an over-the-wire system that utilizes an intravenous sheath with a funnel at its end. The catheter is advanced beyond the thrombus, and a self-­ expanding, nitinol collection bag is exposed, and a stent-like coring element is retracted into the sheath to fragment and collect thrombus into the collection bag. The collection bag, coring element, and captured thrombus are removed through the sheath. Additionally, the sheath itself can be used as an aspiration-type catheter. The system is generally utilized for thrombus entirely above or entirely below the IVC filter, since the device may disrupt the IVC filter. However, techniques to mitigate this risk include externalizing a femoral wire from a jugular access (“floss wire”) and advancing a sheath from the jugular access below the IVC filter, thus protecting the device from the filter collection bag and coring element can retrieved through an indwelling IVC filter.

 leaner Rotational Thrombectomy System (Argon Medical C Devices, Frisco, TX) The system relies on a 6–7 French catheter with flexible wire at its end that attaches to a drive shaft to power and rotate the wire at 4000 rotations per minute, causing maceration of the thrombus. The wire torques in a sinusoidal pattern to assist with wall-to-wall apposition. Care must be taken to avoid entanglement of the Cleaner wire in an IVC filter.

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Complications Treatment of acute thrombus is generally safe regardless of the techniques used. When thrombolytics are used with CDT, the most devastating consequence can be hemorrhage, including intracranial bleeding. Major bleeding complications have been reported in 11% in older trials, but with newer PCDT techniques, these numbers are under 2% [12, 15]. While procedure-related pulmonary emboli are known to occur, clinically significant events are unusual; moreover, a large caval burden— especially one that extends cephalad to the IVC filter—may result in PE even in the absence of endovascular manipulation of thrombus or IVC filter. When evaluating the risks of intervening on IVC thrombus, the clinical interventionalist must likewise consider the consequences of no intervention. Although the risk of developing post-thrombotic syndrome (PTS) was unrelated to IVC filter use in the PREPIC trial, other reports refute this, reporting over half of patients with IVC filters placed for secondary prevention of PE had symptoms of PTS at an average of almost 6-year follow-up [5, 19]. The presence of caval thrombosis may increase the risk of developing PTS given the large clot burden and more limited potential for collateral development relative to distal DVT.  Additionally, chronic thrombosis of the filter-bearing IVC generally makes future filter retrieval attempts more difficult, potentially requiring advanced filter removal techniques [20].

Summary While IVC filters may play an important role in the prevention of PE, thrombotic complications may result within the filter-bearing IVC. Expeditious evaluation and management of symptomatic or otherwise clinically significant thrombus are critical to avoid long-term clinical sequelae. Techniques for thrombus removal from a filter-bearing IVC are well described, effective, and safe, but appropriate training and skills are required to ensure a beneficial outcome to the patient and stave off complications and ineffectual treatments.

Cases Case 1 Patient with Simon-Nitinol IVC filter presenting with massive IVC thrombosis. (A) CT demonstrates total thrombosis of the filter-bearing IVC and bilateral iliac veins. (B) Access was obtained in the bilateral popliteal veins. PCDT was performed with AngioJet catheters using both pulse spray and rheolytic modes, followed by overnight CDT (what dose and for how long?). (C) Post-CDT venogram demonstrates restoration of flow through the IVC.

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Case 2 Patient with total caval thrombosis extending above an 11-year-old Gunther-Tulip IVC filter. (A) Initial venogram reveals thrombus throughout the filter-bearing IVC. (B and C) Following PCDT, there is marked interval clearance of thrombus but with residual, flow-limiting iliac vein clot and thrombus at the apex of the IVC filter. (D) Wires were placed on either side of the IVC filter to facilitate rheolytic thrombectomy of the apical clot. (E) Completion cavagram confirms successful clot resolution. (F) Once stable on and tolerating anticoagulation, the patient returned for IVC filter removal, which required laser-sheath assistance but was accomplished otherwise without difficulty.

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References 1. Mobin-Uddin K, McLean R, Bolooki H, Jude JR. Caval interruption for prevention of pulmonary embolism: long-term results of a new method. Arch Surg. 1969;99(6):711–5. 2. Ahmad I, Yeddula K, Wicky S, Kalva SP. Clinical sequelae of thrombus in an inferior vena cava filter. Cardiovasc Intervent Radiol. 2010;33(2):285–9.

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3. Andreoli JM, Lewandowski RJ, Vogelzang RL, Ryu RK. Comparison of complication rates associated with permanent and retrievable inferior vena cava filters: a review of the MAUDE database. J Vasc Interv Radiol. 2014;25(8):1181–5. 4. Kalva SP, Wicky S, Waltman AC, Athanasoulis CA. TrapEase vena cava filter: experience in 751 patients. J Endovasc Ther. 2006;13(3):365–72. 5. PREPIC Study Group. Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d’Embolie Pulmonaire par Interruption Cave) randomized study. Circulation. 2005;112(3):416–22. 6. Teo TKB, Angle JF, Shipp JI, Bluett MK, Gilliland CA, Turba UC, et al. Incidence and management of inferior vena cava filter thrombus detected at time of filter retrieval. J Vasc Interv Radiol. 2011;22(11):1514–20. 7. Wang SL, Timmermans HA, Kaufman JA. Estimation of trapped thrombus volumes in retrievable inferior vena cava filters: a visual scale. J Vasc Interv Radiol. 2007;18(2):273–6. 8. Wadhwa V, Trivedi PS, Ryu RK, Lessne ML. Increasing anticoagulation use among inpatients receiving inferior vena cava filters. Am J Med. 2017;130(8):e373–4. 9. Chick JFB, Jo A, Meadows JM, Abramowitz SD, Khaja MS, Cooper KJ, et al. Endovascular Iliocaval stent reconstruction for inferior vena cava filter–associated Iliocaval thrombosis: approach, technical success, safety, and two-year outcomes in 120 patients. J Vasc Interv Radiol. 2017;28(7):933–9. 10. McAree B, O’Donnell M, Fitzmaurice G, Reid J, Spence R, Lee B. Inferior vena cava thrombosis: a review of current practice. Vasc Med. 2013;18(1):32–43. 11. Lessne ML, Bajwa J, Hong K. Fatal reperfusion injury after thrombolysis for phlegmasia cerulea dolens. J Vasc Interv Radiol. 2012;23(5):681–6. 12. Vedantham S, Goldhaber SZ, Julian JA, Kahn SR, Jaff MR, Cohen DJ, et  al. Pharmacomechanical catheter-directed thrombolysis for deep-vein thrombosis. N Engl J Med. 2017;377(23):2240–52. 13. Becattini C, Agnelli G, Schenone A, Eichinger S, Bucherini E, Silingardi M, et al. Aspirin for preventing the recurrence of venous thromboembolism. N Engl J Med. 2012;366(21):1959–67. 14. Rivaroxaban or aspirin for extended treatment of venous thromboembolism | NEJM [Internet]. [cited 2019 Jun 2]. Available from: https://www.nejm.org/doi/full/10.1056/NEJMoa1700518. 15. Mewissen MW, Seabrook GR, Meissner MH, Cynamon J, Labropoulos N, Haughton SH. Catheter-directed thrombolysis for lower extremity deep venous thrombosis: report of a national multicenter registry. Radiology. 1999;211(1):39–49. 16. Lin PH, Zhou W, Dardik A, Mussa F, Kougias P, Hedayati N, et al. Catheter-direct thrombolysis versus pharmacomechanical thrombectomy for treatment of symptomatic lower extremity deep venous thrombosis. Am J Surg. 2006;192(6):782–8. 17. Garcia MJ, Lookstein R, Malhotra R, Amin A, Blitz LR, Leung DA, et al. Endovascular management of deep vein thrombosis with rheolytic thrombectomy: final report of the prospective multicenter PEARL (peripheral use of angioJet rheolytic thrombectomy with a variety of catheter lengths) registry. J Vasc Interv Radiol. 2015;26(6):777–85. 18. Garcia MJ. A treatment algorithm for DVT. Endovasc Today. 2014;13:38–40. 19. Fox MA, Kahn SR. Postthrombotic syndrome in relation to vena cava filter placement: a systematic review. J Vasc Interv Radiol. 2008;19(7):981–985.e3. 20. Desai KR, Laws JL, Riad S, Mouli Samdeep K, Errea Martin F, Karp Jennifer K, et al. Defining prolonged dwell time: when are advanced inferior vena cava filter retrieval techniques necessary? Circ Cardiovasc Interv. 2017;10(6):e003957.

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Ethan T. Klepitsch and Kush R. Desai

Introduction Although a rare complication, the development of complete iliocaval thrombosis following the placement of an inferior vena cava filter (IVCF) can have significant impact on a patient’s quality of life and ability to perform activities of daily living [1, 2]. The introduction of retrievable IVCF at the turn of the century led to a significant increase in overall IVCF utilization, thereby placing a greater number of patients at risk for IVCF-related iliocaval occlusion [3]. Ahmad et al. demonstrated that up to 18.6% of patients with IVCFs may develop an IVCF-related thrombus and 2% may develop total occlusion of the filter-bearing IVC [4]. Clinical sequelae of chronic filter-related iliocaval occlusion include the post-thrombotic syndrome (PTS), with the development of chronic severe edema, pain, and soft tissue ulceration. This chapter discusses key considerations for the evaluation and treatment of patients with IVCF-related iliocaval occlusion.

Clinical Presentation and Evaluation Morbidity associated with IVCF-related iliocaval occlusion is largely due to PTS [5, 6]. The pathophysiology of the PTS involves a combination of inflammatory valvular incompetence resulting in venous reflux, as well as luminal narrowing; these factors combine to result in venous hypertension [7]. Symptoms of PTS vary from patient to patient but may include lower extremity pain, leg heaviness, edema, lipodermatosclerosis, and venous ulcers. Most patients with IVCF-related iliocaval occlusion present with lower extremity pain and edema [8, 9].

E. T. Klepitsch · K. R. Desai (*) Division of Interventional Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 K. R. Desai et al. (eds.), Placement and Retrieval of Inferior Vena Cava Filters, https://doi.org/10.1007/978-3-030-45150-9_14

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Assessment of Symptom Severity The venous clinical severity score (VCSS), Villalta PTS scale, and the CEAP (clinical, etiological, anatomical, pathophysiological) system are useful classification symptoms for quantifying symptom severity in venous disease such as IVCF-related iliocaval occlusion. These systems are widely used to quantify symptom severity and outcomes of various treatments for venous disease. The VCSS is a 30-point maximum flat scale that assigns values ranging from 0 to 3 based on the severity of 10 unique symptom attributes [10]. Desai et al. reported that patients presenting with symptomatic IVCF-related thrombosis had mean VCSS edema and pain subscores of 2.5 and 0.9, respectively [9]. The Villalta scale is specific for diagnosing and assessing the severity of PTS. Values range from 0 for absent to 3 for severe and are assigned across five symptoms and six clinical signs. A summed score of ≥5 identifies the presence of PTS, with 5–9 indicating mild disease, 10–14 moderate disease, and ≥15 severe disease. The presence of a venous ulcer automatically classifies patients as having severe PTS [11, 12]. Ye et al. reported that patients presenting with IVCF-related chronic occlusion had a median Villalta score of 22, signifying the presence of severe PTS [13]. The CEAP system allows for specific characterization of patient’s venous disease separated into clinical, etiological, anatomical, and pathophysiological classification. The “C” classification, which characterizes clinical symptoms, is often used alone to report patients’ severity of symptoms [14]. Of note, the CEAP system does not allow for specific grading of severity of symptoms, whereas the VCSS and Villalta scales do. Chick et al. reported that among patients with indwelling IVC filters and symptomatic iliocaval thrombosis, 77.5% of patients were classified as C3–C5, indicating edema, skin changes, and evidence of prior ulceration; 6.6% were classified as C6, indicating the presence of an active venous ulcer [8].

Indications for Treatment, Patient Evaluation Signs and symptoms that are common indications for the treatment of IVCF-related iliocaval occlusion include moderate-to-severe venous insufficiency such as lower extremity edema and pain, skin changes, and ulceration (CEAP C3–C6). In females, pelvic venous disease is another potential sequela of IVCF-related caval occlusion (Fig. 14.1). These patients often present with unilateral or bilateral lower abdominal and pelvic pain. Other possible symptoms include postcoital aching, dyspareunia, dysmenorrhea, perineal pain, urgency, and vulvar and lower extremity varicosities [15].

Ultrasound The first modality used as part of the workup is often duplex ultrasound (DU), owing to its wide availability and accuracy in diagnosis of venous disease. DU

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a

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b

Fig. 14.1  Computed tomographic (CT) venography of pelvic venous insufficiency secondary to inferior vena cava (IVCF)-related occlusion. (a) CT imaging before intervention reveals the presence of tortuous and dilated pelvic collateral veins (arrows), indicating pelvic venous insufficiency. (b) CT imaging after resolution of obstruction via filter retrieval and subsequent iliocaval recanalization demonstrates diminution of pelvic collateral veins

allows for functional and dynamic evaluation of the IVC and other deep veins. Diagnosis of venous obstruction is likely if the following parameters are met: post-­ obstruction turbulence as indicated by noisy signal of mosaic color flow, abnormal Doppler signal at the area of stenosis, sluggish flow or no spontaneous flow in addition to poor augmentation and compressibility, and postphlebitic changes on B-mode imaging. In patients with symptoms of chronic venous disease, diagnosis can be aided by the presence of venous reflux, diagnosed by DU with compression, showing retrograde or reversed flow >1000 ms for deep veins. Although DU is the gold standard for evaluation of lower extremity DVT, quality evaluation of proximal veins such as the iliac veins and the IVC is operator dependent. DU of proximal veins is especially technically challenging in obese patients [16–18].

Computed Tomographic Venography Given the potential challenges of using DU for evaluation of proximal veins including the inferior vena cava (IVC), contrast-enhanced computed tomographic venography (CTV) is a useful modality in the evaluation of IVCF-related occlusion. The main strength of CTV is the ability to visualize the relationship between the IVC, filter, and the occlusion. CTV is also useful for quantifying the extent of thrombosis, potential anatomic variations, presence of venous collaterals, and involvement of the common femoral vein inflow. These findings can be of crucial importance in procedural planning, including access planning and whether thrombectomy or thrombolysis needs to be performed. Thrombotic occlusion can be diagnosed on CTV by the presence of a persistent filling defect within a column of contrast material in the IVC or, more commonly, by atresia of the previously normal IVC (Fig. 14.2). In the case of chronic occlusion, venous collaterals bypassing the obstruction may be visible. Drawbacks to

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Fig. 14.2 Computed tomographic venography (CTV) of inferior vena cava filter (IVCF)-related occlusion. CTV demonstrates atretic IVC and iliac veins caudal to the indwelling IVCF (arrow), suggesting chronic obstruction

contrast-­enhanced CT include radiation exposure and the use of iodine-based contrast material. Cost and availability of equipment should also be considered when choosing CTV as a modality for evaluation of IVCF-related occlusion [1, 19].

Magnetic Resonance Venography Magnetic resonance venography (MRV) is another viable imaging modality for diagnostic evaluation of IVCF-related occlusion. Unlike CTV, MRV does not involve radiation exposure, though potential risks associated with the administration of contrast agents are present. MRV is useful for evaluating the extent of thrombus and degree of IVC occlusion. Much like CTV, thrombotic occlusion can be diagnosed on MR by the presence of a filling defect in the column of contrast in the IVC or relative atresia of a previously normal caliber IVC. However, in the setting of an indwelling IVCF, visualization of IVC thrombus can be limited by susceptibility artifact introduced by the filter, resulting in an imaging void at the filter implantation site. Additional limitations to MRV include cost and availability of equipment, as well as necessity for local expertise for venous-specific imaging pulse sequences [1, 20]. Catheter venography and intravascular ultrasound are invasive imaging modalities and thus are generally used after treatment for IVC occlusion has been indicated. On catheter venography, IVC occlusion appears as non-visualization of the IVC and associated opacification of collateral drainage, including retroperitoneal, lumbar, cross pelvic, and sapheno-saphenous pathways (Fig.  14.3) [21, 22]. Drawbacks to catheter venography include typical invasive procedural risks including bleeding and infection, difficulty visualizing the caudal extent of obstructions, and limitation of the procedure setting to a procedural suite [1, 23, 24].

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Fig. 14.3 Digital subtraction venography demonstrates inferior vena cava (IVCF)-related occlusion. Non-­ visualization of the IVC and proximal iliac veins and presence of mature lumbar and retroperitoneal collaterals indicate chronic obstruction caudal to the indwelling IVCF (arrow)

Intravascular ultrasound (IVUS) is an invasive imaging technique which avoids the radiation and contrast material utilized in catheter venography. Most commonly, IVUS is used as an adjunct modality during endovascular procedures such as venous stent placement. To perform IVUS in the iliocaval segment, a high-frequency US transducer at the tip of a catheter can be introduced through a sheath into the veins. IVUS provides high-resolution intraluminal images of blood vessel structure. Thus, in the setting of IVCF-related obstruction, it is effective for measuring IVC diameter, detecting intraluminal thrombus, and determining the degree of obstruction. Chronic thrombi, if present, often appear highly echogenic on IVUS. One particular advantage of IVUS versus catheter venography is its ability to detect normal venous segments that are obscured by collateral drainage pathways. Limitations of IVUS include its invasive nature and the additional expense associated with the equipment [24, 25].

Treatment Approaches and Considerations For patients with symptomatic chronic venous occlusive disease associated with IVCF obstruction, iliocaval recanalization has been demonstrated to improve venous stasis symptoms. However, the presence of a thrombosed IVCF creates

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challenges related to restoration of flow through the IVC. Presently, the two main options for endovascular treatment of IVCF-related iliocaval obstruction are stent placement across the obstructed filter and simultaneous IVCF retrieval and recanalization [8].

Stent Placement Across Obstructed IVCF One approach to treatment for IVCF-related iliocaval occlusion is stent placement across an obstructed filter. In this method, the obstructed filter-bearing site in the IVC is crossed by a guidewire and balloon-dilated. Consequently, the indwelling IVCF is displaced or crushed, allowing for placement of a stent across the previously occluded segment (Fig. 14.4). Studies have attested to the safety and success of stent placement across obstructed IVCF [8, 26]. Neglen et  al. reported on 25 patients in whom stent placement was performed across an obstructed filter. No tears in the IVC or other clinically significant morbidity was introduced by the procedure. Primary and secondary patency rates at 54-month follow-up were reported at 32% and 75%, respectively. In the same study, secondary patency was shown to be significantly lower in cases of stent placement across obstructed filters when compared to stents placed in patients without IVCF [5]. Stent placement across an obstructed indwelling IVCF is associated with several theoretical risks. For instance, the in situ filter may impede complete stent deployment and result in lower patency rates. Exclusion of an IVCF by a deployed stent Fig. 14.4  Stent placement across an indwelling OptEase inferior vena cava filter (IVCF) (arrow). Digital subtraction venography with contrast injection demonstrates successful recanalization across the previously occluded filter-bearing IVC with brisk flow through the stented segment. The IVCF has been displaced by balloon angioplasty and no longer obstructs the caval lumen

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may also cause device displacement, disfigurement, or fracture, theoretically creating a risk for penetration by the device of patients’ vasculature and surrounding structures [9]. Major complications resulting from filter damage have not been reported in the literature. However, Johnston et al. reported a case of an excluded IVCF that penetrated the caval wall, irritating periaortic nerve bundles and causing clinically significant chest pain [27].

Simultaneous IVCF Retrieval and Recanalization The technique of simultaneous IVCF retrieval with recanalization may be beneficial for patients, as it avoids several potential risks of stent placement across an obstructed IVCF. For instance, removing the obstructed IVCF prior to stent placement averts the theoretical risks of penetration of adjacent structures, as well as potential limitations to complete stent expansion at the IVCF implantation site. This procedure may be performed by obtaining appropriate venous access for IVCF retrieval and recanalization. The iliocaval occlusion is traversed from each access, and following filter retrieval, stents are placed in the previously occluded venous segments. Desai et al. showed that this single-session approach to IVCF retrieval and iliocaval recanalization can be reliably and successfully performed. In 25 patients with IVCF-related obstruction, single-session IVCF retrieval and iliocaval recanalization was performed yielding a 100% successful recanalization rate. On initial follow-up, significant symptom improvement was seen in 100% of patients, and an iliocaval patency rate of 96% was reported [9]. These data can be compared to those of studies in which stents were placed across obstructed IVCF.  Murphy et al. reported a successful recanalization rate of 87% using this IVCF exclusion method [28]. Partial relief of symptoms was achieved in 60% to 91% of patients in several studies [6, 8, 28, 29]. Lastly, Neglen et al. reported a patency rate of 75% for patients in whom a stent was placed across an occluded IVCF [5]. Though further studies are needed to compare efficacy and effectiveness of single-session IVCF retrieval and recanalization versus stent placement across obstructed IVCFs, there is limited evidence to suggest that the single-session method may lead to superior patency rates and reduce the theoretical risk of leaving the IVCF in situ.

Filter Removal Considerations If a single-session approach to IVCF retrieval and iliocaval recanalization is chosen to treat IVCF-related iliocaval occlusion, appropriate venous access for filter retrieval is necessary. Most filters may be retrieved via internal jugular (IJ) vein access; a notable exception is the OptEase (Cordis Corp, Fremont, Calif) filter, which requires femoral vein access, and the Crux (Volcano Corp., San Diego, CA) filter, which can be retrieved via either IJ or femoral access. IVCF retrieval should first be attempted with standard technique, although advanced techniques may be necessary [30].

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Standard retrieval techniques may not be sufficient in all cases, particularly in IVCF with long dwell times. Studies have shown that as many as 60% of IVCF with extended implantation time may embed in the caval wall. Other factors that may render standard retrieval techniques ineffective include filter tilt, encasement of the IVCF hook by a fibrin cap, and filter fracture. Retrieval failure has been reported as high as 43% for IVCF with extended dwell times [31]. However, the advent of advanced filter retrieval techniques has significantly impacted success of filter retrieval, with a study by Desai et al. demonstrating that advanced techniques performed at experienced centers may yield success rates as high as 97% regardless of IVCF dwell time with low rates of complications [32]. A more recent study by Desai et al. demonstrated that advanced techniques were frequently necessary after 7 months of dwell time [33]. Common advanced techniques for IVCF retrieval include the use of rigid endobronchial forceps, the loop wire technique, and excimer laser sheath-assisted tissue ablation. A combination of these techniques may also be necessary for successful IVCF retrieval [30].

Recanalization Considerations Venous access should be planned and obtained such that inflow into the recanalized segments is optimized. Typical sites for access include the bilateral common femoral veins and great saphenous veins if inflow into the iliac segments is not compromised; if there is significant inflow disease, access from the popliteal fossa, including small saphenous, posterior tibial, or popliteal venous access, may be necessary to address common femoral venous occlusive disease. Traversal of chronic venous occlusions can be difficult for a variety of reasons, including non-visualization of the obstructed venous lumen and the presence of collateral drainage pathways which may obscure the correct path for guidewire traversal. Frequently, the “true” lumen can be visualized by the identification of a “string sign” (Fig. 14.5), which should then be targeted for guidewire and catheter traversal. Support catheters and hydrophilic wires can be critical in traversal of the occluded lumen by prevention of wire recoil at areas of dense obstruction. Once traversal of the occlusion is completed, venography should be performed in the patent venous segment to confirm that entry into the intended venous lumen has been achieved. If the occlusion is unable to be traversed with a guidewire and support catheter, sharp or energy-assisted recanalization may be performed. In sharp recanalization, a sheath is positioned as close to the occlusion as possible, and a target, often a snare or a balloon, is established distal to the occlusion via a separate access site. Under fluoroscopic guidance, a needle is advanced through the sheath and the occlusion. As the needle is advanced, careful attention must be paid to relative position of the needle in order to prevent puncture of surrounding structures. Once the needle is engaged with the target and intraluminal positioning is confirmed with contrast injection, a guidewire may be advanced through the needle and followed with a catheter. Energy-assisted recanalization using a radiofrequency (RF) wire has also been reported as an alternative method to safely traverse occlusions within the IVC

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Fig. 14.5 Digital subtraction venography demonstrating the “string sign” (arrow), which represents the true lumen and target for recanalization

when standard techniques are insufficient (Fig. 14.6); the concerns associated with the use of this tool are similar to sharp recanalization [34–36].

Stent Options A variety of different stents have reportedly been used in patients with iliocaval obstruction. Self-expandable Elgiloy stents (Wallstent, Boston Scientific, Natick,

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Fig. 14.6 Fluoroscopic image demonstrating the use of Baylis RF PowerWire for energy-­ assisted recanalization of chronic occlusions. An endovascular snare is positioned distal to the occlusion via a separate access and serves as a target

MA) and nitinol dedicated venous stents are common choices in both the IVC and iliac veins. Large-diameter tracheobronchial stents (Gianturco Z-Stent, Cook Medical, Bloomington, IN) have also been reported in the IVC [1, 4, 5, 8, 9]. On-label iliofemoral venous stents have been used in Europe for some time and have recently become available in the United States; the availability of these stents may alter practice. Stent placement across occluded iliocaval segments may be performed in a “double-­barrel” fashion (Fig. 14.7) or with the use of a large-diameter caval segment stent and smaller iliac vein stents; comparative data between approaches is lacking.

When Filter Retrieval Is Not Possible The appropriate choice of procedure for treatment of IVCF-related iliocaval occlusion will vary from patient to patient. For instance, certain filter types may become

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Fig. 14.7 Digital subtraction venography demonstrates “double-­ barrel” stent placement through the previously occluded iliocaval segment. Brisk flow of contrast reveals stent patency following inferior vena cava filter (IVCF) retrieval and recanalization

exceedingly difficult to retrieve from an occluded IVC. In such cases, stent placement across the occluded IVCF may be the only recanalization option. This is notably true for chronic iliocaval occlusions associated with the OptEase and TrapEase devices (Cordis Corp, Fremont, CA).

Post-procedure Anticoagulation Following endovascular treatment of IVCF-related iliocaval obstruction, a combination of antiplatelet and anticoagulation therapies is typically implemented to minimize risk of thrombosis. A variety of approaches to both antiplatelet and anticoagulation therapies have been reported in the literature, and there is currently no consensus on the best regimen. Current approaches to antiplatelet therapy following

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venous stent placement are largely supported by extrapolated data on arterial stent placement. Approaches to post-procedure anticoagulation are varied as well, though a common approach involves using a low molecular weight heparin (LMWH) for the first several weeks following intervention, followed by a transition to a direct oral anticoagulant or warfarin [5, 6, 8, 9, 37].

Conclusion Treatment of IVCF-related chronic iliocaval occlusion can mitigate the morbidity associated with the post-thrombotic syndrome and improving patients’ quality of life. Presently, the two main avenues of treatment are stent placement across occluded IVCFs and single-session IVCF retrieval with recanalization. Both options have been shown to be safe; the choice between the two should be made on an individual basis and local expertise, taking feasibility of filter retrieval into account. Availability of advanced techniques for IVCF retrieval has made the single-session approach more feasible, and there is some evidence that this option may provide superior patency and clinical outcomes.

References 1. Sildiroglu O, Ozer H, Turba UC. Management of the thrombosed filter-bearing inferior vena cava. Semin Intervent Radiol. 2012;29(1):57–63. 2. PREPIC Study Group. Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d’Embolie Pulmonaire par Interruption Cave) randomized study. Circulation. 2005;112(3):416–22. 3. Grewal S, Chamarthy MR, Kalva SP. Complications of inferior vena cava filters. Cardiovasc Diagn Ther. 2016;6(6):632–41. 4. Ahmad I, Yeddula K, Wicky S, Kalva SP. Clinical sequelae of thrombus in an inferior vena cava filter. Cardiovasc Intervent Radiol. 2010;33(2):285–9. 5. Neglen P, Oglesbee M, Olivier J, Raju S. Stenting of chronically obstructed inferior vena cava filters. J Vasc Surg. 2011;54(1):153–61. 6. Raju S, Hollis K, Neglen P. Obstructive lesions of the inferior vena cava: clinical features and endovenous treatment. J Vasc Surg. 2006;44(4):820–7. 7. Bergan JJ, Schmid-Schonbein GW, Smith PD, Nicolaides AN, Boisseau MR, Eklof B. Chronic venous disease. N Engl J Med. 2006;355(5):488–98. 8. Chick JFB, Jo A, Meadows JM, Abramowitz SD, Khaja MS, Cooper KJ. Endovascular iliocaval stent reconstruction for inferior vena cava filter-associated iliocaval thrombosis: approach, technical success, safety, and two-year outcomes in 120 patients. J Vasc Surg Venous Lymphat Disord. 2017;5(5):770. 9. Desai KR, Xiao N, Karp J, et  al. Single-session inferior vena cava filter removal, recanalization, and endovenous reconstruction for chronic iliocaval thrombosis. J Vasc Surg Venous Lymphat Disord. 2019;7(2):176–83. 10. Rutherford RB, Padberg FT, Comerota AJ, Kistner RL, Meissner MH, Moneta GL. Venous severity scoring: an adjunct to venous outcome assessment. J Vasc Surg. 2000;31(6):1307–12. 11. Villalta S, Bagatella P, Piccioli A, Lensing A, Prins M, Prandoni P.  Assessment of validity and reproducibility of a clinical scale for the post-thrombotic syndrome. Haemostasis. 1994;24(suppl 1):158a.

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12. Kahn S. Measurement properties of the Villalta scale to define and classify the severity of the post-thrombotic syndrome. J Thromb Haemost. 2009;7(5):884–8. 13. Ye K, Lu X, Li W, et al. Outcomes of stent placement for chronic occlusion of a filter-bearing inferior vena cava in patients with severe post-thrombotic syndrome. Eur J Vasc Endovasc Surg. 2016;52(6):839–46. 14. Eklöf B, Rutherford RB, Bergan JJ, et  al. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg. 2004;40(6):1248–52. 15. Knuttinen M-G, Xie K, Jani A, Palumbo A, Carrillo T, Mar W.  Pelvic venous insufficiency: imaging diagnosis, treatment approaches, and therapeutic issues. Am J Roentgenol. 2015;204(2):448–58. 16. Labropoulos N, Borge M, Pierce K, Pappas PJ. Criteria for defining significant central vein stenosis with duplex ultrasound. J Vasc Surg. 2007;46(1):101–7. 17. Labropoulos N, Tiongson J, Pryor L, et  al. Definition of venous reflux in lower-extremity veins. J Vasc Surg. 2003;38(4):793–8. 18. Mousa AY, Broce M, Yacoub M, et  al. Validation of venous duplex ultrasound imaging in determining iliac vein stenosis after standard treatment of active chronic venous ulcers. J Vasc Surg Venous Lymphat Disord. 2016;4(3):307–12. 19. Smillie RP, Shetty M, Boyer AC, Madrazo B, Jafri SZ. Imaging evaluation of the inferior vena cava. Radiographics. 2015;35(2):578–92. 20. Kaufman LB, Yeh BM, Breiman RS, Joe BN, Qayyum A, Coakley FV. Inferior vena cava filling defects on CT and MRI. Am J Roentgenol. 2005;185(3):717–26. 21. Kelman J, Xiao N, Collins JD, Karp JK, Rodriguez H, Desai KR.  Autologous sapheno-­ saphenous bypass collateral development in the setting of chronic unilateral iliac vein occlusion. CVIR Endovasc. 2018;1(1):25. 22. Kapur S, Paik E, Rezaei A, Vu DN. Where there is blood, there is a way: unusual collateral vessels in superior and inferior vena cava obstruction. Radiographics. 2010;30(1):67–78. 23. Ferris EJ, Lim WN, Smith PL, Casali R.  May-Thurner syndrome. Radiology. 1983;147(1):29–31. 24. Aw-Zoretic J, Collins JD. Considerations for imaging the inferior vena cava (IVC) with/without IVC filters. Semin Intervent Radiol. 2016;33(2):109–21. 25. McLafferty RB.  The role of intravascular ultrasound in venous thromboembolism. Semin Intervent Radiol. 2012;29(1):10–5. 26. Meltzer AJ, Connolly PH, Kabutey NK, Jones DW, Schneider DB. Endovascular recanalization of iliocaval and inferior vena cava filter chronic total occlusions. J Vasc Surg Venous Lymphat Disord. 2015;3(1):86–9. 27. Johnston WF, Jain A, Saad WE, Upchurch GR. Chest pain from excluded inferior vena cava filter after stent placement. J Vasc Surg Venous Lymphat Disord. 2014;2(1):70–3. 28. Murphy EH, Johns B, Varney E, Raju S. Endovascular management of chronic total occlusions of the inferior vena cava and iliac veins. J Vasc Surg Venous Lymphat Disord. 2017;5(1):47–59. 29. Arabi M, Krishnamurthy V, Cwikiel W, et  al. Endovascular treatment of thrombosed inferior vena cava filters: techniques and short-term outcomes. Indian J Radiol Imaging. 2015;25(3):233–8. 30. Laws JL, Lewandowski RJ, Ryu RK, Desai KR. Retrieval of inferior vena cava filters: technical considerations. Semin Intervent Radiol. 2016;33(2):144–8. 31. Kuo WT, Robertson SW, Odegaard JI, Hofmann LV. Complex retrieval of fractured, embedded, and penetrating inferior vena cava filters: a prospective study with histologic and electron microscopic analysis. J Vasc Interv Radiol. 2013;24(5):622–630.e621. 32. Desai KR, Lewandowski RJ, Salem R, et al. Retrieval of inferior vena cava filters with prolonged dwell time: a single-center experience in 648 retrieval procedures. JAMA Intern Med. 2015;175(9):1572–4. 33. Desai KR, Laws JL, Salem R, et al. Defining prolonged dwell time: when are advanced inferior vena cava filter retrieval techniques necessary? An analysis in 762 procedures. Circ Cardiovasc Interv. 2017;10(6)

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Index

A Abnormal supracardinal vein development, 25 Accepted (classic) indication, 11, 13 Acute thrombus-bearing IVC filter AngioJet thrombectomy system, 181 AngioVac venous drainage system, 183 asymptomatic caval thrombus, 178 cleaner rotational thrombectomy system, 183 clinical presentation, 177 clot removal, 180, 181 ClotTreiver, 183 complications, 184 Indigo system, 183 PREPIC study, 177 symptomatic caval thrombus, 178, 179 ALN® with hook anesthesia, 97 complication, 96 forceps repositioning, 98 forceps traction, 97 mechanical stress, 99 post retrieval cavagram, 98 rag-doll technique, 96, 97, 99 rotational cavogram, 96, 97 American Heart Association (AHA), 17 AngioJet thrombectomy system, 181 AngioVac Venous drainage system, 183 Asymptomatic caval thrombus, 178 B Bard G2 IVC filter, 132 Bard G2X IVC filter axial CT image, 62 complication, 63 coronal CT image, 62 endobronchial forceps, 64 equipment, 65

general anesthesia, 65 Hangman technique, 63–65 multiple completion inferior venacavograms, 65 post-removal cavagram, 64 pre-removal cavagram, 63 right CFV access, 64 Berenstein catheter, 144 Biconical filters, 115 Bilateral iliac filter retrieval complication, 161 directional snare-assisted retrieval, 161 equipment, 162 incidence, 162 indications, 162 moderate sedation, 162 pre-placement venogram, 162 procedure description, 161 routine retrieval, 163 tri-lobed snare, 163 Bioconvertible device, 2 Bird’s Nest IVC filter, 28, 30, 159 British Society for Haematology (BCHS), 15, 17 C Cardiac migration of IVC filter cardiac anesthesia, 136 completion venogram, 137 complication, 136 countertension, 137 equipment, 136 filter migration, 136, 138 pre-procedure chest X-ray, 135 procedure description, 136 transesophageal echo probe, 137 tri-axial system, 138 Cardiovascular and Interventional Radiological Society of Europe (CIRSE), 15

© Springer Nature Switzerland AG 2020 K. R. Desai et al. (eds.), Placement and Retrieval of Inferior Vena Cava Filters, https://doi.org/10.1007/978-3-030-45150-9

203

Index

204 Chronic thromboembolic pulmonary hypertension (CTEPH), 13 Clinical-etiological-anatomical-­ pathophysiological (CEAP) system, 190 ClotTreiver, 183 Complex filter retrieval planning anesthetic approach, 49 complications, 39 definitions, 40 filter fracture, 48 filter fragment embolization, 49 filter fragmentation, 48 informed consent, 48 post-retrieval hemorrhage, 48 pre-procedure clinical evaluation advanced retrieval techniques, 40 anticoagulation, 42 asymptomatic patients, 41 dwell time, 40 filter placement, 40 filter type, 41 indications, 41 symptomatic patients, 41, 42 pre-procedure imaging computed tomography venography, 46 filter fracture/embolization, 43 filter migration, 45 filter tilt, 43 filter tip, 43 imaging factors, 42 IVCF thrombosis, 46 magnetic resonance venography, 46 perforation, 43 PREPIC study, 42 radiograph, 42 recurrent PE, 46 pre-treatment factors, 40 vena cava thrombosis, 49 Complex SVC filter removal anesthesia, 157 Bard Recovery filter retrieval, 157 complications, 153, 157 conventional snare method, 157 equipment, 156 forceps-assisted SVC filter retrieval, 153 Gunther Tulip SVC filter, 157 post placement radiograph, 153 procedure description, 154, 156 rigid forceps, 155 venogram, 153, 155 wire-loop snare technique, 154, 157 Conical filters, 115

Cook® Celect Filter Amplatzer plug embolization, 85 Amplatzer plug placement, 82, 83 arterial phase CT-angiogram, 84 axial CT image, 81 caval strut penetration, 85 completion cavagram, 84 complication, 82, 83 coronal CT image, 81 endobronchial forceps, 82, 83 equipment, 83 extra-caval strut penetration, 81 general anesthesia, 83 initial cavagram, 82 procedure description, 82 standard removal techniques, 85 Cook® Gunther Tulip DVT axial CT image, 56 completion cavagram, 60 complication, 56 coronal CT reformat, 56 endobronchial forceps retrieval technique, 56, 58 equipment, 61 general anesthesia, 61 pre-removal inferior venacavogram, 57 procedure, 61 sagittal CT reformat, 56 endometrial cancer anesthesia, 78 aortic intraluminal thrombus, 76 axial CT image, 76 balloon angioplasty, 77, 79 complication, 75 coronal CT image, 76 equipment, 77 initiral cavagram, 78 intraprocedural radiograph, 77 post ballooning cavagram, 80 procedure description, 77 retrieval venacavagram, 76 factor V leiden mutation anesthesia, 75 axial CT image, 71 completion cavagram, 72 complication, 71 cordis biopsy forceps, 73 equipment, 74 filter removal, 74 Hangman technique, 72, 73 pre-retrieval cavagram, 72

Index retrieval hook, 72 3D reconstruction, 71 graft-versus-host disease axial CT, 66 completion cavagram, 70 complication, 67 coronal CT, 66 into duodenum lumen, 66 endovascular removal, 70 equipment, 67 general anesthesia, 69 with Glidewire sling, 69 loop snare technique, 67, 68 procedure description, 67 Scout image, 67 Cordis® optease filter complication, 104 equipment, 110 excimer laser sheath, 110 general anesthesia, 110 intra-procedural radiograph, 106 IVC filter retrieval, 104 IVC venogram, 109 laser activation, 109 laser-assisted filter removals, 110 laser sheath, 106 Omniflush catheter, 105 peri-procedural heparinization, 109 photothermal ablation, 106 post angioplasty cavagram, 106 post retrieval cavagram, 106 pre-retrieval venacavagram, 105 scarring and embedment, 110 spot fluoroscopic images, 105 visual inspection, 106 CVX-300 Excimer laser system, 103, 104 D Deep vein thrombosis (DVT), 1, 2 Duplicated IVC, 26, 27 E Eastern Association for the Surgery of Trauma (EAST), 15 Embryogenesis, 21–23 F Femoral vein access, 23 Filter-associated thrombogenesis, 114 Filter geometry, 115

205 Filter misplacement in azygous vein complication, 140 endobronchial forceps, 141 equipment, 140 filter position, 139 general anesthesia, 142 inferior vena cavagram, 139 laser-assisted endobronchial forceps retrieval, 140 nonstandard endovascular techniques, 142 operator error, 142 pre-procedural planning, 142 procedure description, 140 steep oblique image, 141 vena cavagram, 142 venography, 142 Filter misplacement in right renal vein anesthesia, 146 complication, 143 equipment, 146 filter fracture and migration, 146 gooseneck snare, 145 initial error, 146 procedure description, 144, 146 retrievable, infra-renal IVC filter placement, 143 scout radiograph, 144 tri-lobed snare, 145 venogram, 146 Filter-related chronic iliocaval occlusion catheter venography, 192, 193 CEAP system, 190 computed tomographic venography, 191, 192 filter removal, 195, 196 filter retrieval, 198, 199 intravascular ultrasound, 193 magnetic resonance venography, 192 morbidity, 189 pathophysiology, 189 post-procedure anticoagulation, 199, 200 recanalization considerations, 196–198 signs and symptoms, 190 simultaneous IVCF retrieval and recanalization, 195 stent options, 197–199 stent placement, 194, 195 symptoms, 189 ultrasound, 190, 191 Villalta scale, 190

Index

206 Fractured filters ALN and Option Elite filter fractures, 118 biomechanical fatigue, 115 central component embolization, 124 chronic IVCF fracture, 115 complication, 117, 118 conical Bard rIVCF models, 117 Denali trial, 118 extracaval involvement, 121–123 filter fragmentation, 115 fragment characterization, 119 fusiform expansion and longitudinal flattening, 116 intracardiac component embolization, 124, 125 intrapulmonary IVCF fragments, 126, 127 IVCF fracture rates, 116 limitations, 127 locally retained IVCF fragments, 119–121 migration-related injuries, 113 nonconical filters, 116 patient evaluation, 118 patient preference, 127 respiratory variation, 115 G Gonadal vein deployment, capture and redeployment, 24, 25 Gunther-Tulip SVC filter, 157 Gunther-Tulip IVC filter, 185 I Iliac filter placement bilateral iliac filters, 160 Bird’s Nest IVC filter, 159 complications, 159, 161 equipment, 159 iliac venograms, 160 intraoperative IVC venogram, 158 moderate sedation, 159 procedure description, 159 Infrarenal IVC filter placement, 24 Intraprocedural inferior vena cavogram, 23 Intravascular ultrasound, 23 Iodine-based contrast media, 23 K Kimray-Greenfield filter, 2

M Manufacturer and User Device Experience (MAUDE) database, 6 Martensitic transformation, 114 Mega cava, 28, 30, 159 Mobin-Uddin Umbrella filter, 2, 167 N Nitinol, 114 O Option™ filter, 144, 146 P Penumbra’s Indigo mechanical thrombectomy system, 183 Permanent inferior vena cava (IVC) filters, 167–169 adverse events, 168 anticoagulation, 167, 170 complications, 168 CT scan, 170 CT venogram, 169 general anesthesia, 169 May-Thurner Compression findings, 171 Mobin-Uddin Umbrella filter, 167 MR imaging, 169 post removal venograms, 169 pre procedural imaging, 173 PREPIC study, 168 pre-procedural imaging, 169 retrievable IVCF, 167, 168 risks and benefits, 170 VTE/PE protection, 168, 169 Pharmacomechanical catheter-directed thrombolysis (PCDT), 179 Phlegmasia cerulea dolens (PCD), 179 Phynox, 114 Posterior cardinal vein development, 24 Post thrombotic syndrome (PTS), 184 PREPIC study, 12, 13, 15, 16 Pre-procedural imaging, 23 Prophylactic IVCF placement, 17 Pulmonary embolism (PE) and deep vein thrombosis, 1, 2 FDA approved indications for IVC Filters, 3 filter complications, 5, 6

Index filter placement, 4, 5 filter retrieval, 6, 7 filter types, 3 non-permanent filters, 3 PREPIC trial, 4 prevention, 3 randomized prospective trials, 4 Pulmonary filter strut migration Bard G2 IVC filter, 132 complication, 132 equipment, 134 general anesthesia, 134 incidence, 134 intra-vascular component, 134 intra vascular positioning of strut, 133 optimal management, 134 primary filter retrieval, 132 procedure description, 132 right lower lobe pulmonary angiogram, 133 strut removal, 133 R Renal vein variants, 25–26 Retrievable bilateral iliac vein filters, 28 Retrievable inferior vena cava filters (rIVCF), 113 Routine IVC filter removal filter clinic, 33, 34 procedure, 34, 35 recommend equipment, 34, 35 scheduling, 34 tilted filter, 35 Royal Society of Obstetricians and Gynaecologists, 16 S Simon-Nitinol IVC filter, 184 Superior vena cava (SVC) filter placement complication, 150 coronal and axial non-contrast enhanced images, 150

207 equipment, 150 in-hospital mortality rate, 152 moderate sedation, 152 procedure description, 150 risk factors, 152 T1 and T2 weighted MRI images, 150 venogram, 151 Supra-renal filter placement, 16, 28, 29 Symptomatic caval thrombus, 178, 179 Systemic anticoagulation, 11 T Tilted IVF filter anesthesia, 91 complication, 89 degree of angulation, 91 Hangman technique, 92 monoplanar cavography, 91 pre-retrieval planar cavography, 90 rotational cavagram, 89–91 snare retrieval, 90 Tip embedded IVC filter anesthesia, 95 complication, 92 endobronchial forceps positioning, 93, 95 endobronchial forceps retrieval, 93, 94 filter hook engagement, 94 filter position and integrity, 93 filter type, 92 post retrieval planar cavagram, 94, 95 rotational cavagram, 93 Trojan horse technique, 93 Trojan horse technique, 93 V VenaTech LP IVC filter, 144, 173 Venous clinical severity score (VCSS), 190 Venous thromboembolism (VTE) in pediatric patients, 16 in pregnant patients, 16 Villalta PTS scale, 190