Removal of Long Standing IVC Filters: Techniques and Pitfalls

Jafar Golzarian M.D., Siobhan Flanagan M.D.,

Faculty DisclosuresJafar Golzarian: Consultant – BSCI, Guerbet, Medtronic, Penumbra, QX Medical, Shape Memory, Sirtex

Dr. Jafar Golzarian has disclosed that the off-label use of particles will be discussed.

Brand names are included in this presentation for participant clarification purposes only. No product promotion should be inferred.

Filter Follow-up: FDA Recs 2010

• FDA--“Removing Retrievable Inferior Vena Cava Filters: Initial Communication”

• FDA alert acknowledged increasing use of IVC filters and a growing number of reported adverse events

• Adverse events “may be related to a retrievable filter remaining in the body for long periods of time, beyond the time when the risk of PE has subsided”

• Implanting physicians and clinicians responsible for the ongoing care of patients consider IVC filter removal as soon as protection from PE is no longer required

Filter Follow-up

• Unfortunately most IVC filters don’t get removed– Trauma patients (Acute, no IR ownership)– Loss to follow-up– Lack of patient information– ….

• Increased complexity for removal

• Options to track patients– Dedicated IVC filter clinic– IVC filter list with periodic follow-up– Patient and family education at the time of consent

Basic Technique

• Large Sheath (12-20 Fr)– If Filter in place longer than the IFU recommendation: 16 Fr

• Snare• Back-tension on snare• Sheath slides forward over filter• Pull / Push • Inspect filter on back table to confirm intact

Patient with Abdominal pain and 8-years-old Filter

Complex Retrieval Techniques

• Failed standard retrieval• Embedded hooks• Penetrated struts• Flipped transversally

Complex Retrieval Techniques

• Wire-loop techniques• Rigid or flexible forceps• Laser tissue ablation (laser sheath, eg Excimer) • Combinations of methods 1-3

Wire Loop Technique

• Reverse-curve catheter is guided through the filter struts (at least 2)• Hydrophilic wire is advanced cranially • Free end of the wire is snared, pulled through and through and brought out of sheath• Back tension on the wire loop while sheath is coaxially collapsed over filter• Can cause displacement or fracture of filter elements • Similar, modified technique can target fibrin cap

Necrotizing pancreatitis, 3 months post IVC Filter for DVT and GI bleed

Laser Sheath

• CVX-300 Excimer Laser System (Spectranetics, Colorado Springs, CO)– 12-, 14-, and 16-F 50-cm sheaths – Introduced via a larger outer sheath (dry seal)

• The laser is sequentially activated to ablate the encasing tissue– Short bursts, small distances at a time– Eventually allows filter collapse and removal

Laser Sheath

• 57 yo F with DVT• Subsequent ICH on anticoagulation• Retrievable IVC filter placed• 12 months later, was back on anticoagulation,

but filter still in place, abdominal pain• Failed removal at OSH

– Able to snare hook, but couldn’t remove the filter with the classic technique

Laser Sheath

• 60 yo F• History of DVT and intracranial hemorrhage • GT filter placed• Multiple attempts at IVC filter removal failed• Abdominal pain from filter, patient requesting removal

– Referred to our institution

Slow, patient progression with laser sheath

Forceps

• Uses:– Tip/hook embedded filters– Fragmented filters

• Can move the tip of the filter away from the wall or gradually dissect hyperplastic tissue from hook/apex

• Targeted grasping with ability to direct point of contact with filter• Rotational venogram helps determine

Patient with Abdominal and back pain & failed attempt of Filter removal

Complications During Retrieval

• Extravasation/caval injury– Can cause massive bleeding and a need for stentgraft placement

• Caval pseudoaneurysm– If less than 2 cm diameter, will resolve– Intra-procedure- balloon inflation to promote thrombosis of sac

• Filter deformity• IVC stenosis- venoplasty +/- stent

– If gradient across stenosis > 3mmHg, then is HD significant• IVC thrombosis

– Due to prolonged caval collapse during procedure– Prevent w/ Intra-procedure heparinzation 50 units/kg

Conclusions

• All filters should be removed if not needed• Many techniques are available

– Large Sheath/Snare– Forceps– Laser– Combinations

• Complications are rare and manageable

• A functional filter removal program should be established in all hospitals