Advanced Techniques for Removal of Retrievable Inferior Vena Cava Filters
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Inferior vena cava (IVC) filters have proven valuable for the prevention of primary or recurrent pulmonary embolism in selected patients with or at high risk for venous thromboembolic disease. Their use has become commonplace, and the numbers implanted increase annually. During the last 3 years, in the United States, the percentage of annually placed optional filters, i.e., filters than can remain as permanent filters or potentially be retrieved, has consistently exceeded that of permanent filters. In parallel, the complications of long- or short-term filtration have become increasingly evident to physicians, regulatory agencies, and the public. Most filter removals are uneventful, with a high degree of success. When routine filter-retrieval techniques prove unsuccessful, progressively more advanced tools and skill sets must be used to enhance filter-retrieval success. These techniques should be used with caution to avoid damage to the filter or cava during IVC retrieval. This review describes the complex techniques for filter retrieval, including use of additional snares, guidewires, angioplasty balloons, and mechanical and thermal approaches as well as illustrates their specific application.
KeywordsVenous intervention Endovascular treatment Vena cava Deep vein thrombosis (DVT) Pulmonary embolism
Inferior vena cava (IVC) filters have proven valuable for the prevention of primary or recurrent pulmonary embolism in selected patients with or at high risk for venous thromboembolic disease. Their use has become commonplace, and the numbers implanted increase annually. During the last 3 years, in the United States, the percentage of annually placed optional filters, i.e., filters than can remain as permanent filters or potentially be retrieved, has consistently exceeded that of permanent filters [1, 2, 3]. In parallel, the complications of long- or short-term filtration have become increasingly evident to physicians, regulatory agencies, and the public [4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14]. Among these complications are caval thrombosis, extension of lower-extremity deep vein thrombosis (DVT) , caval or adjacent vessel perforation (e.g., aorta, lumbar artery, renal artery, common iliac artery) [15, 16, 17, 18, 19, 20, 21, 22, 23], penetration of adjacent viscera (e.g., duodenum, liver parenchyma, pancreatitis) [17, 24, 25, 26, 27], embedding within adjacent bony structures [15, 28, 29], whole or partial migration, device fracture, and embolization [15, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41]. Lethal complications have occurred [32, 42]. Furthermore, although caval filters have shown an initial benefit in decreasing recurrent pulmonary embolism, there may be no difference in the long-term survival rate of patients with and without continued caval filtration [2, 5, 43, 44, 45, 46]. In August 2010, the United States Food and Drug Administration released an initial communication in response to the filter-related adverse events recommending the removal of retrievable IVC filters as soon as their protection from pulmonary embolism is no longer deemed necessary. It placed this responsibility with both “implanting physicians and clinicians responsible for the ongoing care of patients with retrievable IVC filters” .
It becomes logical that if an optional filter carries no greater risks than a permanent one, that it becomes the primary device used; this is reflected in the aforementioned market trends [2, 3, 5]. As filter retrieval becomes less of an “optional” event, dedicated physician and practice mechanisms to enhance retrieval rates will be required. Current published reports describe a broad range of retrieval rates from 1.0 to 40.5% [3, 48, 49, 50, 51, 52, 53, 54, 55]. Minocha et al. showed the value of this type of a proactive program: Once implemented, IVC retrieval rates increased from 29 to 60% . With this growing awareness and responsibility, physicians will need to be prepared to perform straightforward as well as advanced and highly complex filter retrievals. Herein we review some of the expanded approaches to filter retrieval.
IVC Filters and Dwell Times
Caval filters continue to be an area of active product development and evolution. Because their designs vary, so do retrieval times, techniques, and potential complications. This emphasizes the need for methodical reporting of adverse events through governmental databases, such as MAUDE (Manufacturer and User Facility Device Experience), or national societal registries, such as the CIRSE and imminent Society of Interventional Radiology caval filter retrieval registries. One of the more common unifying filter designs is the “cone” or “umbrella,” placed with the apex directed cephalad. A number of filters share this design, including the Günther Tulip and Celect filters (Cook Medical, Bloomington, IN); the Recovery G2, G2X, and Eclipse filters (Bard Peripheral Vascular, Tempe, AZ), the Option filter (AngioTech, Vancouver, BC); and ALN filter (ALN Implants Chirurgicaux, Ghisonaccia, France). These are removed by using a jugular vein approach to snare the apical “hook” or structure with a dedicated removal device or one of the many available general endovascular snares. The OptEase filter (Cordis Endovascular, Warren, NJ) has a “double-basket” trapezoidal shape, similar to the permanent TrapEase filter (Cordis Endovascular, Warren, NJ), with the exception of a single set of unidirectional fixation hooks. Its retrieval hook is caudal, warranting a femoral snare approach. These devices are inserted and removed safely with a high degree of technical success [2, 5, 50, 52, 57, 58, 59, 60, 61].
The timing for safe and uncomplicated retrievability of an optional IVC filter cannot be universally determined. It depends on the filter design, its orientation at the time of retrieval, caval shape, tissue response, and, finally, the operator’s comfort with potentially more complex retrieval maneuvers. Several investigators have described successful uncomplicated IVC filter retrieval after long dwell times. Binkert et al. reported removal of Recovery filters after a mean of 254 days (range 181–419) . Günther Tulip filters have been similarly retrieved at prolonged intervals, e.g. 317 and 475 days [62, 63] but with a decreasing success rate as dwell times increase . Recently, Lynch reported removal of a filter at 3006 days after implant . Although filter retrieval histology is relatively underreported, adherence of acute clot and fibrin to the devices, later becoming more mature fibrous tissue and neointimal hyperplasia, has been described .
IVC Filter-Retrieval Techniques
There is no defined algorithm for preidentifying more complex retrievals, nor are there certain filters or patients that would be routinely predisposed to them. At present, there is neither suggested mandate nor consensus regarding a need for preretrieval imaging to identify high-risk patients. Because these would likely require additional radiation due to plain radiographs or computed tomography (CT) scans, prescreening is unlikely to be routinely used or indicated. Fortunately, most retrievals are usually uneventful, even in the setting of an extruded leg residing in the paracaval tissues. If during the course of the retrieval complexity is identified (e.g., suspected transcaval component extension), then several approaches can provide additional useful information, particularly CT; or, increasingly, cone-beam angiographic CT [24, 67]; or perhaps rotational angiography [68, 69]. CT has shown excellent ability to demonstrate filter-leg penetration of the cava wall; in one series, it was demonstrated in 85.9% of 64 filter retrievals, and 89% of these filters were retrieved .
When the filter’s apex or “hook” cannot be engaged using the designated retrieval cone or one of the many retrieval snares, then adjunct techniques become useful. Caution is required when employing these techniques to avoid filter distortion, damage, dismemberment, or downstream embolization of the filter or filter components. The choice of secondary retrieval technique must be tailored to each situation.
Loop Snare With Single Access
Stiff Wire-Displacement Technique
Tilted Filter-Straightening Single Access
Wire and Snare With Dual Access
Wire Loop-and-Snare Single Access
Parallel Wire and Dual-Sheath Technique
Rigid Bronchoscopy Forceps, Thermal, Etc
Retrieval of Migrated IVC Filters
Caudal migration of IVC filters is a commonly reported occurrence [60, 83]. In one series, of the patients evaluated for IVC filter removal, as many as 52% of the filters had migrated (12% moved >20 mm, and 40% moved <20 mm) . A small number of cases of caudal migration with caval perforation and successful removal have been described, without major complications, e.g., in a patient with only self-limited abdominal pain and requiring no treatment . Cranial migration within the IVC occurs less frequently . In most cases, conventional removals were performed; in one series, only 8.9% of these downstream caval migrations required advanced retrieval techniques .
The most feared filter migrations are cardiac or pulmonary. These events have been described, either as total or fragmentary migration, with nearly every model of filter. Although these events may be asymptomatic, major (including lethal) complications have been described, including cardiac tamponade, chamber perforation, myopericarditis, and tricuspid valve damage [4, 32, 33, 34, 35, 36, 37, 39, 40]. Retrievals in this setting are rarely reported [84, 85], and surgical management is usually undertaken [35, 36, 38]. Bui et al. reported a double-snare technique for percutaneous removal of a G2 IVC filter that had migrated into a patient’s right ventricle 3 months after placement. The first snare captured the apex while the second snare was used to restrain the legs with the anchoring hooks, thus facilitating retrieval . Such techniques cannot be considered routine, and most patients require surgical intervention for retrieval. The multiplicity of filter hooks, barbs, legs, and risk of disassembly, combined with the potentially embedded state within an atrial or ventricular wall or valve apparatus, should demand guidance exceeding that of fluoroscopy alone. Furthermore, the ability to become entangled within a valve during a retrieval attempt may be difficult to assess with image guidance. In a review of 98 cases of intracardiac or intrapulmonary filter migrations, surgical removal was recommended as the primary approach. Thus, present endovascular options should be reserved for rare cases in which surgery is not an option .
Complications of Filter Retrieval
Minor complications have been reported with filter retrieval, including transient demonstration of caval wall injury . Most of the literature focuses on the complications attributed to the filter’s malpositioning rather than the retrieval per se, e.g. tilt, caval penetration, caval narrowing, and filter fracture [55, 60, 61, 86]. Reported major complications attributed to the actual retrieval are rare [52, 66], but recurrent venous thromboembolism after filter retrieval has been described . It should conservatively be assumed that these events may be underreported or might increase with greater numbers of potentially complex retrieval attempts. It is logical that techniques requiring more aggressive maneuvers may prove to have a greater rate of procedure related complications, particularly during learning phases.
One common question concerns the management of ongoing anticoagulation at the time of intended filter retrieval. Schmelzer et al. 2008  described a retrospective review of 54 filters retrieved from 62 fully anticoagulated patients. There were no intraprocedural or postprocedural bleeding complications. They concluded that retrieval of IVC filters can be performed safely in anticoagulated patients. Nevertheless, it seems logical to interrupt anticoagulation at the time of retrieval, particularly because advanced or more aggressive techniques may be required for removal. The use of injectable low molecular-weight heparins allows this to be easily accomplished.
Retrievable caval filters have increased the pool of candidates for filter placement, in part by holding out the promise of eventual removal. So far, the promise of temporary IVC filter placement has not been broadly fulfilled, as evidenced by the low retrieval rates. Because some of these filters will become increasingly embedded with time, migrate, and/or tilt, one might hypothesize that difficulty of retrieval might grow with longer dwell times. Still, the majority of retrievals are relatively straightforward, and the techniques we review offer a reference for second-order techniques that may prove increasingly valuable. Undoubtedly new or variant approaches will be described.
During the last 3 years, an average of >200,000 annual filters were sold within the United States alone . Endovascular physicians will need dedicated follow-up programs to track their patients and identify appropriate candidates for retrieval. This essential methodical follow-up will result in an increased retrieval rate as well as the need for physician awareness and expertise for conventional and exotic techniques for IVC filter retrievals. A system for tertiary and quaternary referral for the use of the most advanced techniques may be useful.
Conflict of interest
The authors state that there is no actual or potential conflict of interest in relation to this article
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