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BCS
Recanalizable
intervention
22 Interventions oftheHepatic Veins, Inferior Vena Cava, andPortal Vein
Fig. 22.7 Step-wise
management algorithm of
Budd–Chiari syndrome
265
• Anticoagulation
• Treatment of underlying disease
• Management of portal HTN complications
Ascites
and/or high-
risk varices
vein
HV/IVC
angioplasty
Progressive
disease
±stenting
• HV thrombolysis can be attempted in acute BCS
•
Asymptomatic BCS is managed with medical therapy alone; No response
to medical therapy and/or abnormal liver stiffness requires radiological
Imaging plays a crucial role in diagnosing BCS, with
USG Doppler being the rst-line imaging modality. Crosssectional imaging (CT/MRI) helps evaluate the complications
of cirrhosis, conrm the diagnosis of suspicious Doppler
ndings, and plan interventional procedures.
Upon diagnosis of BCS, anticoagulation is started unless
contraindicated. The presence of liver failure necessitates
liver transplantation. Underlying hypercoagulable disorder,
if any, should be addressed to prevent the recurrence of BCS.
Endovascular intervention is increasingly used as a standard of therapy, and it has been shown to have prolonged
5-year survival of up to 75% in BCS [65]. A stepwise
approach is followed in the management of BCS, starting
from anticoagulation, angioplasty ± stenting, creation of portosystemic shunt, and nally liver transplantation (Fig.22.7)
[65, 66].
22.6.1 Techniques ofHV/IVC Angioplasty
Short segment stenosis or membranous obstruction of HV
or IVC is best treated with angioplasty. In HV obstruction,
the best HV is chosen for angioplasty. The best HV should
be a native hepatic vein, straight in the course, echo-free
lumen, caliber of at least 7–8 mm, and draining sizable
liver parenchyma with multiple veno-venous collaterals
joining it [17].
Target HV is approached through the transjugular
approach using an angled 5F diagnostic catheter and guide-
No
Liver
failure
No
recanalizable
vein
TIPS/DIPS
Yes
No response
Liver
transplantation
wire. Placement of a long sheath into the IVC may be
required to provide catheter support during the negotiation of
stricture. In the case of brotic occlusion of HV, an angled
metallic cannula and 5F catheter/trocar stylet assembly
(RUPS-100) may be required to cross the occluded segment.
Once stricture is negotiated, a 5F catheter is advanced beyond
the stricture, and the hydrophilic guidewire is exchanged
with an angled stiff guidewire. Serial angioplasty is performed using a high-pressure, non-compliant balloon. A
check venogram is obtained, and the pressure gradient across
the stricture is measured.
Failed HV cannulation via a jugular approach requires a
percutaneous transhepatic approach. The chosen HV is
punctured under the USG guidance using a 21/22G Chiba
needle, and a 5F vascular sheath is placed to secure venous
access. A 5F KMP catheter with an angled/straight hydrophilic guidewire is used to enter the IVC.In case of tight
stricture, the reverse end of the hydrophilic guidewire may
be used to negotiate the stricture may require manipulation.
The angled hydrophilic guidewire is negotiated into the SVC
and snared out via the jugular approach. After that, angioplasty is accomplished through the jugular route (Fig.22.8).
A successful angioplasty shows a good antegrade ow with
the disappearance of collaterals. In the end, the percutaneous
transhepatic tract is plugged using coils to minimize the risk
of hemoperitoneum.
Short segment/membranous occlusion of suprahepatic
IVC is one of the leading causes of BCS in the Asian population [17]. IVC angioplasty in such cases is performed through
266
bc
R. K. Patel and A. Mukund
a
de f
Fig. 22.8 Hepatic vein angioplasty. (a) Initial USG showing long seg-
mental occlusion of MHV, LHV with short segment ostial occlusion of
RHV with veno-venous collaterals. (b) Snaring of the guidewire
through the jugular access after crossing the stricture via a percutaneous
transhepatic approach. (c) Venogram using a 5F MPA catheter via tran-
a femoral or jugular approach (Fig. 22.9). The femoral
approach is usually preferred. Tight stricture necessitates
additional maneuvers such as:
• Advancing a long sheath till occlusion and attempting
negotiation of the stricture using a guiding catheter and
straight-tip hydrophilic wire through the sheath
• Placing long sheaths till occlusion from both jugular and
femoral sides, followed by probing the stricture from both
sides
Before probing a tight stricture using a long Chiba needle/
Colapinto needle, hardwires on either side of the stricture
sjugular access conrming the complete short segment occlusion of
RHV. (d) Serial dilatation of occlusion using 8-, 10-, and 12-mm balloon; (e) Free ow into the heart following angioplasty; (f) Follow-up
USG showing normal color ow with normal spectral waveform. RHV
Right hepatic vein
should be in a straight line that is conrmed by obtaining
views in the orthogonal planes, i.e., anteroposterior and lateral view. This maneuver mandates utmost precaution to
avoid catastrophic bleeding.
22.6.2 HV/IVC Stenting
Stenting is considered in case of persistence of >30% stenosis
or trans-stenotic pressure gradient >5mm Hg following angioplasty. Uncovered metallic stents are used (10–14mm for HV
and 25–30mm stent for IVC). Primary stenting is preferred
for long-segment HV/IVC stenosis or occlusion [17, 65].
ef
22 Interventions oftheHepatic Veins, Inferior Vena Cava, andPortal Vein
Fig. 22.9 IVC plasty. (a)
Initial IVC venogram
showing complete occlusion
(thick white arrow A) of
intrahepatic IVC near
IVC-RA junction; (b) also
with multiple collaterals
(white arrow B). (c) Stricture
was crossed through the
transfemoral route, followed
by snaring the guidewire
through transjugular route
(black arrow C). (d and e)
Serial balloon dilatation of the
occlusion up to 20mm. (f)
Recanalization of the
occluded segment after. IVC
Inferior vena cava
267
a
b
cd
22.6.3 Tips/Dips
The indications of TIPS/DIPS in BCS include an absence
of any recanalizable hepatic veins, failure to respond to
angioplasty and anticoagulation, and progressive disease
despite successful angioplasty and/or stenting [65]. A stent
size of 10 mm is usually optimal for TIPS in BCS. An
e-PTFE stent is recommended owing to its higher patency
rate [17, 65, 66].
Of note, patients with BCS have distorted hepatic mor-
phology with a larger caudate lobe, resulting in a longer
parenchymal tract, making the puncture of PV during DIPS
more technically challenging. Multiple veno-venous collaterals may also pose difculty during DIPS.Periprocedural
anticoagulation increases the risk of bleeding further in the
case of TIPS in BCS [65].
A surgical shunt is considered only when TIPS is not fea-
sible. Ultimately, patients need liver transplantation.
22.6.4 HV/IVC Thrombolysis
Thrombolysis is usually performed in patients with acute
BCS.It is best suited for thrombus not older than 3–4weeks.
Catheter-directed thrombolysis is done after HV cannulation
via jugular route using t-PA (5mg bolus followed by 0.5mg/
hour for six hours) or urokinase (3000 units/kg bolus followed by 50,000units/hr. for 6–12h). Mechanical thrombolysis may be additionally required for older thrombus
[67]. Of note, stenting is avoided in acute BCS [65].
22.6.5 Discussion
Angioplasty vs. Stenting
The only available RCT comparing angioplasty alone with
primary stenting in the case of BCS, demonstrated a signicantly higher 3-yr restenosis-free survival (96% vs. 60.4%)
268
R. K. Patel and A. Mukund
in the angioplasty + stenting group than the angioplasty
alone group [68]. A retrospective study by Han et al.
(n=177) also showed a signicantly higher re-occlusion rate
with angioplasty alone compared to combined angioplasty
and stenting (31% vs. 7.7%) [69]. Furthermore, studies by
Zhang etal. [70] and Huang et al. [71] concluded that segmental occlusion of HV/IVC was associated with a higher
re-stenosis rate than membranous occlusion following angioplasty with/without stenting. In light of the available studies,
membranous occlusion should be initially treated with
angioplasty alone, while primary stenting is preferred in the
case of segmental occlusion.
TIPS/DIPS in BCS
With the advent of the e-PTFE stent-graft, TIPS/DIPS has
shown improved survival in BCS. The 1-, 5-, and 10-year
transplant-free survival rate varies from 88 to 93%, 78 to
84%, and 69 to 72%, respectively [72–74]. Owing to technical difculties, procedure-related complications in TIPS
range from 0 to 56%. Nevertheless, the incidence of HE following TIPS is lower in BCS patients than in cirrhotic
patients [65]. HV/IVC recanalization re-establishes the normal physiological venous ow, while TIPS reduces the portal perfusion. In support of this pathophysiology, a recent
study by Mukund etal. demonstrated improved hepatic synthetic function in patients receiving HV/IVC recanalization
compared with patients treated with TIPS/DIPS [75].
22.7 Portal Vein Embolization
Inadequate future liver volume or remnant (FLR) after
hepatic resection is associated with a higher risk of posthepatectomy liver failure, thus increasing morbidity and
mortality. Pre-operative portal vein embolization (PVE)
increases the FLR, thereby avoiding the risk of posthepatectomy liver failure [76].
22.7.1 Mechanism ofLiver Regeneration
The non-injured liver rapidly undergoes regeneration (mainly
by hyperplasia) after regional injury, and the degree of regeneration is proportional to the degree of regional injury [77].
The embolized liver parenchyma releases multiple cytokines
and growth factors. It also increases the portal ow to the
non-embolized liver parenchyma. Thus, PVE increases the
supply of hepatic and extrahepatic growth factors to the nonembolized liver parenchyma, which promotes hepatic regeneration. HGF (hepatocyte growth factor) plays an important
role [76, 77].
22.7.2 Portal Vein Anatomy andIts Variants
Normal anatomy and various anatomical variants must be
thoroughly evaluated for successful PVE or hepatectomy.
Figure22.10 depicts the normal PV segmental anatomy. PV
trifurcation (RAPV, RPPV, and LPV arising from MPV) is
the most common variant, seen in ~11% of the population.
22.7.3 Concept ofStandardized FLR (sFLR)
Larger patients need larger liver mass for adequate hepatic
function; thus, FLR should be standardized relative to patient
size.
sFLR=volumetric FLR/TELV
Volumetric FLR is calculated by CT volumetry.
TELV (Total Estimated Liver Volume)=−794.41+1267.28
× BSA* [78].
*BSA=Body surface area.
22.7.4 Indications andContraindications
Indications of PVE
1. sFLR ≤20% in the normal liver [79, 80],
2. sFLR ≤30% in patients with diffuse parenchymal disease
(non-cirrhotic) or with chemotherapy-induced steatohepatitis [76, 81],
3. sFLR of ≤40% in patients with liver cirrhosis [76, 82].
II
IV
VII
VI
Fig. 22.10 Normal portal vein anatomy
VIII
RPPV
V
I
RPV
RAPV
LPV
PV
III
ab
cd
22 Interventions oftheHepatic Veins, Inferior Vena Cava, andPortal Vein
269
Absolute Contraindications [76]
1. Established portal hypertension
2. Widespread PV thrombosis in segment-bearing tumor
3. Non-surgical candidates, such as extensive hepatic disease or extrahepatic disease that precludes surgery
Relative Contraindications
1. Uncorrectable coagulopathy
2. Renal insufciency
22.7.5 Pre-Procedural Evaluation
Routine investigations include complete blood count, PT/
INR, and liver and renal function tests. Indocyanine green
clearance test (ICG) is also performed to quantify liver function. Higher retention at 15 min (ICG-R15) indicates
decreased liver function and the need for increased FLR
[83]. In patients with elevated bilirubin due to biliary obstruction (bilirubin >3mg/dl), pre-PVE biliary drainage is needed
for symptomatic relief and effective FLR hypertrophy.
Multiphasic CT or MRI is imperative before PVE.It helps
to evaluate the disease extent, calculation of FLR, and tumor
volume. Proper assessment of hepatic vascular anatomy,
especially portal vein variations, is also crucial for successful
PVE.
22.7.6 Techniques
PVE is performed in a uoroscopic suite under local anesthesia with/without conscious sedation.
Steps
1. Segmental PV radicle is punctured through a percutane-
ous transhepatic route (ipsilateral/contralateral approach)
under USG guidance using a 21/22G Chiba needle. 5F/6F
vascular sheath is placed over the guidewire. Segment 3
PV radicle is preferred for the contralateral approach
while right anterior sectoral PV is preferred over right
posterior sectoral PV in the ipsilateral approach
(Fig.22.11a).
Fig. 22.11 Portal vein
embolization through an
ipsilateral approach. (a)
Obtaining PV access through
segment 5 using a
micropuncture set. (b) Portal
venogram through a 5F KMP
catheter placed in the main
PV. (c) Embolization of
segmental PV radicles using a
glue-lipiodol mixture
(25–30%). (d) Placing a
vascular plug in right PV,
leaving a 1-cm stump for
surgical ligation during
hepatectomy; percutaneous
transhepatic tract is embolized
using coils/glue while
retracting the sheath. PV
Portal vein, KMP Kumpe
catheter, Glue: N-butyl
cyanoacrylate
270
Table 22.5 Advantages and disadvantages of ipsilateral/contralateral approaches of portal vein embolization (PVE) [76, 84, 85]
Ipsilateral approach Contralateral approach
Through right lobe PV
Seg IV PV is embolized rst to avoid the risk of
thrombus dislodgement from right to left PV during
catheter manipulation
Advantages No injury to FLR/left PV
Disadvantages Difcult cannulation of ipsilateral PV branches due to
acute angulation
Higher risk of dislodgement of embolizing materials
during nal ush portography
Risk of tumor seeding
FLR Future liver remnant, PV Portal vein
Through left lobe PV
Seg IV PV is embolized last
Easy cannulation of ipsilateral PV branches
nal ush portography
No risk of tumor seeding
Risk of injury to FLR/left PV
Difcult cannulation to segment IV branches
R. K. Patel and A. Mukund
2. Flush portography is taken through a 5F catheter placed
in MPV to evaluate the PV anatomy (Fig.22.11b). The
15-degree right anteroposterior (RAP) view allows for
better visualization of PV ramications. In the case of
chronic liver disease, PV pressure is measured as signicant portal hypertension is a contraindication to
surgery.
3. Using a 5F MPA/KMP catheter, segmental PV branches
are cannulated. Acute angulation of PV branches poses
difculty in catheterization (right sectoral PV during ipsilateral approach). In such cases, reverse curve catheters,
such as SIM1/C2/RIM catheters, might be required.
4. Individual PV branches are then embolized. The goal of
PVE is to complete the embolization of the target PV
branches with ow diversion toward the FLR
(Fig.22.11c).
5. Segment IV PV embolization is required for maximum
hypertrophy of segments II and III when extended right
hepatectomy is planned. It is worth noting that an adequate RPV stump (about 1 cm) should be left free of
embolization required for PV ligation during hepatectomy. It also prevents the extension of the thrombus from
right to left PV.
6. Finally, a check portography is performed to ensure the
adequacy of embolization. The tract is embolized using
coils to avoid intra-abdominal bleeding during sheath
removal.
(1) NBCA mixed with Lipiodol and (2) trisacryl microsphere
with coil embolization of the proximal PV trunk.
NBCA glue is mixed with lipiodol in ratios of 1:2–1:8 and
administered in small aliquots. The catheter is regularly
ushed with 5% dextrose solution before and after glue
injection to prevent premature polymerization. Advantages
of NBCA include lower cost, shorter procedure time, and
signicant proximal and distal embolization [86]. However,
glue needs more expertise and control. Notably, NBCA
causes superior hepatic regeneration due to its stronger
inammatory response; however, it may also make resection
more technically challenging [87].
Trisacryl microsphere or PVA embolization starts with
100–300μm particles and increases to 500–700μm particles
as hepatopetal ow is reduced. Finally, coils are placed at the
origin of segmental portal veins. Alternatively, a vascular
plug can be deployed at the right portal vein, leaving a bare
RPV segment of 1cm for stump ligation during hepatectomy
(Fig.22.11d).
22.7.8 Hypertrophy Response
Adequate FLR hypertrophy usually takes 3 to 5weeks. A
contrast-enhanced CT or MRI is performed to evaluate the
FLR hypertrophy.
The potential advantages and disadvantages of ipsilateral
and contralateral approaches are mentioned in Table 22.5
[76, 84, 85].
22.7.7 Embolizing Materials
The embolization should be permanent and as far distal as
possible. Although various embolizing agents have been
tried in PVE, the two most commonly used agents include
22.7.9 Complications ofPVE
PVE is a safe and well-tolerated procedure without any
change or a slight transient uctuation in liver function following the procedure. Unlike trans-arterial embolization,
patients experience either no or minimal post-embolization
syndrome after PVE.This is attributed to the fact that PVE
induces apoptosis rather than ischemic necrosis, thus limiting the release of inammatory mediators [76]. Major complications are:
22 Interventions oftheHepatic Veins, Inferior Vena Cava, andPortal Vein
271
1. Puncture related: Vascular injury causing hemorrhage,
stula, or pseudoaneurysm formation; biliary injury.
2. Embolization related: Non-target FLR embolization,
hepatic infarction, main or left PV thrombosis, and portal
hypertension.
22.7.10 Modication ofPVE
22.7.10.1 Sequential TAE andPVE [76, 84]
In patients with cirrhosis and hepatocellular carcinoma, arterioportal shunting may attenuate the hypertrophic effects of
PVE.Secondly, PVE accentuates the hepatic arterial buffer
system, leading to accelerated tumor growth. Thus, sequential trans-arterial embolization (TAE) followed by PVE
induces more FLR hypertrophy than PVE alone. Additionally,
TAE before PVE provides tumor control during the interval
between PVE and resection.
22.7.10.2 PVE andTwo-Staged Hepatectomy
[85, 88]
This technique has been designed for surgical resection of
bilobar colorectal metastasis. The tumor within the anticipated FLR is surgically resected or ablated in the rst phase.
Once FLR becomes free of tumor, PVE is performed in the
contralateral hepatic lobe, and the non-FLR lobe is resected
after FLR hypertrophy.
22.7.10.3 Simultaneous PVE andHVE (Total
Liver Deprivation) [89, 90]
This approach involves combined embolization of the right
PVE and the right and/or middle hepatic vein in a single setting. HVE should not be performed before PVE as HVE
reduces the peripheral PV ow, preventing distal PV embolization and thereby increasing the risk of non-target embolization. It has shown satisfactory hypertrophy of FLR without
any signicant side effects; however, further studies are
needed to establish the additional benet of simultaneous
PVE and HVE.
Adjuvant intra-portal hematopoietic stem cell therapy
with PVE has also been tried to enhance the rate of FLR
hypertrophy [76, 91].
mortality [92, 93]. Due to its minimally invasive nature, PVE
should be preferred over PVL.However, PVL can be performed during a two-stage procedure with an expected outcome comparable to that of PVE. Although recent
meta-analyses show an improved percentage increase in
FLR with associating liver partition and portal vein ligation
for staged hepatectomy (ALPPS) compared to PVE alone,
ALPPS carries an inherent risk of surgery while PVE is a
minimally invasive procedure [93, 94].
Embolizing Agents
Various studies have shown that n-butyl cyanoacrylate
(NBCA) is superior to microparticles in terms of the hypertrophy of FLR.In the latest meta-analysis, FLR growth with
NBCA was 49.1%±29.7 compared to 42.2%±40 with microparticles (p=0.037). Furthermore, PVE with NBCA was
associated with a shorter procedure time, lower radiation
dose, and lower cost than microparticles, while the major
complication rate was comparable [86].
22.8 Transjugular Kidney Biopsy (TJKB)
22.8.1 Indications
As an alternative to percutaneous kidney biopsy, a transjugular kidney biopsy (TJKB) may be considered in high-risk
patients, such as those with coagulopathy, thrombocytopenia, small bilateral kidneys, severe hypertension, obese
patients, and unable to lie down prone [95].
22.8.2 Rationale
In TJKB, the biopsy is taken after advancing the needle
through the venous wall and away from the larger vessels;
thus, any bleeding will bleed back into the renal vein unless
arterial puncture, signicant transcapsular puncture, or
injury to the collecting system occurs. Additionally, if an
inadvertent capsular puncture occurs, then the biopsy tract
can be embolized using coils or gel foam in the same setting
to prevent bleeding [95, 96].
22.7.11 Discussion
PVE vs. Portal Vein Ligation (PVL)
Two meta-analyses comparing PVE with PVL demonstrated
no signicant difference between the two regarding the rate
of FLR hypertrophy and post-intervention morbidity and
22.8.3 Pre-Procedural Workup
Given a major bleeding rate of 4.5% in a recent meta- analysis,
TJKB should be considered a high-bleeding-risk procedure
[5, 96]. Accordingly, platelet counts and INR should be corrected to >50,000/mm3 and <1.8 before the procedure [5].
272
R. K. Patel and A. Mukund
22.8.4 Techniques
The renal vein is catheterized via a jugular route, similar to
HV cannulation. The right renal vein is preferred over the
left due to the favorable angle and shorter length from IVC.A
venogram is taken to assess the venous anatomy. The 5F
catheter is then advanced into the lower pole branch of the
right renal vein. A 7F introducer sheath with an inner stiffening cannula (RABS-100, Cook Inc., Bloomington, IN) is
gently advanced distally into the peripheral lower pole cortical vein over a stiff guidewire. The guidewire is removed,
and adequate wedging is ensured by cortical staining on
venography. Under real-time USG and uoroscopic guidance, the biopsy needle (19G, 70cm, 2cm throw Quick-core
biopsy needle) is advanced ahead of the sheath into the
parenchyma, avoiding capsular puncture, and biopsy is
taken. Four passes are usually adequate [97]. A check venogram is taken to exclude capsular perforation if any. The
patient is observed in the ward for 24hours.
22.8.5 Diagnostic Yield andComplication
The diagnostic yield of TJKB is >90% [96]. Transient microscopic hematuria is common following TJKB. A recent
meta-analysis showed that most complications are selflimiting, with a bleeding rate of 22.6%, while major bleeding
that requires blood transfusion or intervention is seen only in
4.5% of cases [96].
22.9 IVC Filter
IVC lter prevents pulmonary thromboembolism. Various
indications for IVC lter placement are listed in Table22.6.
Ongoing sepsis is not a contraindication to IVC lter placement [98, 99].
22.9.1 Types ofIVC Filter
IVC lters are of four types: (1) permanent; (2) retrievable;
(3) convertible; and (4) temporary. Currently, all retrievable
lters are approved for permanent ltration. Convertible lters change shape after a period and no longer provide ltration. Temporary lters must be removed when they are no
longer required.
22.9.2 Patient Preparation
According to SIR guidelines, IVC lter placement is a
low- bleeding- risk procedure [5]. A review of cross-sectional imaging is crucial to evaluate caval anatomy and
the presence of thrombus. Anatomical variants of IVC and
renal vein as well as IVC diameter should be considered
before lter placement. Mega vena cava (diameter
>28 mm) requires a lter of appropriate size. The
VenaTech LP (B. Braun Medical, Bethlehem, PA) and
Bird’s Nest lter (Cook Medical Inc., Bloomington, IN)
can be used for IVC diameters up to 35mm and 40mm,
respectively.
22.9.3 Normal Location ofFilter (Figs.22.12
and22.13)
• Single-level cone-shaped lter: The top of the lter placed
just at or slightly above the lower edge of the orice of the
lowest renal vein.
• Bi-level cone-shaped lter: Top of the lter below the ori-
ce of the lowest renal vein.
• Non-cone-shaped lter: Below renal vein orices.
In pregnant patients, the lter is placed at the suprarenal
location to minimize fetal radiation exposure.
Table 22.6 Absolute, extended, and primary prophylactic indications for IVC lter placement [98, 99]
Absolute indications Extended indications Primary prophylactic indications
Contraindications to anticoagulation
Recurrent VTE/PE despite optimization of
anticoagulation
Anticoagulation- related complications,
necessitating discontinuation of
anticoagulants
Inability to achieve or maintain therapeutic
anticoagulation
VTE Venous thromboembolism, DVT Deep vein thrombosis, PE Pulmonary embolism
Iliocaval DVT
Free-oating proximal DVT
Prevention of PE while attempting
thrombolysis/thrombectomy of iliocaval
DVT
Massive PE treated with thrombolysis/
thrombectomy
VTE with limited cardiopulmonary reserve
Poor compliance with anticoagulation
High risk of VTE/PE following trauma or
surgery
Other medical conditions with a high risk of
VTE (e.g., paraplegia, prolonged ICU stay,
advanced malignancy with hypercoagulable
state, etc.)
ab
22 Interventions oftheHepatic Veins, Inferior Vena Cava, andPortal Vein
273
a
b
d
Azygous
vein
Fig. 22.12 Suggested vena caval lter locations: (a) Normal infrarenal
IVC; (b) Infrarenal and renal vein thrombosis; (c) Circumaortic left
renal vein; (d) Duplicated IVC: Single suprarenal or 2 infrarenal lters;
(e) SVC lter for upper limb thrombosis. IVC Inferior vena cava, SVC
Superior vena cava
c
e
SVC
22.9.4 Procedure
Following venous access (femoral> jugular approach), ush
cavography is taken using a pigtail catheter placed at the
conuence of the iliac veins for the IVC lter and the brachiocephalic vein for the SVC lter. The delivery sheath is
advanced over a stiff guidewire to the intended position, and
the lter is deployed as per the manufacturer’s instructions.
A check venogram is taken at the end to ensure appropriate
lter placement.
Alternatively, intravascular ultrasound (IVUS) alone may
be used to guide lter placement in patients with contraindications to contrast agents and bedside lter placement [100,
101]. Transabdominal USG guidance for bedside lter place-
ment has also been described [102].
The procedural success rate is 99%, and post-lter recurrent pulmonary embolism is seen in 0.5 to 6% of cases [98,
102].
c
Fig. 22.13 IVC lter placement. (a–c) Single-level cone-shaped lter (open black arrow) placed in IVC with top of the lter just at the lower
edge of the orice of the renal vein (5F catheter placed in LRV)
274
R. K. Patel and A. Mukund
22.9.5 Complications [98, 102]
1. Caval thrombosis
2. Access site thrombosis
3. Filter fracture: 0.6–8%
4. Filter migration: 2–10%
5. Filter infection
6. IVC penetration/perforation: mostly asymptomatic
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