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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3663_Библиотеки_им_академика_М_И_Перельмана
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26 Extra-Anatomical Venous Bypass Through aMalignant Tumor forPalliation ofMassive Arm Edema
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91
Fig. 26.3 The right arm venography showed the occlusion of the right brachial vein and numerous collateral veins
Fig. 26.4 The space was made with the ination of balloon catheter
inserted via the left internal jugular vein
Fig. 26.5 Using the stent as a target, a 0.035inch guidewire was pulled
through from the right brachial vein to the right internal jugular vein
using a loop snare
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Fig. 26.6 Two VIABAHN stent grafts were placed communicating
between the right brachial vein and the right jugular vein
Y. Arai and M. Sone
Fig. 26.8 The edema of the right upper limb was signicantly
improved 2weeks later
Fig. 26.7 The venography via the right brachial vein showed the
smooth venous return to the right atrium
Retrieval ofPermanent VenaTech Filter
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withRetained Migrated Fragments
intheHeart andLung
MichaelMarkovitz andGlennHoots
27
A 68-year-old male with Factor V Leiden had a permanent
VenaTech inferior vena cava (IVC) lter (B. Braun,
Melsungen, Germany) placed for recurrent thrombosis
despite anticoagulation [1]. Incidental imaging 4years later
showed a tilted lter with struts extending posteriorly beyond
the IVC (Fig.27.1). Despite being aware that the lter was
technically permanent, the patient insisted on attempted lter
retrieval.
ab
Jugular-directed forceps were used to bring the lter legs
together, allowing them to be snared from a femoral
approach. Whilst distracting the lter, the 18 Fr sheath
kinked and mangled it (Fig.27.2). The main lter body was
retrieved from above and retained caval struts individually
removed with forceps. A fragment embolized to the proximal
pulmonary artery was snared and removed. Additional fragments had embolized to the left lung and right heart; the risk
Fig. 27.1 (a) AP and bilateral oblique (not shown) scout images demonstrate a permanent VenaTech IVC lter tilted anteriorly. (b) Digital
subtracted inferior venacavogram shows the posteromedial struts outside the IVC lumen
M. Markovitz (*)
Department of Radiology, University of South Florida,
Tampa, FL, USA
e-mail: michaelmarkovitz@usf.edu
G. Hoots
Department of Radiology, Tampa General Hospital, Florida
Interventional Specialists, University of South Florida,
Tampa, FL, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Z. J. Haskal (ed.), Extreme IR, https://doi.org/10.1007/978-3-031-24251-9_27
94
27 Retrieval ofPermanent VenaTech Filter withRetained Migrated Fragments intheHeart andLung
ab
95
Fig. 27.2 (a) AP uoroscopic image demonstrates kinking of the right femoral vein sheath within the IVC (b) with mangling of the lter upon
sheath retraction
abc
Fig. 27.3 (a) Axial computed tomography (CT) shows a metallic den-
sity in a peripheral branch of the left lower lobe superior segmental
artery (yellow arrow) consistent with fractured lter fragment. (b) Axial
of retrieving these was deemed excessive. Final venography
afrmed an intact IVC.CT demonstrated lter fragments in
a peripheral branch of the left lower lobe superior segmental
artery (7mm) and the tricuspid valve (3mm) (Fig.27.3). At
2-month follow-up, he was asymptomatic. To avoid CT radiation, chest radiography was performed: known lter fragments were not seen (Fig. 27.4). Further imaging was
deferred as the small fragments were considered unlikely to
and (c) coronal CT demonstrate additional metallic density along the
medial tricuspid valve (red arrows)
Removal of nearly every permanent lter has been
reported, intact or in piecemeal fashion [2, 3]. Fluoroscopy
and fused intracardiac echocardiography to remove intracardiac struts has been described [4]. This case emphasizes the challenges and unique risks of such permanent
lters, especially ones where multiple struts make long
segments of wall contact, such as the VenaTech and
TrapEase lters.
cause a complication or migrate.
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Fig. 27.4 Chest radiograph
obtained 2months after lter
retrieval demonstrating no
acute ndings. Known left
lung and right heart lter
fragments are not visualized
M. Markovitz and G. Hoots
Bibliography
1. Millward S, Peterson R, Moher D, Lewandowski B, Burbridge B,
Aquino J, Formoso A.LGM (vena tech) vena Caval lter: experience at a single institution. J Vasc Interv Radiol. 1994;5:351–6.
2. Kuo WT, Deso SE, Robertson SW.Vena tech LGM lter retrieval 16
years after implantation: piecemeal removal by intentional mechanical fracture. J Vasc Interv Radiol. 2013;24:1731–7.
3. Ahmed O, Hadied MO, Madassery S. Retrieval of a permanent VenaTech LGM lter 18 years after implantation using a
novel removal method. J Vasc Surg Venous Lymphat Disord.
2018;6:526–9.
4. Hannawa KK, Good ED, Haft JW, Williams DM. Percutaneous
extraction of Embolized Intracardiac inferior vena cava lter struts
using fused Intracardiac ultrasound and Electroanatomic mapping.
J Vasc Interv Radiol. 2015;26:1368–74.
Think Fast andAct Quick: Complex IVC
Filter Removal
ZacharyHaber andMonaRanade
28
A rare complication of inferior vena cava (IVC) lters is
upper gastrointestinal bleeding (UGIB) secondary to cavalduodenal stula. Here, we present the same complication
managed by a minimally invasive percutaneous approach.
A 61-year-old male with complex surgical history for retroperitoneal liposarcoma, presented to the ED for UGIB
secondary to duodenal perforation by his indwelling IVC
lter strut. Chronic lter-related iliocaval thrombosis was
noted on imaging (Fig.28.1). Vascular access was obtained,
venogram was performed (Fig. 28.2). Complex IVC lter
removal and through access from IJ to bilateral femoral vein
was obtained with a gooseneck snare and serial balloon
venoplasty was performed. Venography demonstrated active
a
extravasation around lter strut into duodenum (Fig.28.3a).
To ensure re-entry, two kissing Vici stents (Boston Scientic,
Marlborough, MA) were placed (Fig.28.3b). Using endobronchial forceps, advanced through a 16 French sheath, the
IVC lter was removed. The caval-duodenal stula was then
cannulated with a Progreat Omega microcatheter (Terumo,
Tokyo, Japan) and embolization was performed with a 1:1
n-Butyl cyanoacrylate and Lipiodol (Guerbet, Villepinte,
France) mixture (Fig. 28.4). Venography with glue cast
(arrow) and coronal CT images conrmed resolution of the
caval-duodenal stula (Fig.28.5). On post-procedure day 2,
the patient resumed a normal diet and had no further episodes of UGIB.
b
Fig. 28.1 (a) Coronal CT demonstrates IVC lter with strut within duodenum. (b) Endoscopy photograph conrms perforated lter strut
Z. Haber · M. Ranade (*)
Department of Interventional Radiology, University of California,
Los Angeles, CA, USA
e-mail: zhaber@mednet.ucla.edu; mranade@mednet.ucla.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Z. J. Haskal (ed.), Extreme IR, https://doi.org/10.1007/978-3-031-24251-9_28
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28 Think Fast andAct Quick: Complex IVC Filter Removal
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Fig. 28.2 Venogram demonstrates iliocaval thrombosis
ab
Fig. 28.4 Spot uoroscopic image with microcatheter within cavalduodenal stula (arrow) and inated balloon within IVC to protect from
non-target embolization (arrowhead)
Fig. 28.3 (a) Venogram demonstrates active extravasation around lter strut into duodenum. (b) Spot uoroscopic image shows placement of two
14×90mm stents within the iliocaval system
100
Z. Haber and M. Ranade
ab
Fig. 28.5 (a) Venogram with glue cast (arrow) with resolution of caval-duodenal stula. (b) Coronal CT correlate with glue cast seen (arrow)
Stent-Excluded IVC Filter Causing
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Severe Abdominal Pain: ThePorthole
Retrieval Technique
RaghuramPosham, RobertLookstein,
andAaronFischman
A 43-year-old female developed sudden severe abdominal
pain and intractable vomiting. She had a history of DVT, PE,
and symptomatic IVC-lter associated iliocaval thrombosis
requiring prior multiple interventions. She ultimately underwent complete iliocaval reconstruction with stent-exclusion
of the lter. On arrival, a CT scan showed one strut of the
lter eroding into the duodenum (Fig.29.1).
29
Fig. 29.2 The right renal vein is catheterized using a 5-F× 65 cm,
Multipurpose A glide catheter, and 150cm, 0.038in Angle Gllidewire
Fig. 29.1 Contrast-enhanced computed tomography axial image at the
inferior aspect of the inferior vena cava (IVC) lter (Günther Tulip,
Cook Medical Inc., Bloomington, IN) shows penetration of the anterior
strut into the duodenum
R. Posham (*) · R. Lookstein · A. Fischman
Department of Interventional Radiology, Mount Sinai Hospital,
New York, NY, USA
e-mail: Raghuram.posham@mountsinai.org;
Robert.lookstein@mountsinai.org;
aaron.schman@mountsinai.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Z. J. Haskal (ed.), Extreme IR,
https://doi.org/10.1007/978-3-031-24251-9_29
(Terumo, Somerset, NJ) through the interstices of the Wallstent (Boston
Scientic, Watertown, MA). The hook of the lter is seen near the origin of the renal vein
Attempts to dissect along the right side of the stent were
unsuccessful as the stent was completely endothelialized.
The right renal vein was successfully catheterized through
the stent interstices (Fig.29.2), showing the lter neck within
the proximal renal vein. A wire was successfully directed
back into the stent for through-and-through access
(Fig.29.3a). Sequential venoplasty was performed through
the interstices to create a “port-hole” in the stent next to the
lter neck (Fig.29.3b).
An 18-Fr sheath was advanced from the internal jugular
vein through the defect using the “swallow-the-balloon”
technique (Fig.29.4), allowing endoscopic forceps to engage
the lter neck and pull it into the sheath (Fig.29.5). A bal-
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29 Stent-Excluded IVC Filter Causing Severe Abdominal Pain: ThePorthole Retrieval Technique
ab
103
Fig. 29.3 (a) The wire is passed back into the stent lumen and snared
from above (6Fr × 120 cm, 20 mm loop diameter gooseneck snare,
Medtronic, Minneapolis, MN) for through-and-through access through
stent interstices. (b) Sequential venoplasty was performed through the
loon was simultaneously inated over a safety wire in the
stent to free the lter legs from the surrounding soft tissue,
prevent stent crumpling as the lter was pulled into the
sheath, and provide hemostasis in case of IVC rupture
(Fig.29.6).
interstices using 4 mm–12 mm × 60 mm balloon (Charger, Boston
Scientic, Watertown, MA) to create a “port-hole” fenestration in the
wall stent in direct apposition to the lter neck
Following retrieval, a cone-beam CT was performed demonstrating a patent stent with adequate opposition to the IVC lumen.
The patient tolerated the procedure well and was discharged
2 days later with complete resolution of abdominal pain. She
remained asymptomatic at 3-month follow-up (Fig.29.7).
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