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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3771_Библиотеки_им_академика_М_И_Перельмана.pdf
Table 22.1 Currently Available Inferior Vena Cava Filters and Device Information (Continued)
Maximum Maximum FDA-
Delivery Caval Deployed Approved
Device Manufacturer Material Design Approach sheath (Fr) Diameter Length Use
OptEase Filter Cordis Nitinol Double Femoral, 6 30 44 Optional
Endovascular, basket Jugular, or
Miami, FL antecubital
ALN Optional ALN, Bormes Stainless Steel Conical Femoral, 7 28 55 Optional
Filter Les Mimosas, Jugular, or
France brachial
240 Charles A. Banks and Marc A. Passman
Sentry Boston Scientific Nitinol frame, Conical Femoral or 7 16–28 57.7 Convertible
Natick, MA Bioabsorbable Jugular
filament
Angel Mermaid Nitinol Conical Femoral 8 15–30 50 Temporary
Catheter Medical
Indications, Techniques, and Retrieval of Inferior Vena Cava Filters 241
Source: Adapted from: Passman M. Vena Cava Interruption. In: Perler SSaB, editor. Rutherford’s Vascular Surgery and Endovascular Therapy. Philidelphia, PA: Elsevier;
2020. pp.2013–30.
26
242 Charles A. Banks and Marc A. Passman
corroborated this finding.
tion of failed standard retrieval techniques and rIVCF dwell time of greater than 90 days.
28–30
However, these studies demonstrated a much earlier associa-
29,30
Based on currently available evidence, rIVCFs should be promptly removed once the indication for deployment has resolved.
Convertible IVCFs are a newer subtype of IVCFs that are designed with a mechanism
to convert from a thromboembolic filtration system to non-filtration state while remaining
implanted. These convertible IVCFs are primarily intended for short-term thromboembolic
prophylaxis without requiring retrieval. There are currently three FDA approved convertible IVCF designs. The VenaTech convertible IVCF (B. Braun Interventional Systems,
Bethlehem, PA) has a conical design with a removable central component that leaves behind
11
a functional IVC stent once removed.
lent in patients with converted filters with low adverse event rates.
Results from this filter at 6 months have been excel-
31
The VenaTech system,
however, requires an additional endovascular procedure for removal of the filtration component. Other convertible IVCFs such as the Sentry (BTG Vascular, Bothell, Washington)
are designed with a bioconvertible central filament that hydrolyzes after 60 days leaving
behind only nitinol scaffolding. The Sentry IVCF has demonstrated high rates of successful
32
bioconversion and low adverse event rates.
The Angel IVCF (Bio2 Medical, San Antonio,
Texas) consists of a multi-lumen central venous catheter that remains attached to the IVCF.
This provides for removal at the bedside in critically ill patients without an additional
endovascular procedure.
33
IVC ANATOMICAL CONSIDERATIONS
In the vast majority of patients (97%), the IVC is a retroperitoneal venous structure that is
positioned to the right of the vertebral column. The confluence of the iliac veins forms the
2,34,35
inferior aspect of the IVC with direct drainage into the right atrium superiorly.
The
IVC consists of four primary segments: infrarenal, renal, suprarenal, and hepatic. Although
rare, there are several anatomic variants to be aware of prior to attempting deployment of
an IVCF. Retroaortic or circumaortic left renal vein is the most common anomaly with a
2,35
prevalence of approximately 3.0–7.0%.
In these patients, the confluence of the left renal
vein and IVC may occur more caudally, which may affect IVCF deployment site. Duplicated
IVC is present in 0.2–3.0% of patients and exists with multiple anatomical subtypes primar-
34
ily affecting renal vein drainage.
these patients is bilateral infrarenal IVCF deployment.
patients to increased risk of PTE despite IVCF deployment.
The most generally accepted IVCF deployment strategy in
35
This anatomical variant predisposes
35
Left-sided IVC is a rare anatom-
ical anomaly (0.5% of patients) that creates difficult determination of anatomical landmarks
33,35
during IVCF deployment.
Typically, the IVC will cross midline via the left renal vein
or hemiazygos venous system. This creates difficulty in recognizing anatomical landmarks
36
for deployment and may prohibit a transjugular approach.
An interrupted IVC or IVC
agenesis occurs in 0.6% of patients and is highly associated with concomitant cardiovascu-
34,36
lar anomalies.
drainage occurring through the hemiazygos and azygos systems.
In these patients, the infrahepatic IVC is interrupted with primary IVC
36
Although these anomalies
are uncommon, detailed imaging should be strongly considered prior to attempting IVCF
deployment.
Indications, Techniques, and Retrieval of Inferior Vena Cava Filters 243
IVC FILTER PLACEMENT TECHNIQUES
There are multiple techniques designed for IVCF deployment that accommodate different
clinical scenarios. These range from IVCF placement in an interventional imaging suite, at the
bedside of critically ill patients under transabdominal duplex ultrasound-guidance, utilization of intravascular ultrasound (IVUS), and deployment using a fixed or mobile C-arm in the
operating room or hybrid suite. Percutaneous venous access is obtained through either femoral vein, jugular vein (right preferred over left), or brachial vein (for lower profile devices).
25
IVCF deployment using conventional venography is the mainstay of current deployment
options. Venography allows for optimal IVCF sizing, precise measurements of anatomical
landmarks, and identification of aberrant anatomy to avoid inadvertent IVCF deployment
into venous tributaries in the infrarenal IVC. Some studies indicate that pre-deployment
selective venography identified unsuspected anatomical variants that altered deployment
anatomical location or technique in 18–26% of cases.
37,38
Venography also allows for direct
visualization of the IVCF post-deployment to confirm optimal placement and ensure IVCF
tilt along the IVC axis is <15°. The optimal positioning of IVCFs in the general population is
just inferior to the lowest renal vein and superior to the iliac veins.
Deployment approaches specific to different filter devices are generally similar but may
vary with specific filter designs. For femoral access, the patient is supine, and both groins are
prepped. For jugular access, positioning the patient supine with head rotation to the contralateral side. Ultrasound-guided access with a micropuncture 5-French sheath is performed followed by an 0.035 wire advanced into the IVC. Apigtail catheter is advanced over the 0.035
wire and an ascending digital subtraction venography of the IVC is obtained (Figure22.2A).
Diameter of the IVC is confirmed and anatomical landmarks such as the iliac vein confluence
and renal veins are identified (Figure22.2A). After sequential venous dilations, the 5-French
sheath is exchanged for a 10-French delivery sheath. Once optimal location is established, the
IVCF is deployed, and location is confirmed by digital subtraction venography (Figure22.2B
and C). After sheath removal, manual pressure is held to achieve hemostasis.
Figure 22.2 Inferior vena cava filter deployment by venography. (A) Pre-deployment digital subtraction angio-
gram. (B) Positioning of IVC deployment sheath with bony anatomic landmarks indicated. (C) IVCF deployed.
244 Charles A. Banks and Marc A. Passman
Other deployment techniques include transabdominal ultrasound guidance and IVUS.
These modalities are typically employed during bedside deployment in critically ill patients or
in patients with contraindications to intravenous contrast or fluoroscopy such as renal insufficiency and pregnancy. In duplex ultrasound-guided placement, pre-deployment ultrasound
is utilized to map and measure the IVC and the lowest renal vein junction. The deployment
process involving serial dilations to upsize to a larger sheath are similar to that described
previously. At time of deployment, a transverse image of the renal vein-IVC junction is generated, and the IVC deployment catheter is visualized. The catheter is retracted inferiorly until
the echogenic catheter tip is no longer visualized indicating appropriate deployment position.
The catheter is then visualized in the longitudinal view and deployed under direct observation.39 Technical success rate using transabdominal ultrasonography is 97%.
40
The deployment of IVCF using IVUS alone or as an adjunct to venography has been performed with success. Utilizing IVUS alone for IVCF placement can be performed by dual or
single venous access.39 Dual venous access can be obtained contralaterally or ipsilaterally
and allows for IVUS to be utilized until the moment of deployment. In the single venous
access technique, IVUS is used to obtain precise measurements of the IVC and location of the
renal veins. These measurements are then applied to the deployment sheath, and the IVCF
Table 22.2 Comparison of Vena Cava Filter Types for the Prevention of Pulmonary Embolism and
Complications Rates Based on Systematic Reviews
PTE PTE
Overall Fatal Insertion Site Vena Cava Filter Filter Leg
Filter Device (%) (%) Thrombosis Thrombosis Migration Tilt >15 Penetration (%)
STAINLESS STEEL 3.5 1.3 8.6 3.5 2.0
*
2–15
GREENFIELD
TITANIUM 3.4 1.8 13.1 4.4 7.5–15
*
13–50
GREENFIELD
PERCUTANEOUS 2.7 0.3 4.3 3 2.6
*
1.0
STAINLESS STEEL
GREENFIELD
SIMON NITINOL 3.3 1.8 11.5 5.2 0–5
BIRD’S NEST 3.4 1.5 7.4 2.8 1.1
VENA TECH LP OR 3.6 0.9 15.3 9.5 6–18.4
*
*
* *
25–95
85
LGM
TRAPEASE 0.9
OPTEASE 1.6
G2 3.4
RECOVERY G2 1.0
GUNTHER TULIP 0.9 0.4
CELECT 1.1
ALN OPTIONAL 0.7
REX OPTION 4.0
DENALI
*
Limited or insufcient systemically reviewed published data to report.
Abbreviation: PTE = Pulmonary thromboembolism.
Source: Adapted from table from: Passman M. Vena Cava Interruption. In: Perler SSaB, editor. Rutherford’s Vascular Surgery
and Endovascular Therapy. Philidelphia, PA: Elsevier; 2020. p.2013–30.
* * * * * *
*
*
*
*
*
*
*
0.4 2 0.9
0.8 3.7 0.3 5.6 1.9
-- 3.7 4.5
10.4 1.0 0.8 15.5 15.1
*
2.3 0.7 5.9 22–78
1.2 0.6 0.6 12.1 22–93
14.0 1.8 0.5
18.0 1.0 2.0
26
* *
*
*
*
2.9–10
44
3.4
2.5
Indications,Techniques, and Retrieval of Inferior Vena Cava Filters 245
is deployed after removal of the IVUS probe. The IVUS technique has been performed with
technical success of 95–96%.
40,41
Alarge systematic review of 21 studies containing 2166
cases revealed similar technical success rates and procedural complication rates when comparing ultrasound guidance, IVUS, and venography.42 Some studies have suggested that IVUS
alone can be more accurate than venography in determining venous anatomy and optimal
deployment location.43 Regardless of IVCF placement strategy, pre-deployment and postdeployment imaging are necessary for optimal filter placement.
Overall, the technical success rate of IVCF deployment is 98% with rare overall incidence
of procedural-related complications.
25
Procedural and postoperative complications vary
by IVCF design (Table22.2). Vascular access complications are most common with a rate
of 4–11%.
44
Arteriovenous fistulas have also been demonstrated at a low rate (0.02%).
44
Malpositioning at time of placement and air embolism are other uncommon procedural
complications occurring in 1.3% and 0.2% of cases, respectively. Procedural mortality is
rare ranging from 0.13–0.34% and is usually associated with patients succumbing to other
comorbidities.26 Filter-related complications include filter tilt >15° (5%), filter migration
(<1.0%) and incomplete filter deployment (0.7–13.9%).
44
In certain cases, such as infrarenal IVC thrombus, pregnancy, and previously malpositioned
IVCF, suprarenal IVCF placement may be necessary. Currently, suprarenal deployment of
IVCFs is considered off-label and has not been approved by the FDA. Due to the larger
diameter of the suprarenal IVC and the more dynamic vessel wall secondary to proximity to
the cardiopulmonary systems, there have been concerns for filter migration. Initial studies
revealed significant IVCF migration as high as 27%.45 More recent appraisal demonstrated
that filters deployed in the suprarenal IVC can be performed with excellent technical success
and complication rates similar to infrarenal IVCF.45 In patients with a contraindication to
anticoagulation in the setting of an obliterated infrarenal IVC secondary to compression by
a gravid uterus or pelvic mass, thrombosed infrarenal IVC, or malpositioned infrarenal IVC,
suprarenal IVC deployment and retrieval are safe and efficacious.
45,46
IVC FILTER RETRIEVAL
Although procedural-related complications are rare, long-term outcomes after IVCF placement are of significant concern. Long-term complications following IVCF deployment
are directly correlated with prolonged IVCF dwell time (>90 days) or non-retrieval.
28,47
These complications include IVC perforation with or without associated organ perforation
(12.4%–20%), device fracture (21%), delayed migration (11.8%), DVT (1.9–14.5%), and
PTE (0.5–12%).
95% of fracture events.
in the United States.
44,47,48
Device fracture has almost exclusively involved rIVCFs comprising
49
After FDA-approval, rIVCFs comprised 75% of the filters utilized
44
Filter thrombosis, device fracture, and IVC perforation may complicate and, in some cases,
prevent successful percutaneous filter retrieval. Nationally, rIVCF retrieval remain relatively
rare at an estimated 12–18% aggregate rate.
47,50
The long-term outcomes associated with
prolonged IVCF dwell time and low retrieval rates highlight the importance of active clinical surveillance and prompt retrieval of IVCFs when clinically appropriate. Currently, IVCF
removal is indicated in patients whose risk for PTE is mitigated, contraindications to anticoagulation have resolved, and the device is eligible for retrieval.
2
The development of institutional databases and registries to promote active clinical sur-
veillance models is critical to promote IVCF removal and prevent delayed complications.
246 Charles A. Banks and Marc A. Passman
Previously, institutions followed a passive surveillance paradigm in which information was
provided to the referring physicians and the patients regarding the importance of eventual
filter retrieval.47 However, follow-up with the interventionalist was not structured. At our
institution, 2926 rIVCFs were deployed between 2000–2018 with initial retrieval rates
of 10–15% from 2007–2015.
51
After implementation of active surveillance programs, we
observed a near 4-fold increase to 40.3% rIVCF retrieval rates in 2018.51 Other institutions have implemented active surveillance protocols with similar success.
47,52,53
In Sterbis’
and colleagues’ study, they demonstrated superior retrieval rates in patients followed by
active surveillance (58.1%) compared to passive surveillance (46.4%) after rIVCF placement
(p = 0.003).
47
Another study utilizing an active institutional registry of patients undergoing
rIVCF placement demonstrated a retrieval rate as high as 92.5% in eligible patients.52 The
Cardiovascular and Interventional Radiology Society of Europe (CIRSE) developed a societal
registry (CIRSE Registry) for rIVCF placement that demonstrated a similar retrieval rate of
92%.54 Other institutions have employed dedicated clinics for IVCF surveillance, which have
also improved IVCF retrieval rates.
19
Generally, standard retrieval techniques are technically successful in 82% of cases with
18% requiring advanced endovascular techniques.28 Prolonged rIVCF dwell time has been
significantly associated with standard retrieval technique failure.
7-months of implantation time, risk of standard retrieval technique failure is over 40%.
28
When extended to
28
The requirement of advanced retrieval techniques predisposes patients to increased rates of
procedural complications.
Standard retrieval modalities vary among different IVC models and are mostly related
to the shape of the device. Each manufacturer provides a retrieval kit that is specific to the
previously deployed IVCF. The most common technique is an endovascular snare that allows
for the collapsing of the filter into a large retrieval sheath. Our experience has primarily been
with the Cook Celect IVCF Retrieval kit. Retrieval is primarily performed through internal
jugular venous access over an 0.035 wire. Apigtail catheter is utilized to perform pre-retrieval
venography to confirm absence of caval thrombus (Figure22.3A). The initial 6-French micropuncture sheath is then upsized to an 11-French sheath. An endovascular snare is used under
fluoroscopic guidance to capture the hook at the cranial extent of the IVCF (Figure22.3B).
Once the device is snared, it is collapsed into the retrieval sheath by gentle retraction. Acompletion venogram is performed post-retrieval and the filter is examined for any device fracture
or missing filter components (Figure22.3C).
ADVANCED IVC FILTER RETRIEVAL TECHNIQUES
Most IVCFs are equipped with struts and barbs that are designed to prevent filter migration
or tilt. However, prolonged IVCF dwell time may lead to extensive endothelization of these
components or caval wall penetration that may require advanced endovascular retrieval techniques.52 Other indications for advanced retrieval techniques include filter fracture, thrombosis, and caval perforation. When employed, advanced endovascular techniques for IVCF
retrieval are successful in 85–98% of cases.
5,28,53,56
Overall, risk factors predictive of complex
filter retrieval include excessive IVCF transverse tilt, embedded tip, leg penetration (>3mm),
thrombosis (>20%), and dwell time >90 days.
5,56
In cases of excessive IVCF tilt or embedded struts precluding routine retrieval, multiple advanced techniques have been described. The guidewire loop and snare technique
involves single venous access with passage of a guidewire through the IVCF struts and with
Indications, Techniques, and Retrieval of Inferior Vena Cava Filters 247
Figure 22.3 Endovascular IVCF retrieval techniques. (A) Pre-retrieval venogram to confirm absence of filter
thrombus. (B) and (C) Standard snare retrieval with IVCF collapsed into the retrieval sheath. (D–F) Represents
the single venous access loop and snare technique with passage of a wire through the struts and redirected
superiorly for snare placement. (G–J) Demonstrates dual venous access advanced retrieval technique.The filter
is snared inferiorly and superiorly and then collapsed into the sheaths. (K) Off-label utilization of endobronchial
forceps for complex retrieval. (L) Fragmented IVCF after retrieval by endobronchial forceps. (Images from
Kuyumcu G,Walker TG. Inferior vena cava filter retrievals, standard and novel techniques. Cardiovasc Diagn
Ther. 2016;6(6):642–50.
55
)
248 Charles A. Banks and Marc A. Passman
Prior Retrievable IVCF
Assessment of ongoing IVCF
requirement at 3-months
placement
Therapeutic anticoagulation no longer
contraindicated and/or need for
thromboembolic protection resolved
Perform Venogram
High risk features identied
on venogram: lter
thrombus, lter fracture,
excessive tilt, excessive lter
perforation
Referral to high volume
center for advanced IVCF
retrieval technique
Failure of advanced
techniques with excessive
device limb penetration
associated with patient
symptoms
Continued need for thromboembolic
protection without ability to tolerate
therapeutic anticoagulation
IVCF to remain in place indenitely or
until need for embolic protection
resolves
No high risk features
Standard percutaneous
retrieval by specic device
Failure of standard
percutaneous retrieval
Consider open IVCF retrieval
Figure 22.4 Algorithm for IVCF retrieval consideration. (Adapted from Charlton-Ouw KM, Afaq S, Leake SS,
Sandhu HK, Sola CN, Saqib NU, etal. Indications and outcomes of open inferior vena cava filter removal.
Ann Vasc Surg. 2018;46:205 e5–e11.
56
)
redirection of the wire tip to proceed superiorly. Asnare is introduced that is used to capture the wire forming a large loop around the cephalad aspect of the IVCF. This maneuver
provides a traction point to free the IVCF struts from the IVCF lumen. Once freed, the IVCF
can be collapsed into a retrieval sheath and removed (Figure22.3D–F).
5,53,55
Acompliant
Indications,Techniques, and Retrieval of Inferior Vena Cava Filters 249
endovascular balloon can also be used as an adjunctive procedure to displace embedded
IVCF struts.
55
In significantly embedded or tilted IVCFs, a dual venous access loop technique that involves internal jugular and transfemoral venous access may be required. The
procedure is similar the single venous access technique. The additional guidewire in the dual
venous access provides a second point of traction to assist in separating the IVCF from the
vena caval wall.
53,55
This technique has been successful in retrieving permanent filters as
well (Figure22.3G–J).
Other advanced retrieval techniques include off-label use of endobronchial forceps and
endovenous laser ablation. Endobronchial forceps as a method of IVCF retrieval was originally introduced by Stavropoulos et al.
ranging from 14–18 Fr.
55,58
The forceps can be used to dissect the IVCF hook or struts free
57
This technique requires a larger introducer sheath
from the vena caval wall. Once dissected free, the forceps can be used to grasp the IVCF
hook to retract the filter into the retrieval sheath. Proceduralists should proceed with caution
when utilizing the endobronchial forceps as they can result in filter fracture and embolization if excessive traction is applied.
by Kuo and colleagues in 2013.
5,55,57,58
59
Endovenous laser ablation was initially described
This technique also requires a larger introducer sheath
ranging from 16–18 Fr. The laser-equipped catheter is positioned near the IVCF, and photothermal energy is emitted allowing for lysis of dense fibrotic tissue adhered to the IVCF.
5,55
This technique has been associated with luminal thermal injury (7%) that can lead to IVC
pseudoaneurysms and perforation.
5
Although employed with success, utilization of advanced retrieval techniques incurs a sig-
nificant increase in overall complication rates at 20%.
5
Due to low possibility of major
complications during advanced retrieval techniques such as IVC rupture, rescue maneuvers
including IVC occlusion balloon (i.e. CODA, Cook Medical Inc. Bloomington, IN) and endovenous stents should be readily accessible.
5
Additionally, advanced IVCF retrieval should
be performed at high-volume centers that are technologically and procedurally equipped to
perform these complex procedures and manage the potential complications.
Open surgical techniques for IVCF retrieval are reserved for patients in which advanced
percutaneous techniques fail, presence of arterial or visceral strut perforation, or in patients
with symptoms related to the filter. Depending upon surgeon preference, IVC exposure may
be obtained by a transperitoneal or retroperitoneal approach. IVC exposure through the
transperitoneal approach usually involves a right medial visceral rotation through mobilization of the ascending colon and duodenum to the patient’s left. The IVCF is typically
extracted through a longitudinal venotomy with subsequent primary vena caval repair.
56
Careful inspection of the IVCF should be performed after retrieval to ensure all components
have been removed successfully. In surgically optimized patients, open IVCF retrieval can
be performed with low morbidity and mortality.
56
An algorithm regarding IVCF retrieval is
presented in Figure22.4.
CONCLUSIONS
Overall, IVCF deployment and retrieval are relatively minor procedures that can be performed with low perioperative complications. However, for the most optimal benefit, IVCF
placement must be reserved for appropriate patient populations and employed with discretion
due to low rates of subsequent removal portending long-term complications. Patients should
be closely surveilled following IVCF placement by clinical follow-up or institutional registry
to ensure IVCF retrieval when clinically appropriate. The importance of close surveillance