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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3892_Библиотеки_им_академика_М_И_Перельмана
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353
Name three indications
for suprarenal IVC filter
placement.
1. Renal vein or gonadal vein
thrombosis
2. IVC duplication
3. Low insertion of renal veins
Name four indications for
IVC filter removal.
Low risk of clinically significant PE
due to primary treatment.
Patient will not return to high risk
for PE status from interruption of
primary treatment.
Life expectancy of patient long
enough to realize benefit from filter
removal (at least 6months).
Filter can safely be retrieved with
adequate venous access.
Name two
contraindications to vena
cava filter removal.
1. Significant thrombus within the
filter
2. Patient unable to achieve
adequate anticoagulation or
prophylaxis
Relevant Anatomy
What defines a
proximal lower
extremity DVT?
Venous thrombus involving the popliteal
vein, femoral vein, iliac veins or IVC
What defines a distal
lower extremity
DVT?
Venous thrombus confined to the
infrapopliteal veins
What is the most
common location for
IVC filter placement?
Infrarenal
(continued)
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354
What is the upper
limit of caval
diameter for filter
placement?
28mm (excluding Bird’s Nest filter)
Name four things
to evaluate for on
prefilter placement
cavogram.
IVC duplication anomalies. In this case, a
filter should be placed in both IVCs or in
the bilateral iliac veins.
Interrupted or absent IVC.
Presence or absence of IVC thrombus.
Determination of IVC diameter.
Location of renal vein inflow. In the
event of circumaortic left renal vein, the
IVC filter should be placed below the
level of the lowest renal vein or two can
be placed in the bilateral common iliac
veins.
What is the most
common route of
venous drainage in a
duplicated IVC?
Left renal vein
Which gonadal vein
drains into the IVC?
Right
How many left renal
veins are seen with
the circumaortic left
renal vein variant?
Two. The filter should be placed below
the level of the lowest renal vein.
Relevant Materials
What are the different types of historically available IVC
filters?
D. Maldow
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355
a
Types of IVC Filters
bc
de f
g h
ijk
l
A Simon Nitinol
B Recovery/G2
C Günther-Tulip
D Greenfield Ti
E Greenfield SS OT
W
F Celect
G Vena Tech LP
H Vena Tech LGM
I TrapEase
J OptEase
K Bird’s Nest
L Option
What are the names of two types of
retrievable filters and what is their
composition?
Cook Celect;
conichrome
Cordis OptEase;
nitinol
What are the names of two non-retrievable
filter types and their composition?
Braun VenaTech LP
or LGM; Phynox
(continued)
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Vena Cava Filter
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356
Cook Bird’s Nest;
stainless steel
Name a contrast agent that can be used in a
patient with renal insufficiency or iodinated
contrast allergy.
CO2
Name a common device used for vena cava
filter retrieval.
Snare
General Step by Step
What are the two usual
routes of peripheral venous
access for IVC filter
placement?
Internal jugular vein and femoral
vein
What is the usual contrast
injection rate for a
cavogram?
15–20cc/sec for 2seconds
How can you identify the
contralateral iliac and renal
veins on a cavogram?
Inflow of non-opacified blood or
reflux of contrast into the veins
For the purpose of prefilter
cavogram, where should the
tip of the pigtail catheter be
placed?
At the confluence of the iliac
veins
At what level should the tip
of the IVC filter be after
deployment?
Generally, the tip is placed at the
confluence of the renal veins as to
allow renal inflow to help prevent
thrombus formation.
Complications
Name three procedural
complications of IVC filter
placement.
1. Incomplete filter deployment
D. Maldow
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357
2. Filter malpositioning
3. Filter tilting
Name three late complications
of IVC filter placement.
1. Filter migration
2. Fractured filter limb
3. IVC thrombosis
What is a feared complication
of infrarenal IVC filter
placement in the setting of a
duplicated IVC?
Recurrent pulmonary embolism.
Filters should be placed in both
IVCs or in the bilateral iliac
veins.
Landmark Research
Haut et al. The effectiveness of prophylactic inferior vena
cava filters in trauma patients: a systematic review and
meta-analysis
• Weak association between IVC filter placement and
decreased incidence of nonfatal and fatal PE in trauma
patients. Benefits must be weighed against the inherent
risks of IVC filter placement. Targeted use of IVC filters
may be beneficial for those who are severely injured or
unable to tolerate anticoagulation, particularly in the set-
ting of retrievable filters.
Mismetti etal. Effect of a Retrievable Inferior Vena Cava
Filter Plus Anticoagulation vs Anticoagulation Alone on
Risk of Recurrent Pulmonary Embolism: A Randomized
Clinical Trial.
• In patients with PE at high risk for recurrence, routine
placement of a retrievable IVC filter does not reduce the
risk of recurrent PE when compared to anticoagulation
alone.
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358
Decousus etal. A Clinical Trial of Vena Caval Filters in the
Prevention of Pulmonary Embolism in Patients with Proximal
Deep-Vein Thrombosis.
• No difference in 2-year mortality for DVT patients ran-
domized to anticoagulation vs. filter.
• Although IVC filters reduced the risk of PE, they were
associated with more recurrent DVT.
Common Questions
True or false: vena cava filters
help prevent formation of new
thrombus.
False
What imaging study should be
performed prior to removal
of a prophylactic vena cava
filter?
Doppler venous ultrasound of
both lower extremities may be
obtained as clinically indicated
to document absence of DVT.
Should anticoagulation be
held temporarily for vena cava
filter removal?
No
Further Reading
Binkert C.Caval filtration. In: Mauro M, Murphy K, etal., editors.
Image-guided interventions. 2nd ed. Philadelphia, PA: Elsevier
Saunders; 2014.
Bjarnason H, Young P, McEachen J. Acute lower extremity deep
vein thrombosis: classification, imaging evaluation, indications
for intervention. In: Geschwind J-F, Dake M, editors. Abrams
angiography. 3rd ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2014.
Dobromirski M, Cohen A.How I manage venous thromboembolism
risk in hospitalized medical patients. Blood. 2015;120:1562–9.
Haut ER, Garcia LJ, Shihab HM, etal. The effectiveness of prophy-
lactic inferior vena cava filters in trauma patients: a systematic
review and meta-analysis. JAMA Surg. 2013;149:194–202.
D. Maldow
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359
Johnson M, Marshalleck F, Johnson C.Pulmonary embolism- IVC
filters: indications and technical considerations. In: Abrams'
angiography: interventional radiology. 3rd ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2014. p.990–7.
Kandarpa K, Machan L, Durham J. Handbook of interventional
radiologic procedures. 5th ed. Philadelphia: Wolters Kluwer;
2016.
Kaufman JA.Guidelines for the use of retrievable vena cava filters.
Endovasc Today. 2006:42–7.
Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for
VTE disease: CHEST guideline and expert panel report. Chest
J. 2016;149:315–52.
Mismetti P, Laporte S, Pellerin O, etal. Effect of a retrievable infe-
rior vena cava filter plus anticoagulation vs anticoagulation
alone on risk of recurrent pulmonary embolism: a randomized
clinical trial. JAMA. 2015;313:1627–35.
Mokry T, Bellemann N, Sommer C, etal. Retrospective study in 23
patients of the self-expanding sinus-XL stent for treatment of
malignant superior vena cava obstruction caused by non-small
cell lung cancer. JVIR. 2015;26:357–65.
Molvar C.Inferior vena cava filtration in the management of venous
thromboembolism: filtering the data. Semin Interv Radiol.
2012;29:204–17.
Rao B, Duran C, Steigner ML, Rybicki FJ.Inferior vena cava filter–
associated abnormalities: MDCT findings. Am J Roentgenol.
2012;198:605–10.
Smillie RP, Shetty M.Imaging evaluation of the inferior vena cava.
Radiographics. 2015;35:578–92.
Weinberg I. Appropriate use of inferior vena cava filters. ACC
Expert Analysis; 2016. http://www.acc.org/latest- in- cardiology.
Wilbur J, Shian B. Deep venous thrombosis and pulmonary embo-
lism: current therapy. Am Fam Physician. 2017;95:296–302.
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361© Springer Nature Switzerland AG 2022
R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_30
Evaluating Patient
What and where are
PAAs?
Although aortic aneurysms are more
common, PAA is an enlargement in an
artery other than the aorta, the aorto-
iliacs, the cerebral circulation, the visceral
circulation, or the coronary vessels. They
occur most commonly in the popliteal
arteries (nearly 70% of all PAAs),
followed by the iliofemoral arteries. Upper
extremity PAAs are relatively uncommon.
An aneurysm is a dilation of an artery
>50% of its native diameter, and it involves
all three layers of the arterial wall.
Chapter 30
Peripheral andVisceral
Artery Aneurysm
JesseChen andAmitRamjit
J. Chen (*) · A. Ramjit
Department of Radiology, Staten Island University Hospital,
Staten Island, NY, USA
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How do PAAs
present?
PAAs are usually asymptomatic and
identified incidentally during workup
for other reasons. Nonetheless, the most
common acute presentation includes
peripheral thrombosis with acute limb
ischemia (pain, numbness, loss of pulses,
etc.), representing roughly 50% of
symptomatic PAAs. If there is insufficient
flow past a thrombosed aneurysm, ensuing
chronic limb ischemia can mimic occlusive
atherosclerotic disease. Symptomatic
aneurysms may also present secondary
to compression of local structures (e.g.,
nerves, veins). PAAs are much less likely
to rupture than aortic aneurysms, with an
incidence of 2–4%.
What symptoms
are typical of upper
extremity PAAs?
The most common presenting symptoms
result from subclavian artery aneurysms,
including a pulsatile neck mass, upper
extremity neuralgia, Horner syndrome, or
stridor from tracheal or recurrent laryngeal
nerve compression.
Are PAAs usually
isolated findings?
No. identification of a single PAA
warrants a thorough search for additional
aneurysms. Roughly 83% of patients
who have at least one PAA identified
will be found to have multiple, including
an increased risk for abdominal aortic
aneurysm (AAA). For example, isolated
popliteal artery aneurysms are very
uncommon, found in only 0.1–3% of
the population. Popliteal aneurysms are
bilateral in 50–70% of cases, and up to
70% of patients with a popliteal aneurysm
will have an AAA.
J. Chen and A. Ramjit
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How are PAAs
evaluated and
followed?
Because many aneurysms are
asymptomatic for a prolonged period,
the true incidence of PAAs is unclear.
Ultrasonography has improved detection
of peripheral aneurysms above physical
exam, but computed tomography
angiography (CTA) and magnetic
resonance angiography (MRA) have
since surpassed duplex ultrasound.
Cross-sectional imaging provides better
anatomical detail, allows definition of both
inflow and outflow vessel diameter, and
assesses for the presence of aneurysmal
thrombus, all of which are important for
intervention.
What will be found
on physical exam of
a PAA?
PAAs are usually diagnosed incidentally by
imaging performed for other reasons. Due
to differences in body habitus, physical
exam generally has low sensitivity for
PAA.Popliteal artery aneurysms, however,
are classic for presenting with a pulsatile
mass, found in 60% of patients. If a PAA is
thrombosed, the only finding on physical
exam to suggest its presence may be a
pulsatile mass on the contralateral side.
What is the most
common upper
extremity PAA?
Subclavian artery aneurysm comprises
88% of upper extremity arterial aneurysms.
Where is the most
common visceral
artery aneurysm?
Visceral artery aneurysms (VAAs) are
rare (estimated prevalence of 0.01–0.2%).
Although about 1/5 present as clinical
emergencies, an increasing number of
incidental VAAs are diagnosed due to the
increasing prevalence of cross-sectional
imaging. The splenic artery is the most
common site, then hepatic artery, celiac
artery, and SMA.
(continued)
30 Peripheral andVisceral Artery Aneurysm
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