Percutaneous inferior vena caval filter placement

Sachin Madaan; Udit Chauhan; Pankaj Sharma

doi:10.4103/JME.JME_192_20

HOW TO DO IT

Year : 2022 | Volume : 3 | Issue : 3 | Page : 288-291

Percutaneous inferior vena caval filter placement

Sachin Madaan, Udit Chauhan, Pankaj Sharma
Department of Radiodiagnosis, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission	27-Nov-2020
Date of Decision	04-Nov-2022
Date of Acceptance	12-Nov-2022
Date of Web Publication	28-Dec-2022

Correspondence Address:
Dr. Pankaj Sharma
Department of Radiodiagnosis, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JME.JME_192_20

How to cite this article:
Madaan S, Chauhan U, Sharma P. Percutaneous inferior vena caval filter placement. J Med Evid 2022;3:288-91

How to cite this URL:
Madaan S, Chauhan U, Sharma P. Percutaneous inferior vena caval filter placement. J Med Evid [serial online] 2022 [cited 2023 Apr 2];3:288-91. Available from: http://www.journaljme.org/text.asp?2022/3/3/288/365859

Introduction

Venous thromboembolism (VTE) deep venous thrombosis (DVT) with pulmonary embolism (PE) is a significant cause of morbidity and mortality. Currently, the primary treatment for VTE is pharmacologic anticoagulation; however, up to 20% of these patients will have recurrent PE.^[1]

The first endovascular inferior vena caval (IVC) filter placement was done in 1967 after the introduction of the Mobin-Uddin filter.^[2] IVC filters can be permanent or retrievable devices. Permanent placement is done in patients needing long-term protection from PE with absolute contraindication for anticoagulation. Retrievable devices may be retrieved after the resolution of the temporary risk of PE or contraindication to anticoagulation, or these may be left in place for long-term protection, if necessary. Different types of devices are available from various manufacturers, which differ in their shape, size, deployment and retrieval techniques, cost, efficacy and safety.

Advantages of filter retrieval include reducing the incidence of long-term complications of indwelling IVC filter, including IVC thrombosis, vena cava perforation, filter dislocation or migration, fracture, recurrent VTE and venous stasis disease.^[3],[4]

[TAG:2]Indications for Inferior Vena Caval Filter Placement^[5][/TAG:2]

Classical indications documented VTE with any of the following:

Contraindication to anticoagulation (e.g., acute haemorrhagic stroke and bleeding diathesis)
The complication of anticoagulation necessitating cessation (e.g., haemorrhage)
Failure of anticoagulation (recurrent VTE despite anticoagulation)
Propagation/progression of DVT during therapeutic anticoagulation.

Extended indications documented VTE with any of the following:

Iliocaval or extensive free-floating proximal DVT
Limited cardiopulmonary reserve
Massive PE with residual DVT in a patient at risk for further PE
Chronic VTE treated with thromboendarterectomy
Poor compliance with anticoagulation
Recurrent PE with IVC filter in place (filter failure).

Prophylactic indications, documented DVT with increased risk of PE as follows:

Major trauma (e.g., multiple long bone/pelvic fractures)
Surgical procedure (e.g., bariatric surgery)
Medical condition
Pregnancy.

Pregnant women are at a greater risk of DVT and PE, especially in the immediate post-partum period. Low-molecular-weight heparins are the drug of choice for prophylaxis and treatment in pregnant women, but these need to be stopped in the peripartum period. A temporary IVC filter can be used to prevent PE in pregnant patients with confirmed DVT in the peripartum period and in those with recurrent PE despite anticoagulation.^[6] Insertion under low-dose fluoroscopy with the use of abdominal shielding results in a low foetal radiation dose. It is recommended that IVC filters be placed in the suprarenal position whenever indicated in pregnant patients, to prevent tilting in infrarenal IVC, due to enlarging uterus and to prevent ovarian vein thrombus.^[4],[5]

Contraindications to IVC filter placement include lack of safe access to IVC or safe placement location in IVC (e.g., IVC thrombosis).^[7] Septic PE is a relative contraindication due to the potential risk of filter infection.^[8]

Filter Placement Technique

Site of access

Percutaneous access is commonly obtained from the jugular or femoral route, the right jugular vein being the most preferred site. The brachial vein can also be used. Access from right-sided veins is better as it causes less filter tilt after placement than left-sided access.^[9] Venous access should be obtained using a sterile aseptic technique, to reduce the chance of filter infection.

Technique

Described below is the technique of infrarenal IVC filter placement after percutaneous access from the right internal jugular vein (IJV) under fluoroscopic guidance:

The right IJV is punctured using an 18G needle attached to a 10cc syringe under ultrasound guidance. Blood is aspirated to confirm venous access. Flexible tip stiff wire is passed through the needle followed by removal of the needle and insertion of 7Fr sheath over a dilator
5Fr KMP or Vert catheter along with 0.035” hydrophilic J wire is introduced and negotiated through the right atrium into the IVC
The catheter is exchanged with a multiside hole catheter, and a subtraction venogram is obtained
Caval diameter is measured to ensure proper filter deployment and attachment to IVC walls, as most filters are suitable within a range of IVC diameter (>15 and <30 mm)
The venogram is also evaluated for caval anatomical variations and the presence of iliofemoral thrombus
The location of the renal vein ostia is identified as a filling defect, as unopacified blood enters the contrast-filled IVC at the ostia [Figure 1]. If renal veins are not identified on the venogram, then either renal vein should be engaged using the catheter, followed by a contrast injection to confirm their location [Figure 2]. The patient's spine is used as a reference for the position of renal veins
The hydrophilic wire is replaced by stiff wire, followed by an exchange of 7Fr introducer sheath by 10Fr sheath
The filter delivery system is introduced over a stiff wire, and the tip is placed in infrarenal IVC [Figure 3]. During deployment, the struts (legs) of the filter should be in apposition with the infrarenal IVC wall [Figure 4], and its apex should lie at the level of renal ostia. This position helps prevent renal vein thrombosis if the filter causes IVC thrombosis
A check venogram is taken through the delivery sheath to demonstrate the position and degree of tilt [Figure 5]
The sheath is removed, followed by manual compression over the access site till the bleeding stops.

Figure 1: Fluoroscopy image shows filling defects in IVC at the level of renal veins due to the inflow of unopacified blood (arrows). IVC: Inferior vena caval

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Figure 2: Spot image shows guidewire and catheter in the left renal vein at the level of the body of the L1 vertebra (arrow)

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Figure 3: Fluoroscopy image shows an unopened filter during delivery within the sheath (white arrow)

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Figure 4: DSA image shows the filter in situ after delivery. DSA: Digital subtraction angiography

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Figure 5: DSA image showing filter tilt: angle between the long axis of IVC (red line) and the long axis of filter (green line). IVC: Inferior vena caval, DSA: Digital subtraction angiography

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Figure 6: Filter thrombus: DSA image shows a filling defect (arrow) at the level of the filter's apex. DSA: Digital subtraction angiography

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Filter insertion is commonly done under fluoroscopic guidance in the digital subtraction angiography suite. Transabdominal and intravascular ultrasound guidance can be used for bedside filter placement in cases where the patient cannot be safely shifted for fluoroscopic insertion.

Routinely, the filter is placed in infrarenal IVC, so that renal veins are spared in cases where IVC thrombosis occurs as a complication after filter placement. Suprarenal filter placement is indicated when there is renal vein thrombosis, IVC thrombosis extending above renal veins, in pregnancy, thrombus extending above a previously placed infrarenal filter, gonadal vein thrombosis causing PE, extrinsic IVC compression or anatomic variants such as duplicated or transposed IVC, circumaortic or low inserting renal veins.^[6],[10]

Filters can also be placed in the superior vena cava (SVC) to prevent for the prevention of PE from upper limb DVT. The incidence of DVT is much lower in the upper limbs, with a low incidence of PE (5.6%) as compared to the lower limbs (25.1%).^[10] SVC filter placement is technically more challenging than IVC placement due to its short length. The filter should be placed distal to the confluence of brachiocephalic veins. Complications related to SVC filters can be severe and include caval wall perforation followed by cardiac tamponade or pneumothorax.^[11]

[TAG:2]Complications^[3],[4][/TAG:2]

Procedural complications

Complications from vascular access

Bleeding: 6%–15%. Usually minor. Major bleeding requiring transfusion or surgery is rare
Access site thrombosis: 2%–35%. Usually asymptomatic. It can be prevented by minimising vessel manipulation and avoiding prolonged compression after sheath removal
Arteriovenous fistula: rare –0.02%. May present with pain, palpable thrill or distal ischaemia. Early treatment is recommended using embolisation or surgery.

Filter-related complications

Tilt: filter tilt is defined as more than 15° of angulation from the long axis of IVC [Figure 5]. The most common cause for failure of retrieval.^[7] Increased incidence of PE and thrombosis
Migration: defined as 2 cm or more superior or inferior movement from the initial location of placement. It may be due to an undersized filter or the placement of central lines. Migration into the cardiopulmonary system is rare but warrants immediate endovascular or surgical intervention as it can be fatal
Incomplete filter opening: 0.7%–14%. It may be due to a defective filter, operator error or existing IVC thrombus. Results in reduced filter efficacy. Immediate removal is recommended.

Operator errors

Non-target placement: may be misplaced in suprarenal IVC, common iliac vein and rarely into gonadal or mesenteric veins. A venogram before placement should be done to assess the anatomy
Inverted orientation: may become non-functional and challenging to retrieve.

Post-procedural complications

Thrombosis

Caval thrombosis: seen in <10% of cases, presents with pain and oedema of both lower limbs and renal failure in case of suprarenal extension. It may be due to captured thrombus or in situ thrombosis [Figure 6]
DVT: a major delayed complication of filters, increased incidence with longer indwelling time. Retrievable should therefore be removed as soon as indicated.

Filter fracture

Structural failure leads to fragmentation of the filter and potential embolisation of fragments. Incidence increases with time; the overall incidence is 1%–2%. Fragments may migrate into the heart, renal veins or pulmonary arteries. Endovascular or surgical removal is recommended.

Perforation

It is defined as >3 mm penetration of the caval wall with the filter in pericaval space or adjacent structures such as the duodenum, aorta or renal pelvis. It may occur as an immediate or late complication-expectant management with close follow-up for asymptomatic patients and endovascular or surgical removal for symptomatic cases.

Filter Retrieval

Retrievable filters should be removed when no longer needed to prevent PE. These filters come with a hook at the apex, which can be engaged by a snare device followed by the mechanical collapse of struts of the filter to help subsequent removal through a vascular sheath. Vascular access for IVC filter retrieval is obtained from IJV. However, most IVC filters cannot be successfully removed through endovascular and are left in situ for life. The retrieval rates range from 6% to 42% and show increasing trends in various studies.^[12],[13] Causes for retrieval failure include longer than recommended indwelling time, formation of fibrin cap around the filter, filter tilt, caval perforation and endothelialisation of filter struts. Complications of filter retrieval include filter fracture, IVC intussusception, haemorrhage or dissection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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10.	Orsini RA, Jarrell BE. Suprarenal placement of vena caval filters: Indications, techniques, and results. J Vasc Surg 1984;1:124-35.
11.	Owens CA, Bui JT, Knuttinen MG, Gaba RC, Carrillo TC. Pulmonary embolism from upper extremity deep vein thrombosis and the role of superior vena cava filters: A review of the literature. J Vasc Interv Radiol 2010;21:779-87.
12.	Belkin N, Jackson BM, Foley PJ, Damrauer SM, Kalapatapu V, Golden MA, et al. Trends in inferior vena cava filter placement and retrieval at a tertiary care institution. J Vasc Surg Venous Lymphat Disord 2019;7:405-12.
13.	Morris E, Duszak R Jr., Sista AK, Hemingway J, Hughes DR, Rosenkrantz AB. National trends in inferior vena cava filter placement and retrieval procedures in the medicare population over two decades. J Am Coll Radiol 2018;15:1080-6.