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IVC Filter Retrieval

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Ep 339 The Importance of a Multidisciplinary Filter Retrieval Program with Dr. Warren Clements and Dr. Premal Trivedi

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Pre-Procedure Prep

Indications

• No further contraindication to anticoagulation
• Permanent filter unnecessary
• Low risk of pulmonary embolism (PE)
• Sufficient life expectancy for removal benefits
• Filter can be safely removed

Benefits

• Prolonged filter implantation is associated with higher filter-related morbidity
• Eliminates risk of filter-associated IVC thrombosis/DVT
• Eliminates risk of filter migration/fragmentation/penetration

Contraindications

• Significant thrombus within/beneath filter
• Lack of venous access site (occluded IJ and/or femoral)
• Severe uncorrectable coagulopathy

Pr-Procedural Evaluation

• H&P - what type of filter was placed and why; interval history since placement
• Contraindications to contrast
• Any prior imaging: CT, US and filter placement images
• Lower extremity doppler ultrasound to rule out DVT
• Patency of jugular or femoral veins

IVC Filter Retrieval Podcasts

Listen to leading physicians discuss ivc filter retrieval on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.

Episode #339

The Importance of a Multidisciplinary Filter Retrieval Program

In this episode, guest host Dr. Robert Ryu interviews Dr. Warren Clements and Dr. Premal Trivedi about the current state of IVC filter retrievals, obstacles to increasing retrieval rates, and their experiences with implementing programs to increase IVC filter retrieval rates within their respective healthcare systems.

Episode #204

Filter Indications and Filter Tracking: Up Your Game

We talk with interventional radiologist Dr. Stephen Wang about building an IVC filter retrieval program, the current guidelines on filter placement, and how to minimize the complications of filters.

Episode #35

Over-the-Wire Technique for IVC Filter Placement

Dr. David Mobley of Columbia University VIR describes his over-the-wire technique to prevent tilting in IVC filter placement. Special thanks to our sponsor Argon Medical.

Procedure Steps

Two Key Issues to Filter Retrieval

• Engage the filter apex
• Remove filter legs through sheath

Have a large balloon catheter readily available in case of IVC injury/extravasation

Access Options

• Jugular access for most cases.
• Femoral access for OptEase filters.

Place Sheath

Place appropriate sheath: 16 and 18 F sheaths often helpful
Perform cavogram - assess for thrombus and filter position
• If significant thrombus is present - consider aborting retrieval and continue anticoagulation
• If no thrombus - introduce the retrieval snare device
• Snare the retrieval hook of the filter

Optimize Imaging

Magnification and multiple obliquities

Remove Filter

• Counterbalance is important - equal amounts of force applied to upward traction and downward sheathing movements
• Using back tension with the snare, advance sheath over the filter to collapse the filter within sheath
• Pull filter out through sheath

If the filter is tilted and the tip cannot be snared, multiple options for more complex retrieval
• Loop snare commonly used
• Endobronchial forceps to disrupt fibrin cap and grasp the apex

Cavogram

After filter is removed - perform cavogram through the sheath to document appearance of the IVC and evaluation for stenosis or extravasation.
• Carefully review imaging to confirm no retained fragments
• Inspect the removed filter
Remove sheath and hemostasis achieved with manual pressure

Post-Procedure

Post-Operative Care

• Monitor vital signs closely for 1-3 hours following procedure

Potential Complications

• IVC filter fracture/migration/embolization requiring foreign body retrieval
• IVC injury spectrum: spasm, pseudoaneurysm, extravasation
• Injury to adjacent structures due to penetrating struts
• IVC thrombosis.

References

[1] Desai KR, Pandhi MB, Seedial SM, et al. Retrievable IVC Filters: Comprehensive Review of Device-related Complications and Advanced Retrieval Techniques. Radiographics. 2017;37(4):1236‐1245. doi:10.1148/rg.2017160167
[2] Laws JL, Lewandowski RJ, Ryu RK, Desai KR. Retrieval of Inferior Vena Cava Filters: Technical Considerations. Semin Intervent Radiol. 2016;33(2):144‐148. doi:10.1055/s-0036-1582119
[3] Stavropoulos SW, Ge BH, Mondschein JI, et al. Retrieval of tip-embedded inferior vena cava filters by using the endobronchial forceps technique: Experience at a single institution. Radiology. 2015 Jun;275(3):900-7.
[4] Al-hakim R, Kee ST, Olinger K, Lee EW, Moriarty JM, Mcwilliams JP. Inferior vena cava filter retrieval: effectiveness and complications of routine and advanced techniques. J Vasc Interv Radiol. 2014;25(6):933-9.
[5] Kuo WT, Odegaard JI, Louie JD, et al. Photothermal ablation with the excimer laser sheath technique for embedded inferior vena cava filter removal: initial results from a prospective study. J Vasc Interv Radiol. 2011;22(6):813‐823. doi:10.1016/j.jvir.2011.01.459
[6] Kuo WT, Tong RT, Hwang GL, et al. High-risk retrieval of adherent and chronically implanted IVC filters: techniques for removal and management of thrombotic complications. J Vasc Interv Radiol. 2009;20(12):1548‐1556. doi:10.1016/j.jvir.2009.08.024
[6] BackTable, LLC (Producer). (2017, September 18). Ep 11 – #FilterOUT [Audio podcast]. Retrieved from https://www.backtable.com/shows/vi

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