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Temporary IVC Filters Why and When

Should They Be Removed?


Techniques for Difficult IVC Filter
Retrieval

Christopher J. Kwolek, M.D.

Division of Vascular and Endovascular


Surgery, Department of Surgery,
Massachusetts General Hospital, Harvard
Medical School, Boston, MA
Faculty Disclosure

I disclose the following financial


relationships:

Receive grant/research support:


None
PREPIC Trial
Prospective study effectiveness IVC filters in France
NEJM 1998
Randomized 44 centers
All received heparin IVC filter as well
Followed w/ V/Q scan or PA 8-12 days, 3mo, 1-2 yrs
Filter + heparin = less PE (1.1% vs 4.8%, p=0.03)
Protective advantage of filter lost over time
No mortality difference at 2 yrs (22% vs 20%, p=0.65)
Filter group had more recurrent DVT (21% vs 12%, p=0.02)
Expanded Indications
1) In the presence of VTE
a) Added protection (during anticoagulation/lysis)
b) Poor compliance to anticoagulants
c) Free floating ilio-caval thrombus
2) In the absence of VTE
a) High risk for DVT, PE and cannot get prophylaxis
- Pelvic/long bone fractures
- Orthopedic, spinal, neurosurgical procedures
8/9/2010: Inferior Venathat
FDA Recommends Cava (IVC) Filters:
implanting Initial Communication:
physicians and clinicians Risk
of Adverse Events
responsible withongoing
for the Long Term
care Use
of patients with retrievable IVC
filters consider removing the filter as soon as protection from PE is
921noDevice
longeradverse
neededevent reports
- 328 device migration
- 146 embolization of device components
-70 IVC perforation
- 56 filter fractures
Retrievable Filters
Cordis Optease
Nitinol shaped like a bi-level
basket
6 F delivery sheath
30mm maximum IVC diameter
Hook on bottom for femoral
retrieval
Barbs attach to IVC wall
Must be removed in 21 days
Cordis Optease
Same delivery system used for
femoral and jugular
placement
MRI compatible
Recurrent PE = 9%
IVC occlusion = 0% (10%)
Cook Celect
Based on Tulip
Conical shape
8.5 F sheath
Femoral/ jugular
IVC diameter = 30mm
Retrieved from neck
Remove up to 90 days
MRI compatible
Bard G2
Nitinol
Bi-level cone
7 F sheath
Femoral/ jugular
Retrieve from neck
90 days
? Easiest to retrieve
Max diameter IVC = 28mm
Bard G2X

Nitinol
Bi-level cone/ Snare
7 F sheath
Femoral/ jugular
Retrieve from neck
Indefinite
? Easiest to retrieve
Max diameter IVC = 28mm
Complications of IVC Filters
Recurrent PE 2-5%
Fatal PE 0.7%
Venous access site thrombosis 2-28%
Filter migration 3-69%
IVC penetration 9-24%
IVC obstruction 6-30%
Filter fracture 1%
140 consecutive filters placed over 2 years

27 removal attempts in 26 pts (18.5%)

Average time to removal 122 days (11-260)


Pre-recovery Work-up
CT scan of abdomen with venous phase
Patency of IVC
Integrity of filter
Location of filter
Location of legs
Office visit
Assess current status
Determine appropriateness of retrieval
IVC 101 Standard Moves
Venogram
Cone no wire
No Wire
Place wire w/ Kumpe
Retrieval
Current Practice
IVC 102 Advanced Techniques
AL1 Guide
Snare
Advanced Move Tilted Filter
Balloon From Below
IVC 302 Extreme Filter Removal
Patient History
52 yo female active military
Fell >10 feet while rock climbing
L1 Burst Fracture w/ decrease in spinal canal width
neurologically intact
Small intracranial hemorrhage
IVC filter placed for PE prophylaxis
Lumbar spine fixation
Did well discharged follow-up in 3 months for eval for
removal
Reuter tip deflecting wire
Agilis Steerable Sheath
Patient History
33 yo male motorcycle crash
Multiple cervical and thoracic spine fracture
Paraplegic
IVC filter placed for PE prophylaxis
Bard G2X IVUS guidance
Follow-up 3 months for removal
Conclusion
Most IVC filters should be placed with plans for
removal
Aggressive follow-up is necessary to achieve
acceptable retrieval rates (93% evaluated)
Most filters can be removed by standard
techniques (95% success rate)
Extreme techniques exist and can be successful
but not all will come out (1548 days)