Inferior vena cava filters

Abstract

Venous thromboembolism (VTE) remains a common disease with significant clinical impact upon our patients. Diagnostic challenges occur because of the nonspecific nature of the presenting symptoms. The advent of multidetector computed tomography, methods to stratify patients into VTE risks (low, intermediate, high) along with serological assays (D-dimers), have helped direct patients through proper workup and into conclusive diagnosis. In most cases, standard medical therapy for VTE is anticoagulation therapy (OAT). In situations where standard OAT is either contraindicated or complications result from that therapy, insertion of inferior vena cava (IVC) filters is considered. Recent reports suggest that although IVC filters are able to prevent pulmonary emboli (PE) in the short and intermediate term, there appear to be long-term consequences including excess recurrent deep venous thombosis (DVT and IVC/filter occlusions). Recognition of the time sequence of IVC filter benefits and complications has encouraged development of optional IVC filters, which can be left in place indefinitely or removed usually before certain time constraints. This article will attempt to address the timing of IVC filter placements to protect patients from significant PE.

Keywords: Venous; embolism; filters; pulmonary; thrombosis; venae cavai.

Figure 1

A 22-year-old male patient with ulcerative colitis who developed a spontaneous left lower-extremity DVT. He was treated with OAT and developed hematochezia. Because of this and upcoming planned colectomy, his surgeons requested an IVC filter. The cavagram was performed from the right common femoral vein and shows a large free-floating iliocaval thrombus. Using a right internal jugular approach a suprarenal Greenfield IVC filter was placed and the patient underwent uneventful colectomy. The risk of PE in such settings despite OAT is somewhat controversial.

Figure 2

A 25-year-old male who suffered massive trauma including head injury and multiple pelvis and long bone fractures and who was consulted for prophylactic IVC filter placement. An initial cavagram performed from the right common femoral vein showed a patent cava of normal size without thrombus. The left renal inflow into the IVC was noted to be substantially larger than from the right renal vein. A selective left venogram revealed the caval duplication, which is better illustrated by adding a catheter from the left common femoral vein. Two IVC filters (infrarenal) were inserted to completely protect the patient from embolism from a lower extremity source. An alternative approach could include a single suprarenal IVC filter.

Figure 3

The patient had lower extremity DVT and a contraindication to OAT. A stainless steel Greenfield over-the-wire IVC filter was deployed and a postdeployment cavagram was done (A), which showed that the IVC filter did not cover the entire IVC width. Keeping the centering wire in place to stabilize the IVC filter, a Kumpe catheter was advanced up through the filter deployment sheath to manipulate the filter struts (B). A completion IVC study after IVC filter manipulation showed complete coverage of the IVC. An alternative, more conservative approach would include adding a second IVC filter.

Figure 4

(A) The patient suffered extensive lower extremity and body burns over 80% of his skin surface area. Unfortunately, he developed a left lower extremity DVT (near phlegmasia). He could not be anticoagulated so mechanical thrombectomy (Trerotola Device) was performed after placement of a Recovery Filter in an infrarenal location. The mechanical thrombectomy device combined with balloon maceration removed substantial amounts of thrombus from the left lower extremity, which embolized to the IVC filter. An attempt to treat the IVC and IVC filter thrombus, unfortunately, resulted in the thrombectomy device becoming stuck on the IVC filter. Thrombus is now extending above the IVC filter. Because of the potential compromise for the patient, a second filter was placed above this (B). (C) The patient is an elderly female patient with hemodialysis catheter-treated end-stage renal disease. She had a lower extremity DVT and bled while on OAT so a stainless steel Greenfield IVC filter was placed in the infrarenal position. She had recurrent chest symptoms several years after the initial filter placement. The IVC study showed an occluded IVC filter with development of prominent left renal collaterals (circumaortic renal vein [lower moiety] and prerenal left renal vein in conventional position [upper moiety]). A second filter was placed in a suprarenal location. (D) An elderly patient with renal cancer and lower extremity DVT had a Trapease IVC filter placed in an infrarenal location. He returned with symptoms of recurrent PE and also arrythmias. During his workup, a coronary angiogram revealed a migrated filter located in the right ventricle, which was removed surgically. He was treated with OAT.