A 7-year retrospective review of the technical success of the "low-profile" hangman technique for complicated inferior vena cava (IVC) filter retrievals

Abstract

Purpose: We aimed to assess the safety and effectiveness of a modified low-profile hangman technique.

Methods: We performed a retrospective review of all filter retrieval procedures performed at a major trauma center, from 2012 to 2019. Records were reviewed for patient demographics, device type, device dwell time, device tilt, embedded hook, success of device retrieval, evidence of caval injury and occurrence of complications.

Results: From 2012 to 2019 there were 473 filter retrieval attempts. An advanced technique was documented in 66 (14%). The low-profile hangman technique alone was documented in 23 procedures (5% of all procedures, 35% of advanced technique procedures). Average screening time was 28 minutes. At the time of retrieval attempt, 9 patients (41%) were anticoagulated. The hangman technique was employed as isolated maneuver in 23 patients and was successful on initial attempt in 22 cases (96%). The average dwell time of filters retrieved by the hangman technique was 228 days (range, 40-903 days; median, 196 days). No procedure-related complications occurred.

Conclusion: The retrieval of IVC filters is an important part of offering an IVC filter service. Advanced techniques to retrieve caval filters are multiple, and the risk of complications is increased in these cases. We demonstrate the safety and effectiveness of a new modified and lower-profile hangman technique. This new technique could be performed with only an 11 French venous access sheath using off-the-shelf equipment and it remains a cost-effective approach to complex filter retrieval.

Figure 1

Inclusion and exclusion flow chart.

Figure 2

Initial digital subtraction angiographic (DSA) cavogram was performed through the Cook retrieval sheath, prior to attempted removal of a filter. Filter tilt and an embedded hook is identified in this case on DSA.

Figure 4

The snare and snared end of the 0.018- inch wire were pulled back through the sheath and removed. The 0.018-inch fixed core wire is now looped around the neck of the filter.

Figure 3

A 0.018-inch fixed core wire (Cook Medical) is directed around the neck of the IVC filter, taking care not to engage the filter struts, and the end is snared using the snare provided in the Cook filter retrieval kit (Cook Medical).

Figure 5

With forward pressure on the sheath and gentle retraction on the 0.018-inch fixed core wire ends, the sheath is then advanced over the hook and filter in the standard manner.

Figure 6

Digital subtraction cavography is performed post filter removal, through the outer sheath.