Retrieval of an IVCF retained for over 6 years via femoral venous approach using a large-bore sheath: a case report and literature review

Abstract

Prolonged retention of inferior vena cava filters (IVCF) predisposes patients to complications, including caval thrombosis, filter tilt, wall adherence, fibrotic adhesion, migration, and perforation, posing significant risks to patient health. Retrieval of long-term retained filters is challenging, as standard retrieval techniques often prove ineffective. Advanced strategies are therefore required to improve success rates. Herein, we report a case of an IVCF retained for over 6 years, in which the patient developed acute thrombosis of the inferior vena cava (IVC) and iliac veins following recent discontinuation of anticoagulation. Concurrently, the retrieval hook was embedded in fibrotic tissue with wall apposition, and the filter struts had perforated the vascular wall with dense adhesions. Initial attempts using a standard retrieval kit failed. Subsequently, a loop snare technique was employed to dissect perihook fibrotic tissue, successfully engaging the retrieval hook. However, due to the filter's firm incorporation into the IVC, the hook straightened under traction, resulting in retrieval failure. Ultimately, the stubborn filter was successfully removed via a retrograde approach using a 20F vascular sheath through the femoral vein. By detailing this case and reviewing relevant literature, we aim to provide insights into advanced retrieval strategies for challenging IVCF, particularly those with prolonged dwell times.

Keywords: case report; inferior vena cava filter; large-bore vascular sheath; prolonged retention; retrieval.

Figure 1

Imaging findings on admission. (A) Abdominal vascular ultrasound demonstrates hypoechoic thrombus (red arrows) in the IVC and bilateral iliac veins with absent Doppler flow signals, consistent with thrombosis. (B–E) CTV reveals: The implantation status of the patient's IVCF. The filter head and the retrieval hook are attached to the wall. There are extensive low-density shadows in the IVC below the filter, and the bilateral common iliac and external iliac veins, indicating extensive thrombosis (the red arrow points to the thrombus, and the yellow arrow points to the filter and its leg branches).

Figure 2

Procedural steps of CDT and mechanical thrombectomy. (A) DSA demonstrates complete filling defects in the bilateral iliac veins and IVC, with collateral drainage via lumbar veins and extensive paravertebral collaterals. (B) Antegrade pulsed-spray infusion of 400,000 IU urokinase through a 4F thrombolytic catheter traversing the thrombus from distal to proximal. (C, D) Mechanical thrombectomy via bilateral femoral venous access using a 10F thrombus aspiration catheter, achieving near-complete clearance of iliac and IVC thrombi. (E) Post-procedural DSA confirms restored patency of the iliac veins and IVC, with minimal residual thrombus adherent to the filter. (F) Extracted thrombi comprising a large amount of fresh thrombus and a small amount of old thrombus.

Figure 3

Procedural steps of loop snare technique for filter retrieval. (A) A guidewire is looped around the filter neck with assistance from a pigtail catheter, and its tip is externalized using a snare device. (B) The looped guidewire dissects fibrotic tissue to free the retrieval hook from the adherent caval wall. (C) The snare successfully engages the freed retrieval hook. (D) Despite straightening the hook, the filter remains firmly anchored by perforated struts and cannot be fully retrieved.

Figure 4

Filter retrieval and IVC balloon angioplasty. (A–D) Retrograde retrieval of the IVC filter via femoral venous access using a 20F vascular sheath. (E) Retrieved filter demonstrating deformation but structural integrity. (F) Post-retrieval DSA confirms IVC patency without contrast extravasation, with mild stenosis at the filter implantation site. (G) Balloon angioplasty for IVC stenosis. (H) Post-angioplasty DSA shows significant luminal improvement.