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Vena Cava Filters

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Vena Cava Filters

  1. 1. Vena Caval Filters Dustin Thompson MD
  2. 2. Definition • An intravascular device designed to prevent venous emboli from reaching the pulmonary circulation
  3. 3. Filter Types • Permanent – Not intended to be repositioned or retrieved in any manner • Temporary – Must be removed or repositioned within a certain time frame • Optional/Retrievable – Can be retrieved or repositioned up to a predetermined time limit – They will then become incorporated into the wall of the vena cava and function the same as a permanent filter
  4. 4. Absolute Indications • Deep venous thrombosis (DVT) or pulmonary embolism (PE) with a contraindication to anticoagulation (e.g. intracranial hemorrhage, active gastrointestinal bleeding, vascular intracranial neoplasm) • Progression of DVT or PE while anticoagulated
  5. 5. Absolute Indications • Complication of anticoagulation that requires interruption or termination of anticoagulants • Massive life threatening PE requiring thrombolysis or thrombectomy • Recurrent PE due to failure of an existing vena caval filter with continued contraindication to anticoagulation
  6. 6. Relative Indications • DVT and/or PE with limited cardiac or pulmonary reserve • DVT and/or PE and poor compliance with medications, fall risk, or inability to monitor anticoagulation
  7. 7. Relative Indications • DVT and/or PE and large residual thrombus burden • Patient with previous history of DVT/PE undergoing a surgical procedure with high risk of postoperative thrombosis • No history of DVT/PE but high risk of developing thromboembolic disease as in multiple trauma (prophylactic)
  8. 8. Temporary or Optional Filters • Absolute indications are the same as for permanent filters when the contraindication to anticoagulation is expected to end during the appropriate time frame • Relative indications are also similar except that poorly compliant patients or those with limited cardiac or pulmonary reserve should receive permanent filters
  9. 9. Contraindications • Total thrombosis of the vena cava • Inability to gain vascular access • Inability to image during filter placement
  10. 10. NOT Contraindications • Sepsis – Infected thrombus trapped in the filter vs. septic pulmonary emboli • Inability to document peripheral thrombus in a patient with known PE – May not be able to identify the source – New thrombus may develop after imaging
  11. 11. Technique • Access – Common femoral or internal jugular vein – Can also use external jugular, subclavian, brachial or direct translumbar IVC puncture
  12. 12. Technique • Imaging – Position catheter at confluence of the common iliac veins – Use same position and magnification that will be used during deployment – Perform DSA with 30-40 mL IV contrast – Define caval and renal vein anatomy/variants – Measure diameter of vena cava – Evaluate for presence of thrombus
  13. 13. Technique • Procedure for proper positioning and deployment varies by manufacturer and product
  14. 14. Technique • Placement – Note level of renal vein inflow – Position delivery sheath – Make sure filter is oriented properly for the direction of your access – Advance filter to end of delivery sheath – Recheck positioning and then deploy filter – Repeat cavagram through delivery sheath
  15. 15. Filter Location • Apex of filter should be at or slightly above the lower edge of the orifice of the lowest renal vein to decrease dead space • If thrombus is present the filter may have to be placed in the suprarenal IVC • For SVC placement use a short filter and avoid the right atrium
  16. 16. Filter Location • Duplicated IVC, usually drains into left renal vein, may need two separate filters or one suprarenal filter • Mega cava (diameter >28 mm) should use a Bird’s Nest filter or one filter in each common iliac vein
  17. 17. Risks specific to filter placement • 5% risk of recurrent PE • 5% risk of symptomatic caval thrombosis • <1% risk of migration, filter fracture, symptomatic perforation of the vena cava, or malposition • When being placed for prophylaxis, include 3% risk of symptomatic thrombosis at the venous access site
  18. 18. Complications During or After Placement • Kinked sheath • Incomplete opening of the filter • Guidewire entrapment • Filter migration • Filter fracture • Penetration of IVC
  19. 19. Currently Available Filters
  20. 20. Valji page 403
  21. 21. Valji page 404
  22. 22. Cook Celect™ Vena Cava Filter
  23. 23. Günther Tulip™ Vena Cava Filter Cook
  24. 24. Günther Tulip™ Vena Cava Filter Retrieval Set Cook
  25. 25. G2® Filter BARD
  26. 26. ECLIPSE™ Vena Cava Filter BARD
  27. 27. Case 1 • Retrievable filter for prophylaxis • Right femoral access
  28. 28. Case 2 • Patient with DVT, PE, obstructive uropathy and intracranial metastases • Right internal jugular access
  29. 29. Case 3 • Patient with previous history of DVT and IVC filter placement 2 years ago • Currently admitted for diverticulitis and gastrointestinal bleeding • CT incidentally showed thrombus superior to the IVC filter • Right internal jugular access
  30. 30. Case 4 • Prophylactic filter retrieval
  31. 31. Final Question • What is the risk of pulmonary embolism from upper extremity deep vein thrombosis?
  32. 32. J Vasc Interv Radiol. 2010 Jun;21(6):779-87. Pulmonary embolism from upper extremity deep vein thrombosis and the role of superior vena cava filters: a review of the literature. Owens CA, Bui JT, Knuttinen MG, Gaba RC, Carrillo TC. Division of Interventional Radiology, University of Illinois Medical Center, M/C 931, 1740 West Taylor Street, Chicago, IL 60612, USA. cowens@uic.edu Abstract The placement of superior vena cava (SVC) filters to prevent pulmonary emboli (PE) from upper-extremity deep vein thrombosis (UEDVT), although controversial, has been reported. A total of 21 publications were identified that reported 209 SVC filters and documented eight major filter-related complications (3.8%), including four cardiac tamponades, two aortic perforations, and one recurrent pneumothorax. The in-hospital or 1-month mortality rate was 43.1%. Twenty-eight additional publications were identified that reported 3,747 cases of UEDVT. The rates of PE and associated mortality were 5.6% and 0.7%, respectively. Studies imaging both upper and lower extremities found deep vein thrombus 14.7 times more likely to occur in the lower extremities and the rate of PE from a lower-extremity thrombus to be 25.1%. The lack of evidence documenting the risk from UEDVT and the absence of data supporting the safety and efficacy of SVC filters bring their benefit into question.
  33. 33. References and links • Kandarpa K. Aruny J. Handbook of Interventional Radiologic Procedures, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2002. • Valji K. Vascular and Interventional Radiology, 2nd ed. Philadelphia: Saunders Elsevier, 2006. • Multiple videos on placement and retrieval of various filters available at http://www.cookmedical.com/di/familyListingAction.do? family=Vena+Cava+Filters • http://www.bardpv.com/_vascular/prod-catalog.php • http://www.cordis.com/products/trapease-permanent-vena-cava-filter

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