Filter Retrieval

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Pre-Procedure

Indications:
• No further contraindication to anticoagulation
• Permanent filter unnecessary
• Low risk of pulmonary embolism (PE)
• Sufficient life expectancy for removal benefits
• Filter can be safely removed

Benefits:
• Prolonged filter implantation is associated with higher filter-related morbidity
• Eliminates risk of filter-associated IVC thrombosis/DVT
• Eliminates risk of filter migration/fragmentation/penetration

Contraindications:
• Significant thrombus within/beneath filter
• Lack of venous access site (occluded IJ and/or femoral)
• Severe uncorrectable coagulopathy

Preprocedural evaluation:
• H&P - what type of filter was placed and why; interval history since placement
• Contraindications to contrast
• Any prior imaging: CT, US and filter placement images
• Lower extremity doppler ultrasound to rule out DVT
• Patency of jugular or femoral veins

Procedure

Two key issues to filter retrieval:
• Engage the filter apex
• Remove filter legs through sheath

Have a large balloon catheter readily available in case of IVC injury/extravasation

Procedure:
Jugular access for most cases.
• Femoral access for OptEase filters.

Place appropriate sheath: 16 and 18 F sheaths often helpful
Perform cavogram - assess for thrombus and filter position
• If significant thrombus is present - consider aborting retrieval and continue anticoagulation
• If no thrombus - introduce the retrieval snare device
• Snare the retrieval hook of the filter

Optimize imaging: magnification and multiple obliquities

Remove filter
• Counterbalance is important - equal amounts of force applied to upward traction and downward sheathing movements
• Using back tension with the snare, advance sheath over the filter to collapse the filter within sheath
• Pull filter out through sheath

If the filter is tilted and the tip cannot be snared, multiple options for more complex retrieval
• Loop snare commonly used
• Endobronchial forceps to disrupt fibrin cap and grasp the apex

After filter is removed - perform cavogram through the sheath to document appearance of the IVC and evaluation for stenosis or extravasation.
• Carefully review imaging to confirm no retained fragments
• Inspect the removed filter
Remove sheath and hemostasis achieved with manual pressure

Post-Procedure

Postoperative care:
• Monitor vital signs closely for 1-3 hours following procedure

Potential complications:
• IVC filter fracture/migration/embolization requiring foreign body retrieval
• IVC injury spectrum: spasm, pseudoaneurysm, extravasation
• Injury to adjacent structures due to penetrating struts
• IVC thrombosis.

Related Procedures

No related procedures.

Step-by-step guidance on how to perform IVC Filter Placement. Review tools, techniques, pearls, and pitfalls on the BackTable Web App.
 

References

[1] Desai KR, Pandhi MB, Seedial SM, et al. Retrievable IVC Filters: Comprehensive Review of Device-related Complications and Advanced Retrieval Techniques. Radiographics. 2017;37(4):1236‐1245. doi:10.1148/rg.2017160167
[2] Laws JL, Lewandowski RJ, Ryu RK, Desai KR. Retrieval of Inferior Vena Cava Filters: Technical Considerations. Semin Intervent Radiol. 2016;33(2):144‐148. doi:10.1055/s-0036-1582119
[3] Stavropoulos SW, Ge BH, Mondschein JI, et al. Retrieval of tip-embedded inferior vena cava filters by using the endobronchial forceps technique: Experience at a single institution. Radiology. 2015 Jun;275(3):900-7.
[4] Al-hakim R, Kee ST, Olinger K, Lee EW, Moriarty JM, Mcwilliams JP. Inferior vena cava filter retrieval: effectiveness and complications of routine and advanced techniques. J Vasc Interv Radiol. 2014;25(6):933-9.
[5] Kuo WT, Odegaard JI, Louie JD, et al. Photothermal ablation with the excimer laser sheath technique for embedded inferior vena cava filter removal: initial results from a prospective study. J Vasc Interv Radiol. 2011;22(6):813‐823. doi:10.1016/j.jvir.2011.01.459
[6] Kuo WT, Tong RT, Hwang GL, et al. High-risk retrieval of adherent and chronically implanted IVC filters: techniques for removal and management of thrombotic complications. J Vasc Interv Radiol. 2009;20(12):1548‐1556. doi:10.1016/j.jvir.2009.08.024
[6] BackTable, LLC (Producer). (2017, September 18). Ep 11 – #FilterOUT [Audio podcast]. Retrieved from https://www.backtable.com/podcasts

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Demos

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IVC Filter Removal Using Forceps Technique

Complex inferior vena cava filter removal using endobronchial forceps.

Tips and Tricks for Difficult IVC Filter Retrieval

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Tools

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IVC Filter Compendium

IVC Filter Compendium on BackTable

Easily searchable mobile application that contains information on the more than 20 FDA approved IVC filter devices.

 

Literature

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Seminars in Interventional Radiology (Jun 2017)

Techniques for Retrieval of Permanent Inferior Vena Cava Filters

In this article, we will present our approach to the retrieval of Greenfield, TrapEase, and Simon Nitinol filters. For each device, we will provide a brief history of the device’s development and implementation into clinical practice; this will be followed by a description of our procedural approach, which we will illustrate with a case and images from our practice. We will alsodiscuss techniques described in the literature for the retrieval of VenaTech devices.

RadioGraphics (Jul 2017)

Retrievable IVC Filters Comprehensive Review of Device-related Complications and Advanced Retrieval Techniques

The purpose of this article is to present an imaging and data review of the dominant device-related factors that complicate RIVCF retrieval and to describe the relevant advanced retrieval techniques to manage these factors.

 

Podcasts

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Dr. Robert Ryu

Dr. AJ Gunn

Robert Ryu and AJ Gunn discuss building a filter retrieval practice, equipment preferences, and challenging cases.

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