VENOUS VARIA

IVC FILTER PLACEMENT

Introduction

Last updated: apr 5, 2023

Pulmonary embolism (PE) continues to be a major cause of morbidity and mortality. Estimates of the incidence of non-fatal PE range from 400,000-630,000 cases per year and 50,000-200,000 fatalities per year directly attributable to PE. The current preferred treatment for deep venous thrombosis (DVT) and PE is anticoagulation. However, up to 20% of these patients will have recurrent PE.

Interruption of the inferior vena cava (IVC) for the prevention of PE was first performed in 1893 using surgical ligation. Over the years, surgical interruption took many forms (ligation, plication, clipping, or stapling) but IVC thrombosis was a frequent complication after these procedures. Endovascular approaches to IVC interruption became a reality in 1967 after the introduction of the Mobin-Uddin filter.

In recent years, filter technology has therefore focused on means to afford temporary protection for those patients with short-term risk of PE (e.g. patients undergoing orthopaedic surgery, patients with temporary contraindication to anticoagulation, patients undergoing thrombolysis for deep venous thrombosis [DVT], and patients whose anticoagulation requires temporary cessation due to surgery). These patients are often young or have an otherwise normal life expectancy.

This has led to the development of temporary tethered filters that must be removed within 2 weeks of insertion and retrievable IVC filters (without tether) that can be retrieved or left in place as permanent filters. The permanent option of the retrievable filter is especially suitable for those patients where uncertainty exists regarding the ethiology of the thrombosis and may in retrospect require permanent partial vena cava interruption.

Vena Cava Segments

1. Iliac segment from the posterior cardinal veins
2. Subrenal segment from the right supracardinal vein
3. Renal segment from the anastomosis between the right supracardinal and subcardinal veins
4. Suprarenal segment from the right subcardinal vein
5. Hepatic segment from the hepatocardiac canal.

 

Anatomy

File NameTypePermissionsChanged DateDateSize

 

Indications

Patients with evidence of pulmonary embolus or IVC, iliac, or femoral-popliteal DVT and one or more of the following:

  • Contraindication to anticoagulation
  • Complication of anticoagulation
  • Failure of anticoagulation (recurrent PE despite adequate therapy or inability to achieve adequate anticoagulation)

Selected patients

  • Massive pulmonary embolism with residual deep venous thrombus in a patient at risk of further PE
  • Massive PE treated with thrombosis/-ectomie
  • Free floating iliofemoral or inferior vena cava thrombus
  • Severe cardiopulmonary disease and DVT (e.g. cor pulmonale with pulmonary hypertension)
  • Poor compliance with anticoagulant medications
  • Severe trauma without documented PE or DVT (Closed head injury, Spinal cord injury, Multiple long bone or pelvic fractures)
  • High risk patients (e.g. immobilised, ICU patients, prophylactic pre-operative placement in patients with multiple risk factors of venous thromboembolism)

Supra-renal placement

  • Renal vein thrombosis
  • IVC thrombosis extending above the renal veins
  • Filter placement during pregnancy; suprarenal placement is also appropriate in women of childbearing age
  • Thrombus extending above previously placed infrarenal filter
  • Pulmonary embolism following gonadal vein thrombosis
  • Anatomic variants: duplicated IVC, low insertion of renal veins

 

Contra indications

Absolute

  • Those receiving therapeutic anticoagulants
  • Those with thrombus between the venous access site and expected deployment site
  • Patients expected to undergo magnetic resonance imaging (MRI) after filter placement

Relative

Vena Cava Filter Manufactorers
 

Materials

Essentials

  • Standard angio set
  • Introducer 6F
  • Disinfectant
  • Cava filter set

Non-Essentials

 

Positioning the patient

  • Supine

 

The procedure in steps

  • Time out
  • Sterile washing
  • Draping
  • Ultrasound-guided venipuncture
  • 6F sheath
  • Visualize the IVC with identification of renal veins
  • Placement below the lowest renal veins
  • Remove sheath
  • Manual compression

 

Tips and tricks

 

Complications

Published rates for individual types of complications are highly dependent on patient selection and are, in some cases, based on series comprising several hundred patients, which is a volume larger than most individual practitioners are likely to treat. It is also recognised that a single complication can cause a rate to cross above a complication-specific threshold when the complication occurs in a small volume of patients, e.g. early in a quality improvement programme.

Clinically significant penetration and migration are felt to be rare. The rate of clinically significant penetration is undefined in the literature.

ComplicationReported rate (%)Threshold (%)
Death0,12<1
Recurrent PE0,5-65
IVC Occlusion2-3010
Filter embolisation2-52
Access site thrombosis0-61
Migration0-18
Fracture2-10
Perforation0-41
 

Post-op

  • Removal in consultation with the treating physician

 

Report

Time-out akkoord. Toegang via de vena femoralis. Cavogram toont geen thrombus in de VCI. Identificatie van de niervenen. Plaatsing van het filter juist onder deze venen. Verwijderen delivery device. Toegang gesloten met manuele compressie.

 

Literature

File NameTypePermissionsChanged DateDateSize

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