tips and tricks for challenging & complex ivc filter …

Fakhir Elmasri, MDLakeland Vascular Institute

Lakeland, Florida

TIPS AND TRICKS FOR CHALLENGING & COMPLEX

IVC FILTER REMOVAL

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Fakhir Elmasri, M.D.LVI President and Founder

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Providing a comprehensive

approach to patient care.

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IVC Filter Complications• Thrombosis/PE

• Caval Thrombosis: 3.7%

• DVT: Increase 50%

• PE: 5.6% Non-Fatal, 3.7% Fatal

• Malposition & Migration

• Defective Deployment

• Bleeding

• Infection

• Leg Perforation/ Fracture

• Incident rate 40%, unclear on

how time of implantation affects thrombosis rate.

7Ha, T. G. (2006). Complications of Inferior Vena Caval Filters. Retrieved June 29, 2016, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3036364/

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MISPLACEMENTS

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MISPLACEMENTS

Tilted Filters

Case # 1

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Start with a 16F x 45cm sheath with a 9F x 55cm sheath through it.

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Loop the neck of the filter with a wire and snare it back through the 9F sheath

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Advance the 9F sheath and cinch it tight around the neck of the filter

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Advance the 16F sheath down against the neck of the filter

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Pull the 9F cinched sheath and BARD G2 & Eclipse filters will fold in half at the neck into the 16F sheath. Successful retrieval with a normal post cavagram.

CASE #2

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Switch to 16F loop snare technique

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Freed the hook from wall for another snare attempt

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Snared the hook and retrieved the filter successfully

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Retrieval of tilted filter in a 39 year old

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Unable to snare the hook as it is embedded in the wall

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Convert to 16F loop snare technique

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Fold the Eclipse filter in half and retrieve through the 16F sheath

Case # 3

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PE in a patient with a Tilted Guenther Tulip Filter

Retrieval of an embedded Guenther Tulip filter in place for over 2 years

➢63 yr old patient w/Gunther Tulip presented with PE

➢Patient recently presented w/recurrent lower extremity DVT along with new episodes of pulmonary embolism➢No DVT was observed in the upper extremeties

➢Upon review of CT, tilt was observed and was cause for concern due to patient symptoms

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Hook of the filter embedded in the Vena Cava Wall

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Gooseneck + Forcep Retrieval Technique

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Gooseneck + Alligator Forceps Technique

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Gooseneck snare Alligator Forceps

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Filter is removed

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Final Cavagram

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Denali Placed Post-Tulip Removal

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Case # 1

Filter Penetration

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• Upper GI bleed and endoscopy was performed. Bleeding was found in the duodenum where a limb of the filter had perforated.

• Was contacted by surgeon who was having difficulty retrieving the filter due to apex of the filter being embedded in the cava wall.

• After attempting to talk surgeon through various retrieval techniques with patient on the table the decision was made to refer patient to us.

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Multiple techniques used to remove difficult embedded filter

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Case # 2Back Pain Started Immediately Post IVC Filter

Filter Penetration

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F/U after 4 months back pain didn't subside, CT Scan performed…

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Penetrated leg from Simon Nitinol filter causing pain

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Mal Deployment

Case # 1

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CT Coronal Reformats

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CASE #2

Mal Deployment

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Mal Deployment

Case # 3

Case Number 1

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67 year old male comes in for AV shunt access

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What is that ?

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What is that doing there?

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Lets go get it!

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Lets go get it!

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Maybe not

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Pre- angioplasty

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Filter Migration

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Case # 1

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63 year old male presents with bilateral PE’s

Taken to cath lab for treatment

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What is going on here?

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CT 1 month earlier

CASE # 1

Chronic IVC Occlusion

•60 y/o male S/P Trapease filter placement more than 10 years ago, and has been

suffering from lower extremity edema/pain and large veins in the legs and abdomen for

6 years

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CASE # 2

Chronic IVC Occlusion

This cavogram was performed by one of my colleagues and he called me for a consult

Patient History: A“prophylactic” IVC filter was placed prior to a total knee

replacement in 2008

• The patient developed extensive bilateral lower extremity edema starting in 2010

I ordered a CT scan for planning

Recanalization of the chronically occluded IVC was scheduled.

Right CFV and Right IJ were accessed in preparation to recanalyze the cava

From Tree Trunks To

Chicken Legs

Caval Thrombosis

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Management of a patient with an occluded Trapease filter and significant lower extremity swelling and edema.

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Bilateral iliac stent placement and high pressure angioplasty of the occluded filter

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4 months later patient swelling/edema still not resolved

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Placement of Palmaz stent through the occluded Trapease filter

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Sequential high pressure angioplasty with 16mm & 20mm Atlas balloons

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Completion cavagram of patent Palmaz stent and a Meridian IVC filter placed above for continued thromboembolic protection

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What really happens to the crushed Trapease Filter ?

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( Angiovac &Penumbra CAT 8)

Caval Thrombosis

60 y/o male has a retrievable IVC filter, presented with caval thrombosis and bilateral leg swelling.72 hours post TPA thrombolysis performed using Ekos catheters (Ultrasound enhanced thrombolysis catheter) showed improvement but still with significant residual IVC clots

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A Greenfiled filter complication case from last month

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57-year-old male with a prior history of DVT and PE status post Greenfield IVC filter placement 7 years ago.

Patient with extensive bilateral lower extremity edema, 3+ pitting edema and arteriovenous malformation which is very complex involving the iliac arteries and veins as well as contribution from the femoral artery on the left.

He has undergone 2 prior glue embolizations of these AVMs. Of note, he has IVC occlusion from the IVC filter and is very well collateralized with hypertrophied collaterals from the iliac veins. However, he has a enlarging 6.5 cm left external iliac venous aneurysm. It was felt that this may decompress somewhat after the glue embolization of the pelvic AVM but it has not as there continues to be arterialized flow through the venous system as there are multiple branches contribute into the AVM which cannot be successfully embolized. The plan is to perform renal field filter extraction with possible reconstruction of the IVC to decompress the venous outflow and hopefully relieve tension on the venous aneurysm and also help with the patient's bilateral lower extremity edema.

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In Conclusion:

When you are placing an IVC filter you are ethically, legally, financially liable and

responsible for patient outcomes…. so just be careful!!!

THANK YOU

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