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Imaging and Technical Skills Applied to the Complex Management of a Thrombosed IVC Filter
Inferior vena cava (IVC) filter placement is indicated for an expanding list of clinical situations to prevent pulmonary embolism (PE), including prophylactically for those with a high risk for venous thromboembolism (VTE) who have undergone a surgical procedure.1 Once placed, optional or temporary IVC filters often become permanent2 and are at the same time associated with myriad complications, both thrombotic and mechanical. Filter thrombosis has been shown to be the most common delayed complication from IVC filter placement.3
IVC filter extraction is a well-established procedure1 that increases with complexity and risk in the presence of IVC thrombosis.4 If the filter is not successfully retrieved, other mechanical complications may occur such as filter angulation, fracture, migration or perforation, or the filter may become embedded in the IVC wall. It is important to be familiar with advanced retrieval techniques and tools to perform lifesaving, image-guided interventions. The case described herein illustrates the coordinated use of novel devices to provide embolic protection against pulmonary embolism while extracting a thrombosed filter.
Case Presentation
A 48-year-old female presented to the emergency department with fatigue and abdominal pain. Her hemoglobin was 6 g/dL and a computed tomography (CT) scan confirmed a recurrent gastrointestinal stromal tumor (GIST) with hemorrhage. A large thrombus was seen attached to the apex of an IVC filter (Figure 1A) which had been placed after a gastrointestinal resection surgery 2 years prior (Figure 1A). Due to embolization concerns, a complex intervention to retrieve the IVC filter safely and extirpate the residual IVC thrombus was undertaken. Given the bleeding risk, the patient did not receive anticoagulation.
The patient was positioned supine, and her right neck and bilateral inguinal regions were prepped. A focused ultrasound of the right neck was performed demonstrating that the right internal jugular (IJ) vein was patent and free of thrombus. Under direct sonographic visualization, the vessel was accessed with a micropuncture kit. An .035-inch guidewire was advanced into the IVC and the micropuncture sheath was exchanged for a 6 French (F) vascular sheath. A multi-side port infusion catheter was advanced and an inferior venacavogram showed a large filling defect corresponding to the prior CT finding (Figure 1B).
The 6F sheath was exchanged for an Intri24 sheath (Inari Medical) (Figure 2A), which was advanced over the wire into the IVC and positioned above the level of the filter.
A focused ultrasound of the right inguinal region demonstrated that the right common femoral vein (CFV) was patent and free of thrombus. Under direct sonographic visualization, the right CFV was then accessed with a micropuncture kit, and an .035-inch wire was advanced centrally into the IVC. The micropuncture sheath was exchanged for a 12F vascular sheath that was advanced into the IVC with a radiopaque tip placed just above the IVC filter. An Inari FlowTriever catheter containing 3 self-expanding nitinol mesh discs (Figure 2B) was advanced through the sheath and the 2 most cephalad discs were deployed in the IVC above the level of the existing right IJ vein sheath tip, to provide embolic protection during filter retrieval (Figure 1C).
An Inari Triever24 aspiration catheter was advanced through the right IJ vein sheath to the level of the thrombus. Aspiration thrombectomy was performed with multiple aspirations. Acute thrombus formation was noted within the catheter. The benefit of giving heparin outweighed the bleeding risk and 3000 units were administered intravenously. After multiple attempts of aspiration thrombectomy, a repeat venogram was performed, demonstrating limited removal of the large thrombus. The removed thrombus demonstrated an organized, chronic component and was presumably adhered to the IVC wall.
After thrombus aspiration, a 12F sheath was advanced through the existing 24F Intri sheath with the distal tip advanced to the level of the filter. A 15 mm EN Snare System (Merit Medical) and 6F catheter were inserted through the introducer. After multiple unsuccessful attempts to engage the filter hook, a guidewire was advanced centrally through the sheath to help redirect the snare and catheter. Subsequently, the snare was used to successfully engage the filter hook. The 12F sheath was advanced over the filter and the snare and filter removed as a single unit. The IVC filter was closely inspected, confirming that the IVC filter was intact and had been removed in its entirety. A large piece of chronic thrombus was aspirated through the sheath at the time of filter retrieval and no significant thrombus remained in the filter (Figure 1D).
A repeat inferior venacavogram demonstrated a residual large filling defect, further confirming that the chronic thrombus and scarring was associated with the caval wall.
Subsequently, the Inari ClotTriever System (Figure 2C-D) was advanced through the 24F Intri sheath, placed distal to the thrombus, and the nitinol coring element was expanded. With a single pass, additional chronic thrombus was successfully removed. A final inferior venacavogram demonstrated successful thrombus resolution (Figure 1E).
All wires and catheters were removed. The right CFV and IJ vein sheaths were removed, and hemostasis was achieved with manual compression and purse string suture, respectively. The patient was transferred to the postanesthesia care unit without postprocedure complications. A follow-up CT performed 2 weeks later confirmed thrombus clearance (Figure 1F).
Conclusion
This case highlights how thoughtful planning and combinatorial use of a suite of venous interventional products can allow for the safe treatment of patients with complex interventional needs.
References
1. DeYoung E, Minocha J. Inferior vena cava filters: guidelines, best practice, and expanding indications. Semin Intervent Radiol. 2016 Jun; 33(2): 65-70. doi: 10.1055/s-0036-1581088
2. Angel LF, Tapson V, Galgon RE, et al. Systematic review of the use of retrievable inferior vena cava filters. J Vasc Interv Radiol. 2011; 22: 1522.e3-1530.e3. doi: 10.1016/j.jvir.2011.08.024
3. Ramakrishnan G, Willie-Permor D, Yei K, et al. Immediate and delayed complications of IVC filters. J Vasc Surg Venous Lymphat Disord. 2022 Oct 4: S2213-333X(22)00410-3. doi: 10.1016/j.jvsv.2022.08.011
4. Quencer KB, Smith TA, Deipolyi A, et al. Procedural complications of inferior vena cava filter retrieval, an illustrated review. CVIR Endovasc. 2020 Apr 27; 3(1): 23. doi: 10.1186/s42155-020-00113-6
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