Translumbar high inferior vena cava access placement in patients with thrombosed inferior vena cava filters

Venous access is a dire necessity in some patients such as those with end-stage renal disease or short gut syndrome. The right internal jugular vein is the preferred entry site for tunneled central venous catheters. Alternatively, the left internal jugular is considered next, with the external jugular and subclavian veins being considered later. Catheter-related venous stenosis approaches 40% in certain sites, resulting in loss of access sites. As sites are lost, insertion of functional long-term central venous catheters becomes challenging. Translumbar inferior vena cava (IVC) access created in two patients with limited venous access sites who had thrombosed IVCs containing IVC filters is described. Because of the higher IVC punctures in these cases, procedural planning with cross-sectional imaging is crucial to avoid puncturing the right renal artery as it passes posterior to the IVC.     

Pulse-spray thrombolysis of inferior vena cava thrombosis complicating filter placement

Inferior vena cava thrombosis is an uncommon but potentially serious complication of caval filter placement. A 34-year-old man with symptomatic caval thrombosis, which occurred 6 weeks after filter placement, was successfully treated with a combination of pulse-spray and local infusion of urokinase.     

Venous thromboembolism after retrieval of inferior vena cava filters

PURPOSE: To determine the incidence of venous thromboembolism (VTE) after removal of retrievable inferior vena cava (IVC) filters. MATERIALS AND METHODS: Retrospective study was conducted of 67 patients who underwent 72 consecutive filter retrievals at a single institution. Data collected included VTE status at the time of filter placement, anticoagulant medications at the time of filter retrieval and afterward, new or recurrent VTE after filter removal, and insertion of subsequent filters. Patient questionnaires were completed in 50 cases, chart review in all patients. RESULTS: At the time of filter placement, 30 patients had documented VTE, 19 had a history of treated VTE, and 23 were at risk for but had neither previous nor present VTE. Mean duration of follow-up after filter removal was 20.6 months +/- 10.9. A total of 52 patients (57 filters) received anticoagulation and/or antiplatelet medications after filter removal. There were two documented episodes of recurrent deep vein thrombosis (2.8% of filters removed), both in patients who had VTE at the time of filter placement and underwent therapeutic anticoagulation at the time of filter removal. One of these patients (1.4% of filters removed) also experienced pulmonary embolism. Of the 23 patients without VTE when the filter was placed, none developed VTE after filter removal. Four patients (5.5% of filters removed) required subsequent permanent filters, three for complications of anticoagulation, one for failure of anticoagulation. CONCLUSIONS: VTE was rare after removal of IVC filters, but was most likely to occur in patients who had VTE at the time of filter placement.     

Value of frontal caval measurement in the placement of inferior vena cava filters.

OBJECTIVE: Inferior vena cavae (IVC) can be of unusual geometry, often having odd shapes and being oriented (in long axes) away from the horizontal plane. However, after insertion of a filter, most IVC adopt a circular cross-section. The objective of this study was to determine if the IVC diameter estimated by frontal measurement (cavogram equivalent) reflects the true circular diameter of the infrarenal vena cava. Diameter estimation is clinically important in the correct selection of a filter, because mega cavae (diameter 28 mm or greater) require a particular filter. METHODS: The infrarenal IVC was measured on computed tomographic (CT) scans in 136 patients. The frontal diameter was recorded as that which would be obtained by a cavogram. Corrected circular diameter was obtained by mapping the circumference of each cross-section on CT to a straight line and calculating diameter from circumference. RESULTS: The average frontal caval diameter was 20.5 (standard deviation 3.7) mm, whereas the average corrected circular diameter was 23.0 (standard deviation 3.4) mm. By frontal measurements, 6 IVC diameters were 28.0 mm or greater. Similarly, by corrected circular diameter, 6 IVC diameters were 28.0 mm or greater. However, of the 6 mega cavae extrapolated to cavograms, only 3 corresponded to mega cavae when corrected for true circular diameter. Yet, of the 6 mega cavae identified by corrected circular diameter measurement, 3 were not identified by frontal diameter assessment. Of the 6 patients with true mega cavae, 2 were being evaluated for right lower quadrant pain, 2 for lymphoma, 1 for a pelvic mass, and 1 for staging of a head and neck cancer. CONCLUSIONS: Cavograms can over- or underestimate the true diameter of an IVC, and may thus lead to incorrect filter choice. It is recommended that a sonogram or CT scan be obtained to visualize the IVC in cases of suspected mega cava, and that true circular diameters be used for selection and placement of IVC filters.     

Multisegmental anomaly of the inferior vena cava with thrombosis of the left inferior vena cava

We present a rare case of an extensive venous thrombosis associated with a multisegmental anomaly of the inferior vena cava (IVC), double IVCs, a hypoplastic right IVC, an aneurysm arising at the distal portion of the right IVC, and a severe stenosis between the prerenal and the hepatic segments of the IVC.     

Update on inferior vena cava filters

The ravages of thromboembolic disease continue to plague patients despite improvements in diagnostic imaging and anticoagulation regimens. In certain cases, standard medical therapy for thromboembolism is contraindicated, results in complications, or fails to adequately protect patients from embolic insults. These patients are treated with insertion of inferior vena cava (IVC) filters. Although it appears that IVC filters do reduce long-term pulmonary embolism (PE) rates, there may be a higher associated incidence of IVC thrombosis and lower-extremity deep venous thrombosis (DVT) than with anticoagulation alone. This article will address attributes of the theoretical ideal IVC filter, recently introduced IVC filters, complications of use of IVC filters, and results of recent IVC filter studies. Alternative sites for filter placements are then reviewed, along with use of temporary and retrievable IVC filters and use of IVC filters for prophylactic situations.     

CT fluoroscopy-guided placement of inferior vena cava filters: feasibility study in pigs

Purpose

To evaluate the feasibility of computed tomography (CT)–guided placement of inferior vena cava (IVC) filters in a swine model.

Materials and Methods

Five domestic pigs (60–70 kg) underwent transfemoral and transjugular IVC filter placement under real-time CT fluoroscopic guidance. Filter position was confirmed by contrast-enhanced CT and digital subtraction angiography. Filter tilt, distance to target position, and fluoroscopy time were analyzed.

Results

A total of 10 filters were successfully implanted (five via transfemoral approach, five via transjugular approach) without complications. The mean distance to the target position was 0.3 cm ± 0.2. Mean filter tilt was 3.2° ± 2.3 (range, 0°–7°), without differences between deployment techniques (P = .8486). Average fluoroscopy time was 25.9 s ± 6.9 per procedure.

Conclusions

CT fluoroscopy–guided placement of IVC filters is safely feasible. Use of this technique may avoid the need to move critically ill patients.     

Evaluation of the inferior vena cava with intravascular US after Greenfield filter placement.

An animal model was used to evaluate the utility of intravascular ultrasound (US) imaging of the inferior vena cava (IVC) following Greenfield filter placement. Ten Greenfield filters were placed in the IVCs of five sheep and three dogs. Experimentally induced thrombi were injected into four filters at the time of placement. Intravascular US and cavography were performed 4 weeks after filter implant. The imaging studies were evaluated for demonstration of filter position, orientation, and leg distribution, as well as prediction of caval wall penetration by filter hooks. Experimentally induced and spontaneous intrafilter thrombi were also imaged. Findings were compared with those of postmortem examination. Exact filter position and orientation were most simply and accurately demonstrated on radiographs. Filter leg distribution and extent of intrafilter thrombus were best evaluated on intravascular US images. The prevalence of caval wall penetration was underestimated with both studies. The results of this animal study suggest that the information about the IVC provided at cavography and intravascular US following Greenfield filter placement may be complementary.     

Deep venous thrombosis and inferior vena cava malformation

We report on five patients with anomalies of the inferior vena cava who all presented with deep venous thrombosis. The anomalies of the inferior vena cava were diagnosed with CT, and at the same time thrombosis of the inferior vena cava and/or iliofemoral thrombosis could be demonstrated. Malformation of the inferior vena cava might be a predisposing factor for deep venous thrombosis. Correspondence to: B. Bollinger     

Venographic findings at retrieval of inferior vena cava filters

OBJECTIVE: The purpose of this study was to evaluate inferior venacavograms at the time of inferior vena cava (IVC) filters for clot within filter, IVC stenosis, or IVC injuries. CONCLUSION: Abnormal venographic findings at filter retrieval include clot in the filter, IVC stenosis, and minor IVC injury after filter retrieval. Most abnormalities decrease or resolve over time.     

CT fluoroscopic guided insertion of inferior vena cava filters

The value and use of inferior vena cava (IVC) filters is well documented and has been growing since the first reported filter placement in 1973 and the first percutaneous insertion in 1982. Access routes now include both jugular veins, both ante-cubital veins and both femoral veins. However, all insertions require some form of imaging, usually fluoroscopy, to identify the location of the filter with respect to the IVC and the renal veins. We describe two cases where the patients' weight was significantly greater than the weight limit of the angiography table, necessitating insertion under CT fluoroscopic guidance.     

Outcomes with retrievable inferior vena cava filters: a multicenter study

PURPOSE: To retrospectively review the outcomes after placement and retrieval of retrievable inferior vena cava (IVC) filters at two academic medical centers. MATERIALS AND METHODS: All patients who underwent retrievable filter placement between May 2001 and December 2005 were included. Hospital records at both institutions were reviewed, and relevant data were collected concerning the placement and retrieval of all removable filters. RESULTS: A total of 197 patients underwent placement of a retrievable IVC filter. Of those, 143 patients (72.5%) had Günther Tulip filters (GTFs) placed, and 54 patients (27.5%) had Recovery filters placed. A total of 94 patients underwent attempted filter retrieval, accounting for just less than half of all retrievable filters placed during the study period (47.7%). Retrievals were successful in 80 patients (85.1%). Half the retrieval failures (n = 7) were the result of thrombus within the filter, and technical difficulties (eg, filter embedded in IVC wall, tilted filter) were the cause of retrieval failure in the other half. There was no significant difference in retrieval failure rates between the GTF and Recovery filter (16.4% vs 9.5%, respectively). GTFs were removed after a median implantation time of 11 days (range, 1-139 d), whereas Recovery filters were removed after a median implantation time of 28 days (range, 6-117 d). CONCLUSIONS: Placement and retrieval of nonpermanent IVC filters can be performed safely with a high technical success rate. In patients at high risk for venous thromboembolism and contraindication to anticoagulation, retrievable filters may be used aggressively to prevent the potentially devastating outcome of pulmonary embolism.     

The use of inferior vena cava filters in young children

The present report describes the authors' experience with the placement and retrieval of inferior vena cava (IVC) filters in children with a maximum IVC diameter of 1 cm. Over a 14-month period, three filters were placed in three children. Two filters were placed via the right internal jugular vein, with one placed via the right femoral vein. The filters were deployed successfully in all three children and retrieved in two. In one case, the child was receiving palliative care and removal was not attempted. No complications were encountered during placement, the period of implantation, or retrieval.     

Computerized tomography in the follow-up of inferior vena cava filters

CT was employed to evaluate IVC filters in 37 patients; most devices (25) were Greenfield filters. Filters were localized below the renal veins in 26 patients; a suprarenal position was observed in 11 cases. Filter malpositioning was shown by CT in 1 case (filter partially located in the left renal vein); migration of the device into left pulmonary artery was detected in 1 patient. IVC perforation occurred in 11 cases--in 6 of them, the filter penetrated into adjacent structures (duodenum in 2 cases, abdominal aorta in 2, liver in 1, and right kidney in 1 patient). IVC thrombosis was seen in 16 patients; complete caval obstruction developed in 2 cases two or more years after filter positioning. IVC perforation caused by a filter is a frequent complication (30% of our series), but in most cases it is asymptomatic and has no significant clinical relevance; surgical removal of the filter had to be performed in 3 cases only. CT scanning is a valuable adjunct to plain abdominal radiography in the follow-up of IVC devices, when a complication (especially IVC perforation) is suspected.     

滤器置入后症状性下腔静脉血栓形成的介入治疗

目的 评估局部置管溶栓治疗滤器置入后症状性下腔静脉血栓形成的疗效和安全性.方法 2005年10月至2009年9月采用局部置管溶栓治疗滤器置入后症状性下腔静脉血栓形成患者4例,累及8条肢体.经右颈内静脉置入下腔静脉滤器后,采用导丝及导管开通闭塞的下腔静脉并置管溶栓治疗.血栓消融后分别经骨静脉或颈内静脉取出滤器.记录技术成...     

Technical problems associated with placement of the Bird's Nest inferior vena cava filter.

Technical problems encountered during percutaneous placement of 165 Bird's Nest filters over 16 months are described. Filter deployment was successful in all patients. Although frequent, the technical problems were all minor with no long-term sequelae. Several problems were inherent to the design of the filter. Other problems related to the patient's anatomy were seen as well. Because deployment of the Bird's Nest filter is more operator-dependent than is deployment of other types of inferior vena cava filters, knowledge of pitfalls and means to avoid problems are particularly important.     

Anomalous inferior vena cava with lumbar vein thrombosis: CT diagnosis

A case of thrombosis of the ascending right lumbar vein in a patient with infrahepatic interruption of the inferior vena cava and azygos-hemiazygos continuation is reported and the CT findings are described.