Selective venography versus nonselective venography before vena cava filter placement: evidence for more, not less

OBJECTIVE: We undertook this study to determine whether additional use of selective venography, compared with nonselective venography alone, reveals more abnormal anatomic venous findings that lead to changes in vena cava filter (VCF) position. METHODS: From January 1998 to June 2002, 94 patients underwent VCF placement by vascular surgeons at a university tertiary care center. Indications, techniques, decision analysis, and complications were reviewed. Nonselective venography and selective venography of the inferior vena cava (IVC) were evaluated for image quality, abnormal findings, aberrant anatomy, and the anatomic relationship of vertebral bodies to major venous tributaries. RESULTS: Absolute and relative indications for VCF placement were 44% and 56%, respectively. Jugular, femoral, and subclavian vein approach was used in 47%, 47%, and 6% of patients, respectively. Seventy-three percent of VCFs were placed in the catheterization laboratory, 21% in the operating room, and 5% at the bedside. Nonselective venography was performed in 80 patients (85%), of whom 44% had undergone selective venography. At nonselective venography plus selective venography 7.5% of patients had an abnormal finding (IVC compression, n = 3; IVC thrombus, n = 2; tortuosity, n = 1). Similarly, 17.5% of patients had aberrant anatomy (accessory renal vein, n = 8; IVC duplication, n = 3; large low right gonadal vein, n = 2; megacava, n = 2). Nonselective venography plus selective venography demonstrated that 16% of VCFs required a major change in position, 10% of which were placed above the renal veins. Compared with nonselective venography alone, selective venography enabled detection of significantly more abnormal and aberrant findings (9% vs 49%; P <.001). Changes in VCF placement were necessary significantly more often in patients undergoing additional selective venography compared with nonselective venography alone (31% vs 4%; P =.003). In one patient in the series, a VCF was malpositioned in the iliac vein with intravascular ultrasound visualization. CONCLUSION: When nonselective venography plus selective venography were performed, 23% of patients had either an abnormal finding or aberrant anatomy, and most of these required a major change in VCF position. Nonselective venography plus selective venography redefines the criterion standard and, because of limitations of other methods of vena cava visualization for VCF deployment, should be performed in most patients.