DOI:10.2214/AJR.05.0253
AJR 2006; 187:575-578
© American Roentgen Ray Society
Complicated Inferior Vena Cava Filter Retrieval Using an Amplatz Snare Device
Charles E. Ray, Jr.1 and
C. Clay Cothren2
1 Department of Interventional Radiology, Denver Health Medical Center, 777
Bannock St., Mail Code 0024, Denver, CO 80204.
2 Department of Surgery, Denver Health Medical Center, Denver, CO.
Received February 16, 2005;
accepted after revision March 23, 2005.
Address correspondence to C. E. Ray, Jr.
(cray{at}dhha.org).
Keywords: implantable devices • inferior vena cava filter • venography
Introduction
Percutaneous placement of retrievable inferior vena cava (IVC) filters is
becoming increasingly common. Although early studies promoted placement of IVC
filters
[1-5],
long-term results of such devices is lacking. Some express concern that the
devices may be overused, particularly when placed prophylactically or in
younger individuals (< 30 years old in some instances) in whom the filter
cannot be removed. In this article, we describe a complication of removal of
one of the commercially available retrievable IVC filters to remind
practitioners of the potential morbidity associated with these devices.
Case Report
A 46-year-old morbidly obese man presented to the emergency department
complaining of left lower quadrant pain for 2 days. He underwent
contrast-enhanced CT of the abdomen and pelvis, which showed duodenal
thickening, intraperitoneal free air, and extravasation of oral contrast
material into his peritoneum. Operative exploration revealed a perforated
duodenal ulcer, which was repaired with a Graham patch.
His postoperative course was complicated by respiratory compromise, acute
renal failure superimposed on chronic renal insufficiency, mild liver
dysfunction, and a second operation related to a breakdown of his prior
repair. Because of the patient's immobility and protracted ICU course and his
significant associated comorbidities, he was placed on prophylactic
anticoagulation with low-molecular-weight heparin (LMWH) to prevent deep
venous thrombosis (DVT). After the initiation of LMWH, his platelet count
dropped to 126,000/µL, and he was subsequently diagnosed with
heparin-induced thrombocytopenia. Direct thrombin inhibitors were considered
but not used because of the patient's underlying renal and hepatic
insufficiency. Because of his high risk for the development of DVT and
pulmonary embolus (PE) and his poor cardiopulmonary reserve, interventional
radiology was consulted for placement of a prophylactic retrievable IVC
filter.
In the angiography suite, right internal jugular vein access was obtained
with sonographic guidance. A 5-French pigtail catheter was placed into the
right iliac vein, and venography was performed with nonionic iodinated
contrast material. The pigtail catheter was exchanged for a Günther Tulip
IVC filter deployment sheath (Cook) over a standard length (150-cm) stainless
steel wire. Because of the length of the catheter and wire, the wire was
withdrawn to the suprarenal IVC during removal of the pigtail catheter. The
filter deployment sheath was advanced to the level of the third lumbar
vertebra, and the filter was deployed in standard fashion. Because of the
patient's morbid obesity, the filter was barely visible; when a spot film of
the abdomen was obtained, it was noted that the filter legs had not deployed.
A repeat contrast injection of the IVC was obtained, and it was noted that the
filter was outside the wall of the IVC
(Fig. 1A), presumably in the
right gonadal or ascending lumbar vein. Because the apex of the filter
extruded into the IVC, the decision was made to snare the filter and
reposition it into the IVC.
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Fig. 1A —46-year-old morbidly obese man presented to emergency
department complaining of left lower quadrant pain for 2 days. Posteroanterior
view of digital subtraction vena cavagram after initial filter deployment
shows malposition of filter.
|
|
Via the 10-French filter deployment sheath, a 35-mm Amplatz gooseneck snare
device (GN500, EV3) was placed adjacent to the filter in standard fashion.
With minimal difficulty, the filter hook was snared and the device was
captured by advancing the 10-French sheath. The sheath-filter system was
replaced to the infrarenal IVC, and the filter was redeployed
(Fig. 1B). Multiple attempts at
removing the snare from the filter hook proved unsuccessful. Neither
manipulating (advancing, retracting, rotating) the snare device nor
resheathing the entire system facilitated snare removal. After several
minutes, a safety wire was placed into the IVC via the outer sheath, adjacent
to the indwelling filter, and the entire sheath-filter-snare system was
removed. A new Günther Tulip deployment sheath was advanced into the
infrarenal IVC, and a filter was deployed in standard fashion.
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Fig. 1B —46-year-old morbidly obese man presented to emergency
department complaining of left lower quadrant pain for 2 days. Magnified
posteroanterior unsubtracted image obtained after device capture using snare
device shows that snare could not be removed from filter apex to deploy it
into inferior vena cava.
|
|
The first filter was deployed on the angiographic table. It was noted that
the radiopaque marker from the distal end of the snare catheter had dislodged
and engaged the hook of the IVC filter, trapping the snare between the hook
apex and the radiopaque band (Figs.
2A,
2B, and
2C).
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Fig. 2B —Images obtained after removal of entire snare retrieval
system and filter. Close-up image of apex of filter shows that snare is
entrapped by metal band that had dislodged from snare system catheter.
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Fig. 2C —Images obtained after removal of entire snare retrieval
system and filter. Photograph shows distal end of snare catheter (left) used
during procedure. Radiopaque inner metal band on catheter could not be
visualized during procedure. Second catheter (right), which was not used, is
shown for comparison.
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The patient had a normal postprocedure course; of note, his hematocrit
remained stable after the IVC filter placement (24.3% vs 23.6%, pre- and
postprocedure, respectively). The filter was removed without complication 9
days after placement, once the patient was transitioned from lepirudin and put
on therapeutic warfarin sodium (Coumadin, Upsher-Smith Labs). He remains in
stable condition 16 days after his initial filter placement.
Discussion
The availability of retrievable IVC filters has changed the clinical
indications and practice of filter placement. More filters are now being
placed in patients for indications such as prophylaxis in high-risk
populations who historically would not have undergone placement of permanent
devices [1,
2]. In many of these instances,
the temporary nature of the filter is the primary reason it is placed, acting
as a bridge during the time frame of high clinical risk for PE. In addition,
filters may be used prophylactically when traditional short-term DVT
prophylaxis, such as LMWH, is contraindicated because of solid organ injury or
intracranial hemorrhage. However, it is known that a certain percentage of
these filters cannot be removed, often related to technical factors such as
filter tilt or incorporation into the IVC wall
[3-5].
Three commercially available retrievable IVC filters are currently
available in the United States. Two of these filters (the Günther Tulip
and the Opt-Ease [Cordis]) require removal by a standard snare retrieval
system as used in this instance; the Recovery filter (Bard Peripheral
Vascular) uses a different recovery-capture system. In our practice, the
Amplatz gooseneck snare is used in all instances to retrieve both the
Günther Tulip and the Opt-Ease filters.
Inadvertent placement of IVC filters in a gonadal vein is a rare but
recognized complication of filter placement from a jugular vein approach
[6]. Invariably, the cause of
insertion into the gonadal or ascending lumbar vein is either the lack of
predeployment venography or, as in this case, losing access to the lumen of
the IVC during the procedure. Once the lumen of the IVC is catheterized, care
should be taken to maintain that access. One way to accomplish this is to use
an exchange-length guidewire (e.g., 180-260 cm in length) or to use a shorter
diagnostic angiographic catheter (< 75 cm) to facilitate exchange for the
filter delivery system. Finally, a small injection of contrast material just
before filter placement can be performed to confirm filter placement within
the IVC just before deployment.
The Amplatz gooseneck snare is available in a variety of sizes; which one
is used depends on the size of the vessel in which the snare is deployed.
Included in the snare kit is the catheter through which the snare itself is
advanced, and against which the snare is tightened during foreign body
retrieval. This catheter (which is 6-French in the snare used in the case
presented here but is 4-French in the smaller snares) has a radiopaque metal
band at the end of the catheter to facilitate fluoroscopic visualization. This
band is stamped on the inside of the catheter rather than on the outside or
integrated into the catheter itself during manufacture. Because of this
internal location, the band is prone to shear from the catheter by
manipulations within the lumen of the catheter, as noted in the case presented
here.
Options to prevent the complication noted here include using a different
directional outer catheter that does not have the radiopaque band while
deploying the snare or using a different snare system entirely. Medical Device
Technologies produces a triple-loop snare system (EN Snare system) with the
radiopaque band impressed on the outside of the guide catheter. We have no
experience using this device for IVC filter retrieval. Any nontapered 6-French
catheter, such as a guiding catheter, could be used in lieu of the catheter
provided with the snare system. Care should be taken, however, because many of
these guiding catheters also have radiopaque bands at the distal end of the
catheter. To our knowledge, the type of complication described here has not
been reported when using these sheaths or guiding catheters for other
indications.
In summary, this case shows a newly reported complication of retrieval of
an IVC filter. Recognition of this technical issue and the use of alternative
snare systems may prevent future difficulties with IVC filter retrieval.
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Introduction
Case Report
