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DOI:10.2214/AJR.05.1401
AJR 2007; 188:1039-1043
© American Roentgen Ray Society

Clinical Observations

Venographic Findings at Retrieval of Inferior Vena Cava Filters

Christoph A. Binkert1, Megan Chew Morash1 and Jonathan D. Gates2

1 Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115.
2 Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Received August 11, 2005; accepted after revision October 25, 2005.

 
Address correspondence to C. A. Binkert (cbinkert{at}partners.org).


Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
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.

Keywords: embolism • implantable devices • inferior vena cava filter • venography


Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
The standard therapy for venous thromboembolic disease is anticoagulation [1]. In cases in which anticoagulation is contraindicated, an inferior vena cava (IVC) filter can be placed to prevent pulmonary embolism. In certain populations, such as trauma patients, the contraindication to anticoagulation is temporary. For these patients, retrievable or optional filters have been introduced. The term "optional" indicates that these filters are permanent with the option for removal if clinically indicated. Three optional IVC filters have been approved by the U.S. Food and Drug Administration: the Recovery removal system (Bard Peripheral Vascular), the Günther Tulip vena cava filter (Cook Incorporated), and the OptEase retrievable vena cava filter (Cordis). The feasibility and safety of retrieval of these filters have been described previously [2-6].The purpose of the present study was to evaluate the IVC at the time of IVC filter retrieval.


Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Patients
The local institutional review board approved this retrospective study. All 66 patients who underwent attempted IVC filter retrieval between June 2003 and June 2005 at our institution were included. The mean age was 46 years with an age range of 15-82 years. One half of the patients were female (n =33). The main indication for retrievable filter placement was temporary contraindication to anticoagulation secondary to trauma (n = 35) or surgery (n = 24). Deep venous thrombosis (DVT) was documented in four of the 35 trauma patients and in 14 of the 24 perioperative patients. One patient in the perioperative group had documented pulmonary embolism (PE). The indications for filter placement in the other seven cases were preparation for catheter-directed thrombolysis (n = 3) and management of bleeding during anticoagulation therapy for pulmonary emboli (n = 3) and iliofemoral DVT during pregnancy (n =1). The following types of retrievable filters were used: Recovery (n = 46), Günther Tulip (n = 18), and OptEase (n = 2). Both patients with the OptEase filter had occluded upper extremity veins. The OptEase filter is the only retrievable filter that can be placed and retrieved through a femoral vein approach.

The mean dwell time of the filters was 102 days with a range of 2-408 days. Anticoagulation was no longer contraindicated in all patients at the time of attempted filter retrieval. At the time of retrieval, 26 patients were receiving anticoagulation therapy with warfarin. Warfarin therapy was not reversed for the retrieval procedure but was adjusted so that the international normalized ratio was less than 2.5 at the time of the procedure.

Technique
Inferior venacavography was performed at the beginning of every attempt at IVC filter retrieval. This venogram was compared with the venogram obtained during filter placement in regard to filter location and IVC diameter. If stenosis was detected, the smallest diameter was measured and compared with the diameter of the nearest normal segment. The right internal jugular vein was used for access in patients with a Recovery or Günther Tulip filter and the right femoral vein in the two patients with an OptEase filter. A 5-French pigtail catheter was positioned below the filter.

Digital subtracted angiographic images were obtained in a frontal projection during power injection of contrast material (iopromide, Ultravist, Berlex) at a rate of 15-20 mL/s for a duration of 2 seconds. The Günther Tulip and OptEase filters were retrieved with a loop snare (Amplatz gooseneck snare, Microvena). A dedicated retrieval cone was used for the Recovery filters. To assess the complexity of the retrieval procedure, the fluoroscopy times were recorded. A second IVC venogram with the same parameters as for the previous images was obtained in the case of successful filter retrieval. When an IVC abnormality was encountered, a follow-up clinic visit, which included a brief physical examination, history interview, and venography, was scheduled for 3 months after retrieval.


Figure 1
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  		Fig. 1A —56-year-old woman who had undergone resection of carotid cavernous fistula and received inferior vena cava filter after detection of peroneal deep venous thrombosis. Venogram at retrieval shows large clot trapped in filter.

 


Figure 2
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  		Fig. 1B —56-year-old woman who had undergone resection of carotid cavernous fistula and received inferior vena cava filter after detection of peroneal deep venous thrombosis. Follow-up venogram shows clot has dissolved. Patient wanted to keep filter.

 


Figure 3
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  		Fig. 2A —56-year-old man who received inferior vena cava (IVC) filter because of severe epistaxis during anticoagulation for pulmonary embolism. Arrowhead indicates inflow of right renal vein. Venogram before retrieval shows filter tilted to IVC wall (arrow).

 


Figure 4
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  		Fig. 2B —56-year-old man who received inferior vena cava (IVC) filter because of severe epistaxis during anticoagulation for pulmonary embolism. Arrowhead indicates inflow of right renal vein. Venogram after retrieval shows stenosis present where tip (arrow) of filter had been.

 


Figure 5
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  		Fig. 2C —56-year-old man who received inferior vena cava (IVC) filter because of severe epistaxis during anticoagulation for pulmonary embolism. Arrowhead indicates inflow of right renal vein. Follow-up venogram shows normal findings.

 

Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Normal inferior cavographic findings, including no filter migration, were observed in 58 of 66 cases. An abnormal finding was detected in eight (12%) of 66 patients. In three (4.5%) of the patients, a clot was found trapped within the filter after short filter dwell times of 11, 14, and 21 days (Fig. 1A). One of these patients received the filter prophylactically, one had only peroneal DVT, and one had a PE. IVC occlusion was found in one (1.5%) of the patients, who had a Recovery filter. This patient had extensive iliofemoral DVT at the time of filter placement. No retrieval attempt or follow-up was undertaken in that case.

In four (6%) of the patients, the IVC had 25-50% stenosis at the level of the filter (Figs. 2A and 3A). Stenosis was not present on the venogram at filter placement and was characterized by smooth narrowing of the IVC around the tip of the indwelling filter (Figs. 2B and 3B). No collateral drainage pathways were visible in any case. Stenosis occurred in three (6.5%) of 46 Recovery filters and in one (5.5%) of 18 Günther Tulip filters. The dwell times of these filters (mean, 110 days; range, 21-262 days) were comparable with those of the overall study population. In three of these patients, the filter was placed prophylactically; one patient had a PE. Anticoagulation was not administered for IVC stenosis. Only the patient with PE continued anticoagulation therapy.


Figure 6
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  		Fig. 3A —47-year-old male trauma patient who received inferior vena cava filter for intracranial hemorrhage and multiple fractures. Venogram before retrieval shows filling defect around filter tip (arrow).

 

Figure 7
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  		Fig. 3B —47-year-old male trauma patient who received inferior vena cava filter for intracranial hemorrhage and multiple fractures. Venogram after retrieval shows irregular stenosis (arrow) remains.

 


Figure 8
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  		Fig. 3C —47-year-old male trauma patient who received inferior vena cava filter for intracranial hemorrhage and multiple fractures. Follow-up venogram shows stenosis but with smoother contour (arrow) than in B.

 
All but four filters were successfully removed. The reasons for failed retrieval were IVC occlusion in one patient and filter tip embedded into the IVC wall in three cases. Two of the embedded filter tips were on a Recovery filter and one on a Günther Tulip filter.

Venography after filter retrieval showed two new abnormalities not visible on the venogram before retrieval: one case of 20% stenosis of the IVC and one IVC wall injury. The wall injury was characterized by a new sharply delineated horizontal IVC wall irregularity with a small amount of contrast material visible outside the IVC lumen (Fig. 4A). Both abnormalities were seen at the level of the secondary strut wrapping the leg of the Günther Tulip filter after dwell times of 49 (Fig. 4B) and 317 days. The patient with the IVC injury was treated with warfarin for 3 months. The fluoroscopy times for these two retrievals were 4.1 and 5 minutes, respectively, indicating a fairly straightforward retrieval procedure. The median fluoroscopy time of the other retrievals was 4.1 minutes (range, 2.1-52 minutes). Fluoroscopy times longer than 20 minutes (31.4, 42, and 52 minutes) were recorded for three patients. In these cases, the tips of two Günther Tulip filters and one Recovery filter were positioned against the IVC wall. The filter was removed with a Sos catheter (AngioDynamics) and a guidewire snared around the tip of the filter.


Figure 9
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  		Fig. 4A —33-year-old woman who had undergone intracranial aneurysm clipping received inferior vena cava (IVC) filter for recent pulmonary embolism. Venogram after filter retrieval, which required increased force, shows sharply delineated IVC wall abnormality with small amount of contrast material (arrow) outside IVC lumen. Arrowhead indicates indentation of right common iliac artery.

 

Figure 10
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  		Fig. 4B —33-year-old woman who had undergone intracranial aneurysm clipping received inferior vena cava (IVC) filter for recent pulmonary embolism. Photograph of explanted Günther Tulip (Cook Incorporated) filter shows residual tissue (arrows) that has grown between legs and secondary wire.

 
None of the patients except the one with IVC occlusion, who had moderate bilateral leg swelling, had symptoms related to IVC abnormality. Details on all patients with IVC abnormalities are summarized in Table 1.


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  		TABLE 1: Patients with Abnormalities of the Inferior Vena Cava (IVC)

 


Figure 11
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  		Fig. 4C —33-year-old woman who had undergone intracranial aneurysm clipping received inferior vena cava (IVC) filter for recent pulmonary embolism. Follow-up venogram shows IVC irregularity is no longer visible. Arrowhead indicates indentation of right common iliac artery.

 
Follow-up venograms were available for nine of 10 abnormalities. One patient with stenosis detected before retrieval refused follow-up venography. The clot trapped within the IVC filter resolved with anticoagulation in all three patients (Fig. 1B). In two patients, the filter was subsequently retrieved; one patient wanted to keep the filter in place. The IVC diameter improved in two of three patients with stenosis before filter retrieval (Fig. 2C). In one patient, the stenosis remained unchanged, but the area of stenosis was smoother on the follow-up venogram (Fig. 3C). The stenosis that occurred after filter retrieval and the one IVC wall injury were no longer visible on follow-up venograms (Fig. 4C).


Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
The concept of retrievable IVC filters is more than 30 years old [7]. It has been supported by the observation of Decousus et al. [8] that patients with IVC filters have a reduced rate of PE within the first 12 days after filter placement but an increased rate of DVT 2 years after placement. An 8-year update [9] of the study by Decousus et al. showed continuous reduction in the incidence of PE, which, however, was counterbalanced by an increased rate of DVT.

Most reported series of retrievable IVC filters have short dwell times of less than 4 weeks [4, 5, 10]. Longer dwell times are clinically desirable in certain patients, such as those with prolonged immobility or with inaccessible jugular veins because of the presence of a cervical collar. Prolonged filter dwell times have been described. Terhaar et al. [2] reported prolonged implantation times of 7-126 days (mean, 44 days), and Imberti et al. [11] reported times of 30-345 days (mean, 123 days). The latter implantation times are similar to ours (mean, 102 days; range 2-408 days).

Trapped clot within the filter has been found at the time of attempted retrieval [2-4]. The reported percentages of trapped clot tend to be higher in series with shorter implantation periods, such as those of Wicky et al. [3] (19%; mean implantation time, 8 days) and Millward et al. [4] (11%; mean implantation time, 9 days), compared with series with longer dwell times, such as those of Terhaar et al. [2] (4%; mean implantation time, 44 days) and our study (4.5%; mean implantation time, 102 days). The higher incidence of trapped clot after a shorter dwell time is in concordance with the findings of Decousus et al. [8] who described a high incidence of PE within the first 12 days after filter implantation. The lower incidence of trapped clot after a longer dwell time may be explained by dissolving of the clot over time, especially in patients receiving anticoagulants. This hypothesis is supported by our findings. Trapped clot was found after relatively short dwell times and dissolved with anticoagulation in all three patients who had clot trapped in the filter.

IVC occlusion is a known complication of IVC filters. In a large retrospective study, Athanasoulis et al. [12] found an overall IVC occlusion rate of 3.2%, which is higher than the 1% in our population. In addition to IVC occlusion, however, in four patients (6%) we found IVC stenosis at the level of the IVC filter that was independent of filter design. Stenosis was present in 6.5% of Recovery filters and 5.5% of Günther Tulip filters. The stenosis occurred where the filter was touching the IVC wall. This stenosis was detected after rather long dwell times of 21-262 days (mean, 110 days), which may explain why other human studies with shorter dwell times did not encounter the problem. Stenosis of the IVC has been described in an animal study [13] of the Tempofilter (B. Braun), which has a large area of contact with the IVC wall.

The exact cause of IVC filter occlusion is unclear. Athanasoulis et al. [12] postulated that occlusion is caused by entrapment of emboli rather than by thrombus formation around the filter. This hypothesis is likely true for our patient with IVC occlusion and extensive preexisting iliofemoral DVT at the time of filter placement. However, our finding of IVC stenosis at the level of the filter may explain a different mechanism of IVC occlusion. After successful filter retrieval, IVC stenosis resolved in two patients and remained unchanged in one patient. Brountzos et al. [14] similarly found IVC narrowing after a 12-week dwell time of Recovery filters in sheep. The IVC diameter improved 8 weeks after retrieval. In that animal study, stenosis was found to be caused by intimal thickening, which resolved after filter explantation.

Two new abnormalities were seen after retrieval of Günther Tulip filters. In both cases, the damage occurred where the secondary strut loops around the filter leg allowed tissue to grow in over time. This tissue had to be torn apart during retrieval, which led to one mild case of stenosis and one IVC wall injury. The Recovery filter has separate arms and legs without a connecting wire. This design seems less likely to allow tissue ingrowth, which explains why no IVC abnormalities were found after retrieval of Recovery filters.

In conclusion, abnormal findings are infrequent on IVC venography at filter retrieval. Abnormalities after filter retrieval include trapped clot in the filter, IVC stenosis, and IVC wall injury. Trapped clot resolved effectively with anticoagulation. IVC stenosis resolved or at least stabilized over time without further treatment.


References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Buller HR, Agnelli G, Hull RD, Hyers TM, Prins MH, Raskob GE. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126 [suppl 3]:401S -428S[Erratum in[Abstract/Free Full Text]Chest 2005;127 : 416
  2. Terhaar OA, Lyon SM, Given MF, Foster AE, McGrath F, Lee MJ. Extended interval for retrieval of Günther Tulip filters. J Vasc Interv Radiol 2004; 15:1257 -1262[CrossRef][Medline]
  3. Wicky S, Doenz F, Meuwly JY, Portier F, Schnyder P, Denys A. Clinical experience with retrievable Günther Tulip vena cava filters. J Endovasc Ther 2003;10 : 994-1000[CrossRef][Medline]
  4. Millward SF, Oliva VL, Bell SD, et al. Günther Tulip retrievable vena cava filter: results from the Registry of the Canadian Interventional Radiology Association. J Vasc Interv Radiol 2001; 12:1053 -1058[Medline]
  5. Hoff WS, Hoey BA, Wainwright GA, et al. Early experience with retrievable inferior vena cava filters in high-risk trauma patients. J Am Coll Surg 2004;199 : 869-874[CrossRef][Medline]
  6. Asch MR. Initial experience in humans with a new retrievable inferior vena cava filter. Radiology2002; 225:835 -844[Abstract/Free Full Text]
  7. Williams RW, Schenk WG Jr. A removable intracaval filter for prevention of pulmonary embolism: early experience with the use of the Eichelter catheter in patients. Surgery1970; 68:999 -1008[Medline]
  8. Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deepvein thrombosis: Prevention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group. N Engl J Med1998; 338:409 -415[Abstract/Free Full Text]
  9. PREPIC Study Group. Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d'Embolie Pulmonaire par Interruption Cave) randomized study. Circulation 2005;112 : 416-422[Abstract/Free Full Text]
  10. Rosenthal D, Wellons ED, Levitt AB, Shuler FW, O'Conner RE, Henderson VJ. Role of prophylactic temporary inferior vena cava filters placed at the ICU bedside under intravascular ultrasound guidance in patients with multiple trauma. J Vasc Surg 2004;40 : 958-964[CrossRef][Medline]
  11. Imberti D, Bianchi M, Farina A, Siragusa S, Silingardi M, Ageno W. Clinical experience with retrievable vena cava filters: results of a prospective observational multicenter study. J Thromb Haemost 2005; 3:1370 -1375[CrossRef][Medline]
  12. Athanasoulis CA, Kaufman JA, Halpern EF, Waltman AC, Geller SC, Fan CM. Inferior vena caval filters: review of a 26-year single-center clinical experience. Radiology 2000;216 : 54-66[Abstract/Free Full Text]
  13. Kuszyk BS, Venbrux AC, Samphilipo MA Jr, Magee CA, Olson JL, Osterman FA Jr. Subcutaneously tethered temporary filter: pathologic effects in swine. J Vasc Interv Radiol 1995;6 : 895-902[Medline]
  14. Brountzos EN, Kaufman JA, Venbrux AC, et al. A new optional vena cava filter: retrieval at 12 weeks in an animal model. J Vasc Interv Radiol 2003; 14:763 -772[Medline]

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