Recurrent Deep Vein Thrombosis (DVT) and Inferior Vena Cava (IVC) Filter: Should a Computed Tomography (CT) Venogram and Inferior Vena Cavagram Be the Standard of Care?

A pulmonary embolism (PE) is a life-threatening complication of deep vein thrombosis (DVT). Although timely anticoagulation is the first-line treatment for DVT, an inferior vena cava (IVC) filter can be considered when anticoagulation is contraindicated. Unfortunately, IVC filters come with complications of their own, including thrombus formation in or around the filter. An 89-year-old man with a past medical history of coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, and prior DVT status post IVC filter implantation five years ago in 2018 presented with hypotension, dizziness, and syncope. Computed tomography angiography (CTA) of the chest showed bilateral PEs. Venous Doppler ultrasound of the bilateral lower extremities was negative for DVT. CT venogram was performed; however, the contrast filling was suboptimal and as such, a venous thrombosis could not be ruled out. Therefore, an inferior vena cavagram was performed through the right common femoral vein and confirmed a large thrombus positioned cephalad to the IVC filter. A thrombectomy was performed and the IVC filter was replaced given the patient was at high risk for venous thromboembolism recurrence and complications.  Although an IVC filter offers some protection from recurrent PEs, it does have risks and complications. As seen in our patient, the IVC filter can be a nidus for the formation of a thrombus which has the risk of dislodging. When evaluating a patient for the source of a PE, it is important to consider prior IVC implant and perform further workups, such as a CT venogram or an inferior vena cavagram, to evaluate for thrombus in or around the filter.

Positional priapism and scrotal swelling: An unusual presentation of IVC filter associated thrombosis and May-Thurner syndrome.

Scrotal edema and positional priapism are uncommon chief complaints with a scant differential. May-Thurner syndrome as well as inferior vena cava thrombosis are not often associated with these symptoms. This report outlines the case of a 50-year-old male who has undergone pulmonary artery thrombectomy and inferior vena cava filter placement. He presents with a chief complaint of scrotal swelling and positional priapism, likely low-flow priapism. Upon further work up, in-filter thrombosis was identified, likely attributed to a lack of anticoagulation and May-Thurner syndrome was diagnosed. The patient subsequently underwent thrombolysis and thrombectomy and was found to have May-Thurner syndrome which was treated with left iliac vein stenting.

A Rare Case of Right Atrial Thrombus in a Patient With Recurrent Classical Hodgkin Lymphoma.

Patients with cancer are at risk for thrombotic complications due to a hypercoagulable state. However, the benefit of prophylactic anticoagulation is unclear in many subsets of these patients. For the first episode of acute thromboembolic disease (VTE) in patients with active cancer, anticoagulant therapy is administered for at least three to six months. Herein, we present a 31-year-old female with active, recurrent stage IIIa classical Hodgkin lymphoma (CHL) (nodular sclerosis), previously treated for proximal upper extremity deep vein thrombosis (DVT), presenting for evaluation of shortness of breath and eventually diagnosed with bilateral pulmonary embolism (PE) secondary to a right atrial thrombus. The patient was successfully treated with surgical resection of the thrombus. With this case report, we hope to encourage physicians to use prophylactic indefinite anticoagulation in patients with active cancer and previous DVT, including patients with upper extremity DVT.

The Degree of Inferior Vena Cava Filter Tilt Associated with Challenging Retrieval.

OBJECTIVE: Inferior vena cava (IVC) filter tilt is associated with technical difficulties at the time of retrieval. However, the degree of tilt that predisposes patients to undergo complex or failed retrieval has not been defined. METHODS: The electronic charts of patients undergoing IVC filter removal between 2010 and 2019 at a single tertiary center were reviewed. Patient and procedural characteristics were recorded. Venograms of placement and retrieval procedures were reviewed, and IVC filter tilt was determined based on its deviation from the IVC axis. IVC diameter and the distance from the lowest renal vein were measured using corresponding filter's length for calibration. All measurements were performed by 3 reviewers and confirmed by 2 reviewers. Patients were divided into 2 groups: those who underwent successful removal procedures requiring standard retrieval methods ("simple retrieval group") and those who required advanced endovascular techniques or had failed completely IVC filter retrievals ("challenging retrieval group"). A regression analysis was performed to determine factors associated with challenging retrieval. RESULTS: There were 365 patients who underwent IVC filter retrieval (n=294 (80.6%) and n=71 (19.4%) in the simple and challenging groups, respectively) with no difference in age, sex, comorbidities or indication between the 2 groups. Failed retrieval occurred in 21 patients (5.8%) and was more common among patients requiring advanced endovascular techniques compared to standard techniques (18.0% vs. 3.2%, p < 0.001). In the overall cohort, the mean filter tilt at the time of retrieval was 4.9° ± 4.4° [0 - 27°], and 145 patients (39.7%) had a filter tilt ≥ 5.0°. Compared to the simple retrieval group, patients in the challenging group had significantly longer dwell time, greater tilt of IVC filter during placement and retrieval, as well as higher tilt change between the 2 venograms. There was no correlation between the access site during placement and challenging retrieval. However, patients undergoing filter placement via right jugular vein had lower filter tilt as compared to femoral access. Patients with filter tilt ≥ 5.0° were more likely to have a challenging filter retrieval compared to patients with ˂ 5.0° tilt (29.7% vs 12.7%, p<0.001). Regression analysis showed that tilt ≥ 5.0° (OR=1.18 [1.11-1.25]), dwell time (OR=1.04 [1.01-1.07]), and age (OR=0.97 [0.95-0.99]) were independently associated with challenging retrieval. CONCLUSION: IVC filter tilt ≥ 5.0°, dwell time and age are associated with challenging retrieval. Right jugular vein access, multiple imaging projections, and careful filter manipulation during deployment should be considered to maintain tilt at ˂ 5.0° and decrease the likelihood of challenging retrieval.

A baffling case of inferior vena cava filter removal in a patient with transposition of the great arteries.

A 47-year-old man with a history of transposition of the great arteries after a Mustard atrial switch procedure and prior inferior vena cava filter placement for venous thromboembolism presented for removal before being listed for orthotopic heart transplantation in anticipation of cardiopulmonary bypass cannulation. The filter was retrieved using a right transjugular approach without disruption of his existing atrial baffle. Contingency planning in the event of unsuccessful baffle navigation included a transfemoral everted filter approach. A thorough understanding of unique patient anatomy and multidisciplinary team approach is critical to safe procedural intervention in patients with congenital cardiovascular anomalies.

Surgical removal of an inferior vena cava filter in the duodenum: A rare case report and literature review.

Background: Inferior vena cava filters are typically retrieved using endovascular procedures. However, in cases where complications related to the filter arise or when endovascular retrieval becomes challenging, open surgery could be considered. Case presentation: A 65-year-old woman underwent inferior vena cava filter placement surgery for progressive venous thrombosis embolism (VTE). Following an unsuccessful endovascular retrieval attempt at an external hospital two months later, she experienced abdominal pain and was transferred to our facility for further treatment. Examination revealed that she was encountered a complication where the inferior vena cava filter penetrated both the vena cava and the duodenum post-implantation. But fortunately, the patient's blood test results were within normal range. Ultimately, our institution successfully removed the filter through open surgery and the patient was discharged without any complications. Conclusions: This case, along with our literature review, illustrates the viability and safety of duodenal-penetrated filter removal via open surgery, resulting in favorable outcomes and a promising prognosis for the patient.

Delayed Arterial Hemorrhage From a Lumbar Artery Following Inferior Vena Cava Filter Placement: A Case Report.

Pulmonary embolism (PE) is a feared complication of deep venous thrombosis (DVT) that can lead to respiratory distress and even death. The mainstay of preventing PE is anticoagulation, but other strategies exist. Inferior vena cava (IVC) filters are an alternative strategy for PE prophylaxis in individuals who may have contraindications to receiving anticoagulation. Although the placement of an IVC filter is a minimally invasive and typically uncomplicated procedure, all procedures have their risks. We present a case of a 35-year-old woman who experienced a rare complication of IVC filter placement and suffered a retroperitoneal hemorrhage. The patient underwent placement of an IVC filter for PE prophylaxis before a scheduled sleeve gastrectomy. Hours after placement, she returned with new symptoms and signs of blood loss. She was found to have a retroperitoneal hematoma due to bleeding from a lumbar artery that was penetrated by a strut of the filter. Arterial hemorrhage from a lumbar artery is a rare complication of IVC filter placement, and it can result in poor outcomes for the patient. We aim to increase awareness of this rare but dangerous complication to improve recognition and patient outcomes in cases of delayed arterial hemorrhage following IVC filter placement.

The Role of IVC Filters in the Management of Acute Pulmonary Embolism.

Venous thromboembolism (VTE), comprising deep venous thrombosis (DVT) and pulmonary embolism (PE), is a prevalent cardiovascular condition, ranking third globally after myocardial infarction and stroke. The risk of VTE rises with age, posing a growing concern in aging populations. Acute PE, with its high morbidity and mortality, emphasizes the need for early diagnosis and intervention. This review explores prognostic factors for acute PE, categorizing it into low-risk, intermediate-risk, and high-risk based on hemodynamic stability and right ventricular strain. Timely classification is crucial for triage and treatment decisions. In the contemporary landscape, low-risk PE patients are often treated with Direct Oral Anticoagulants (DOACS) and rapidly discharged for outpatient follow-up. Intermediate- and high-risk patients may require advanced therapies, such as systemic thrombolysis, catheter-directed thrombolysis, mechanical thrombectomy, and IVC filter placement. The latter, particularly IVC filters, has witnessed increased usage, with evolving types like retrievable and convertible filters. However, concerns arise regarding complications and the need for timely retrieval. This review delves into the role of IVC filters in acute PE management, addressing their indications, types, complications, and retrieval considerations. The ongoing debate surrounding IVC filter use, especially in patients with less conventional indications, reflects the need for further research and data. Despite complications, recent studies suggest that clinically significant issues are rare, sparking discussions on the appropriate and safe utilization of IVC filters in select PE cases. The review concludes by highlighting current trends, gaps in knowledge, and potential avenues for advancing the role of IVC filters in future acute PE management.

Endovascular management of KILT syndrome and COVID-19-related extensive deep vein thrombosis in a pregnant patient: A case report.

We report on a 20-year-old pregnant woman who tested positive for SARS-CoV-2 and was diagnosed with KILT syndrome, a rare condition that increases the risk of thrombotic events. The patient showed signs of deep vein thrombosis that extended from the bilateral iliac vein to the inferior vena cava (IVC), which was treated with placement of an IVC filter and endovascular thromboaspiration/thrombolysis. The IVC was successfully recanalized; however, during follow-up, thrombotic restenosis occurred at the filter level, requiring filter removal. This case highlights the potential benefits of endovascular thromboaspiration/thrombolysis and IVC filter placement in patients with KILT syndrome presenting with acute thrombotic events.

Utilization Practices of Inferior Vena Cava Filters at an Academic Medical Center.

INTRODUCTION:  Anticoagulation is the mainstay of management for patients with venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). Inferior vena cava (IVC) filters are indicated in select patients who are not candidates for anticoagulation. There is a lack of quality evidence supporting other indications. In addition, long-term benefits and safety profiles of IVC filters have not been established. We investigated the utilization practice of IVC filters in a contemporary series of patients in a tertiary academic medical center. METHODOLOGY:  A retrospective review of 200 patients who received IVC filters at Virginia Commonwealth University (VCU) Medical Center in the years 2017 and 2018 was conducted. Adult patients 18 years of age or older with or without cancer were included, and patients were selected consecutively until data on 200 patients were collected. Data on patient demographics, an indication of IVC filter placement, filter retrieval rate, and re-thrombosis events over a median follow-up period of nine months were extracted from the electronic medical record and analyzed. RESULTS: A total of 200 patients (105 male and 95 female) were included with a median age of 61 years (range 17-92 years). Of the 200 patients, 97 (48.5%) had a DVT, 28 (14%) had a PE, 73 (36.5%) had both a PE and DVT, and 2 (1%) had thrombosis at other sites. A total of 130 (65%) patients had an IVC filter placed because of a contraindication to anticoagulation, while 70 (35%) had an IVC filter placed for other nonstandard indications, which included new or worsening VTE despite anticoagulation, recent VTE who must have anticoagulation held during surgery, primary prevention in high-risk patients, and extensive disease burden among other reasons. Seventy-two (36%) patients had active malignancy at the time of filter placement, and 64 (32%) were lost to follow-up. Of the 119 patients who were potentially eligible for filter retrieval, 55 (46%) patients had their IVC filters removed at a median of five months after insertion. Of the 55 patients who had IVC filters removed, 8 (14.5%) patients experienced a re-thrombosis event within a median follow-up of 39 months. Of the 145 patients who still had their filter in place at the time of death or last follow-up, 5 (3.4%) patients experienced a re-thrombosis event within a median follow-up of three months. CONCLUSIONS:  One-third of the patients in this series had an IVC filter placed without a standard indication, and less than half of them had the IVC filters removed within one year of placement. Additionally, one-third of the patients were lost to follow-up, highlighting the need for improved structured follow-up programs and education among both patients and providers regarding the indications for placement and retrieval to minimize complications.

Successful retrieval of tip-embedded inferior vena cava filter using a modified forceps technique: case report.

BACKGROUND: The retrieval of inferior vena cava (IVC) filter is essential for preventing complications associated with the device. Advanced techniques have been developed to improve the success rate of retrieving tip-embedded filters. The forceps technique is frequently used to address this issue. CASE PRESENTATION: We present a case study of two patients who underwent a successful tip-embedded IVC filter retrieval using a modified forceps technique, which has not been previously reported. This technique involves using a wire loop under the filter tip and a forceps to grasp the filter shoulder. By pulling the wire loop and pushing the forceps in counterforce, the filter tip is straightened and aligned with the vascular sheath. The vascular sheath can then dissect the filter tip out from the caval wall and get inside the sheath to complete the retrieval. CONCLUSIONS: The modified forceps technique we present here offers a new solution for the complex retrieval of IVC filters.

Explant of an infected, endo-trashed IVC filter in an immunosuppressed patient with chronically occluded iliocaval stents.

BACKGROUND: In the absence of a contiguous bowel perforation or intraabdominal source, infection of a retained vena cava filter in an occluded IVC has never been described. OBJECTIVE: To describe a case of an infected IVC filter in a chronically occluded iliocaval segment. METHODS: Here we present a case of an immunosuppressed 35-year-old female with chronically occluded iliocaval stents and an extensive staphylococcus hominis infection of a previously endo-trashed Bard Eclipse® filter. Particular attention is paid to supportive imaging in establishing the diagnosis and technical aspects of successful device explant and retroperitoneal debridement. RESULTS: At 6 months postoperatively, the patient was doing well without evidence of recurrent infection. Her lower extremity edema was controlled with compression alone. CONCLUSIONS: The main objective of this operation was source control with debridement of the infection and removal of the filter and as much of the iliac vein as safely possible. Superinfection of a previously placed iliocaval stents and inferior vena cava filter remains a concern in patients with retroperitoneal infection and chronic iliocaval occlusion. Operative explant and debridement can be safely performed in patients with favorable cardiopulmonary risk.

Extensive Iliocaval Deep Vein Thrombosis Provoked by Coronavirus Disease 2019 (COVID-19) in the Setting of an Inferior Vena Cava Filter.

Thrombotic events are well-known complications of coronavirus disease 2019 (COVID-19). Inferior vena cava filters (IVCF) are devices used to prevent pulmonary embolism (PE) and also increase the risk of thrombotic complications. Here, we describe the case of a 38-year-old female with extensive bilateral lower extremity deep vein thrombosis (DVT) and thrombosis of the infrarenal inferior vena cava (IVC) in the setting of an IVCF and symptomatic COVID-19. The IVCF had been placed a few months prior for a left femoral DVT and PE after spinal surgery. This patient was treated with pharmacomechanical thrombectomy and ultrasound-assisted thrombolysis followed by angioplasty and anticoagulation. The IVCF was retrieved after confirming there was no residual DVT when the patient recovered from COVID-19 infection. This case of a rare combination of IVCF-related thrombosis secondary to COVID-19 highlights the potential pitfalls of IVCF in this situation.

Reverse sheathing technique for iliocaval thrombectomy in the setting of IVC filters.

The Inari ClotTriever system (Inari Medical, Irvine, California) is safe and effective for the treatment of DVT. However, because it consists of a 31 cm coring device and collection bag that must be extended for use, application may be precluded by available intravascular "running room", such as in the presence of an IVC filter. Here we present a technique for bypassing IVC filters via retrograde deployment of the ClotTriever within a sheath, as illustrated in three cases. This technique extends the applicability of the ClotTriever to locations in which its length would otherwise preclude use.

Racial and gender disparities in the management of acute pulmonary embolism.

OBJECTIVE: The aim of this study was to assess race and sex disparities in use and outcomes of various interventions in patient with acute pulmonary embolism (PE). METHODS: We included 129,445 patients with acute PE from the NIS from January 2016 to December 2019. Rates of inferior vena cava (IVC) filter placement, catheter-directed thrombolysis (CDT), CDT with ultrasound, systemic thrombolysis, surgical embolectomy, percutaneous thrombectomy, extracorporeal membrane oxygenation, and mechanical ventilation were compared between race and sex subgroups, along with length of hospital stay, major bleeding events, mortality, and other adverse events. Multivariate linear regression analysis was used to adjust for variables that were significantly different between race and sex, including demographic factors, comorbidities, socioeconomic factors, and hospital characteristics. RESULTS: Compared with White male patients, all subgroups had significantly higher odds of in-hospital mortality highest in Hispanic male patients (odds ratio [OR], 1.34; 95% confidence interval [CI], 1.090-1.640; P < .01). All subgroups also had a higher odds of major bleeding events and increased length of stay. All subgroups also had lower odds of receiving CDT, lowest in Black female patients (OR, 0.740; 95% CI, 0.660-0.820; P < .001) and Hispanic female patients (0.780; 95% CI, 0.650-0.940; P < .001) compared with White male patients. There was no significant difference in the use of systemic thrombolysis among subgroups. CONCLUSIONS: Black and Hispanic patients and female patients are less likely to undergo CDT compared with White male patients, in addition to having higher odds of mortality, major bleeding, and increased length of stay after management of PE. Further efforts are needed to mitigate disparate outcomes of PE management at not only an institutional, but at a national, level to promote health care equality.

Cardiac Arrest Following Retrieval of Inferior Vena Cava Filter: A Case Report and Literature Review of Pericardial Effusion and Cardiac Tamponade.

This report presents the clinical details and management of a 58-year-old Caucasian male with pericardial effusion and cardiac tamponade following outpatient inferior vena cava (IVC) filter removal. The patient was unresponsive and experienced cardiac arrest minutes after the procedure, requiring cardiopulmonary resuscitation. After return of spontaneous circulation he displayed somnolence, confusion and chest discomfort. Investigations revealed a large pericardial effusion, and an echocardiography confirmed cardiac tamponade. Prompt intervention involved pericardiocentesis, resulting in haemodynamic stabilisation and reduction in effusion size. The patient responded favourably with treatment. Differential diagnoses were considered and treatment options were discussed, highlighting the importance of timely recognition and appropriate intervention in managing pericardial effusion and cardiac tamponade. This report adds to the limited literature on pericardial effusion and cardiac tamponade following a scheduled outpatient IVC filter removal, emphasising the unique clinical presentation and successful management of this rare phenomenon. LEARNING POINTS: Understanding the link between pericardial effusion and cardiac tamponade following IVC filter removal.Recognising and differentiating cardiac tamponade from other emergencies using clinical and diagnostic tools.Learning the immediate management of cardiac tamponade, emphasising the role of pericardiocentesis.

Comparison of success and cost after retrieval of two inferior vena cava filters.

OBJECTIVE: The objective of this study was to help guide inferior vena cava (IVC) filter choices by better understanding the retrieval characteristics, complications, and total costs between two commonly used IVC filters. METHODS: All patients who underwent retrieval or attempted retrieval of Denali (Bard Peripheral Vascular) or Option (Argon Medical Devices) IVC filters were identified between March 2016 and October 2021 at a single tertiary care center. Those with imaging studies that permitted evaluation of filter placement, presence or degree of tilt, and/or hooking of the filter into the IVC wall were included in the present study. Filter retrieval success, number of attempts, use of advanced techniques, and fluoroscopy and procedural times were recorded and compared between the two filters. RESULTS: A total of 87 patients presented for retrieval of 52 Denali and 35 Option Elite filters during the study period. Denali filters were more likely to be successfully retrieved at the first attempt (94% vs 77%; P = .019). The procedural and fluoroscopy times were shorter for Denali filters (29 minutes vs 63 minutes [P < .001] and 7 minutes vs 25 minutes [P < .001], respectively). Denali filters were less likely to be significantly tilted (≥15○) at retrieval (12% vs 29%; P < .001) or to have the filter hook embedded in the IVC wall (6% vs 40%; P < .001). Tilting of the filter of ≥15○ had no significant effects on the retrieval success rate (no tilt or tilt <15○ vs tilt of ≥15○: 98% vs 100%; P = .58). In contrast, filter hook penetration into the IVC wall significantly reduced successful recovery (41% vs 99%; P < .001). CONCLUSIONS: The findings from this study suggest that although the filter designs are similar, a benefit exists in the ease of retrievability of the Denali over the Option filter. We found that tilting and hooking of the filter in the IVC wall occurred significantly more with the Option filter. These factors likely made retrieval more difficult and contributed to the longer procedure and fluoroscopy times.

The development of a novel endovascular grasper for challenging inferior vena cava filter retrieval.

OBJECTIVE: Although inferior vena cava (IVC) filters are commonly retrieved using a snare, lateral tilt and fibrosis around struts can complicate the procedure and sometimes require the use of off-label devices. We describe the development of a novel articulating endovascular grasper designed to remove permanent and retrievable IVC filters in any configuration. METHODS: For in vitro testing, the IVC filters were anchored to the inner wall of a flexible tube in a centered or tilted configuration. A high-contrast backlit camera view simulated the two-dimensional fluoroscopy projection during retrieval. The time from the retrieval device introduction into the camera field to complete filter retrieval was measured in seconds. The control experiment involved temporary IVC filter retrieval with a snare. There were four comparative groups: (1) retrievable filter in centered configuration; (2) retrievable filter in tilted configuration; (3) permanent filter in centered configuration; and (4) permanent filter in tilted configuration. Every experiment was repeated five times, with median retrieval time compared with the control group. For in vivo testing in a porcine model, six tilted infrarenal IVC filters were retrieved with grasper via right jugular approach. Comparison analysis between animal and patient procedures was performed for the following variables: total procedure time, the retrieval time, and fluoroscopy time. RESULTS: The in vitro experiments showed comparable retrieval times between the experimental groups 1, 2, and 4 and the control. However, grasper removal of a centered permanent filter (group 3) required significantly less time than in the control (29 vs 79 seconds; P = .009). In the animal model, all IVC filters were retrieved using the grasper with no adverse events. The total procedure time (21.2 vs 43.5 minutes; P = .01) and the fluoroscopy time (4.3 vs 10 minutes; P = .044) were significantly shorter in the animal model compared with the patient group. Moreover, in the patient group, 16.7% of retrievals required advanced endovascular techniques, and one IVC filter could not be retrieved (success rate = 91.7%), whereas all the IVC filters were successfully retrieved in the animal model without the use of additional tools. CONCLUSIONS: The novel endovascular grasper is effective in retrieving different types of IVC filters in different configurations and compared favorably with the snare in the in vitro model. In vivo experiments demonstrated more effective retrieval when compared with matched patient retrievals.

Upper Gastrointestinal Bleeding Secondary to Duodenal Wall Perforation by Inferior Vena Cava Filter: A Rare Clinical Presentation.

Patients with venous thromboembolism (VTE) frequently employ inferior vena cava (IVC) filters to keep them from getting pulmonary embolisms. Even though they are usually thought to be safe, there can be complications during or after their placement. IVC filter perforation into adjacent structures, such as the duodenum, is an uncommon but potentially serious complication. We present a case of a 62-year-old female with a past medical history of recurrent deep vein thrombosis (DVTs) and pulmonary embolism who presented with dizziness and dyspnea due to gastrointestinal (GI) bleeding, resulting in anemia. Esophagogastroduodenoscopy (EGD) was done and revealed a metallic object extending into the duodenum, identified as the IVC filter.