A subclavian guidewire and inferior venacaval (IVC) filter affair. A unique problem and a double snare endovascular approach for filter retrieval

Abstract

Introduction: An increasing trend is seen in the use of IVC filters. In addition, increased use of guide-wires and catheters for monitoring and treatment has amplified the likelihood that the IVC filter may get entangled and dislodged. Since the first reported case by Loesberg et al in 1993, a few additional cases have been reported in literature. We report a case where a dislodged IVC filter secondary to guidewire entanglement was retrieved successfully using percutaneous techniques. Patient and methods: Our patient was a 54 year-old male with acute gangrenous cholecystitis and bilateral pulmonary embolus. An IVC filter was placed. During the patients stay in the intensive care unit a right subclavian central venous catheter was attempted. The guide-wire used could not be retrieved and a post procedure chest X-ray confirmed the entanglement of the filter to the wire. The filter was noted to be in the junction of the right atrium and the IVC. The patient was taken emergently to the cardiac catheterization lab. The right subclavian vein was entered, using a 5-French sheath over the existing wire and replaced with a 10 French sheath. An Amplatz snare catheter and gooseneck snare was used to snare the filter. The filter could be moved up and down minimally but could not be fully released. After multiple such attempts, a 12-French venous sheath was placed from the right femoral vein. A 25-mm Amplatz snare catheter was advanced over the IVC filter, and the combination of one snare from above and one snare from below and careful manipulation ultimately allowed retrieval of the IVC filter through the right femoral vein. Prior to removing the femoral sheath, a new IVC filter was placed. Results and Conclusions: Guide wire entrapment in IVC filters although rare, is a known complication. Important precautions to remember among others are to obtain an adequate history of prior IVC filter placement and the coagulation status of the patient. The guide-wire should be inserted no further than necessary (approximately 15-20 cm) as it only needs to gain and maintain access. At times of difficulty at retrieving the filter, a double snare combination approach can help dislodging the filter and aid in its removal. Endovascular retrieval of the filter is possible although technically challenging and needing a multispecialty approach.