Inferior Vena Cava Filter Removal Research Articles

Perforation of the Heart During Elective Removal of an Inferior Vena Cava Filter.

A common treatment for venous thromboembolic disease in patients with contraindications to anticoagulation includes placement of an inferior vena cava (IVC) filter. Temporary filters are available to avoid the risk of long-term permanent placement. A woman in her 60s with a history of uterine serous carcinoma presented to the emergency department with cardiac arrest following elective attempted IVC filter removal. Three months prior, a temporary filter was placed because anticoagulation medication was stopped in preparation for a hysterectomy. During the IVC retrieval procedure, which was performed using an intravascular approach from the right jugular vein, the filter was tilted, requiring the use of a different retrieval sheath. During catheter reentry, the patient complained of discomfort in the chest and neck, after which she became hypotensive, lost consciousness, and died. Autopsy revealed 2 cardiac perforations, one in each ventricle. Approximately 600 mL of liquid and clotted blood was within the tense pericardial sac. An IVC filter was found in place, with no adjacent hemorrhage.To our knowledge, this is the first reported fatality due to cardiac perforation by an access sheath during intravascular removal of an IVC filter. This instance also documents the time course of the cardiac perforations to the resultant loss of consciousness.

Technical feasibility and safety of the alternative snare technique using a 0.018-inch guide wire and 5-French catheter for double-J ureteral stent removal.

To evaluate the technical feasibility of the alternative snare technique using a 0.018-inch guide wire and 5-French (Fr) catheter for double-J ureteral stent (DJUS) removal. In this retrospective study, 11 DJUS were removed in 9 consecutive patients between July 2023 and October 2023. We evaluated patient characteristics, DJUS characteristics, and procedure characteristics. Out of 11 cases, 8 (72.7%) were successful in removing the DJUS using the alternative snare technique without major complications. The average time between DJUS insertion and removal was 47.4 ± 50.0 days. The most common DJUS size was an 8-Fr, with proximal tips predominantly in the proximal ureter and renal pelvis. The mean procedure time for successful cases was 15.2 ± 16.8 minutes. Three failed cases, attributed to obstructions like debris, were later successfully addressed using the ALN inferior vena cava filter removal kit, forceps, and modified snare technique. The alternative snare technique using a 0.018-inch guidewire and Fr catheter is safe and effective in cases of DJUS removal.

Complications Associated With Inferior Vena Cava Filter Retrieval: A Systematic Review.

Inferior vena cava (IVC) filters have been used successfully in high-risk patients to prevent thromboembolism. The filters are widely created as retrievable devices, but complication rates progressively increase during IVC filter retrieval. This study aims to analyze IVC filter retrieval cases and associated complications during and following the procedures regarding dwell times, specific filter types, filter positioning, and advanced retrieval techniques.This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to select and analyze relevant articles. A literature search for articles was performed on September 23, 2023, through three research databases: PubMed, ProQuest, and ScienceDirect. The keywords used to identify relevant publications were "IVC Filter retrieval AND complications" and "IVC filter removal AND complications". The articles before 2012 were excluded. Relevant articles were selected based on the inclusion and exclusion criteria. In total, 20,435 articles were found: 812 from PubMed, 15,635 from ProQuest, and 3,988 from Science Direct. Among the exclusions were 18,462 articles, which were excluded in the automatic screening process, leaving 1,973 for manual screening. The manual screening of articles was conducted based on title, abstract, article type, duplicates, and case reports, where 1,918 articles were excluded. Ultimately, 55 articles were included in this review. This study demonstrates that IVC filter retrievals have significant complication rates. Many complications have a common theme: prolonged dwell time and lost follow-up appointments. Therefore, importance should be placed on patient education and implementing strict protocols regarding the timelines of IVC filter removals.

Balloon-Assisted Retrieval of a Retained Vascular Sheath during Complex Inferior Vena Cava Filter Removal.

A potential complication of complex endovascular procedures is retained foreign bodies such as fragmented catheters, wires, stents, or sheaths in the intravascular space. Different techniques are available for retrieval of intravascular foreign bodies including snares, forceps, baskets, tip-deflecting wires, and balloon catheters. The aim of this article is to describe our experience in which a lost large intravascular sheath was retrieved using balloon assistance. We also provide a review of different techniques used for intravascular large sheath retrieval and methods to avoid this complication during endovascular procedures such as complex inferior vena cava filter removal.

Removal of inferior vena cava filter by open surgery after failure of endovenous retrieval.

The permanent placement of inferior vena cava (IVC) filters may lead to numerous complications and their removal is recommended once the risk of pulmonary embolism is reduced. Removal of IVC filters by endovenous means is preferred. But failure of endovenous removal happens when recycling hooks penetrate the vein wall and filters are left in place for too long time. In these scenarios, open surgery may be effective for removal of IVC filters. We aimed to describe the surgical approach, outcomes, and 6-month follow-up of the removal of IVC filter by open surgery, after the failure of removal via the endovenous method. A total of 1,285 patients with retrievable IVC filters were admitted from July 2019 to June 2021, including 1,176 (91.5%) endovenous filter removals, and 24 (1.9%) open surgical IVC filter removals after the failure by endovenous method, of whom 21 (1.6%) were followed-up and eligible for analysis of the study. Patient characteristics, filter type, filter removal rate, IVC patency rate, and complications were retrospectively analyzed. Twenty-one patients were left with IVC filters for 26 (10, 37) months, of which 17 (81.0%) patients had non-conical filters and 4 (19.0%) had conical filters; all 21 filters were successfully removed, with a 100% removal rate, no deaths, no serious complications, and no symptomatic pulmonary embolism. At the 3rd month follow-up after surgery and 3rd month follow-up after discontinuation of anticoagulation therapy, only 1 case (4.8%) had IVC occlusion, but without any occurrence of new lower limb deep venous thrombosis and silent pulmonary embolism. Open surgery can be used for the removal of IVC filters after failure of removal by endovenous method or when accompanied by complications without symptoms of pulmonary embolism. Open surgical approach can be used as an adjunctive clinical intervention for the removal of such filters.

Temporary inferior vena cava filters factors associated with non-removal.

Inferior vena cava filter (IVCF) placement is indicated when there is a deep vein thrombosis and/or a pulmonary embolism and a contraindication of anticoagulation. Due to the increased risk of recurrent deep venous thrombosis when left in place, IVCF removal is indicated once anticoagulant treatment can be reintroduced. However, many temporary IVCF are not removed. We aimed to analyze the removal rate and predictors of filter non-removal in a university hospital setting. We collected all the data of consecutive patients who had a retrievable IVCF inserted at the Saint-Etienne University Hospital (France) between April 2012 and November 2019. Rates of filter removal were calculated. We analyzed patient characteristics to assess factors associated with filter non-removal, particularly in patients without a definitive filter indication. The exclusion of this last category of patients allowed us to calculate an adjusted removal rate. The overall removal rate of IVCF was 40.5% (IC 95% 35.6-45.6), and the adjusted removal rate was 62.9 % (IC 95% 56.6-69.2%). No major complications were noted. Advanced age (p < 0.0001) and cancer presence (p < 0.003) were statistically significant predictors of patients not being requested to make a removal attempt. Although most of the filters placed are for therapeutic indications validated by scientific societies, the removal rate in this setting remains suboptimal. The major factors influencing IVCF removal rate are advanced age and cancer presence. • Most vena cava filters are placed for therapeutic indications validated by scientific societies. • Vena cava filter removal rates in this setting remain suboptimal. • Major factors influencing IVCF removal rate are advanced age and cancer presence.

Developing a Cancer-Associated Thrombosis Clinic: Two-Year Experience

Background: Cancer-associated thrombosis (CAT) is a common comorbidity in patients with cancer. Prior trials have demonstrated that direct oral anticoagulants (DOACs) and low-molecular weight heparins (LMWHs) are safe and effective for CAT management. Despite these data, treatment of CAT is complicated by consequences of both cancers and cancer-directed therapies that can impact anticoagulation options. Methods: We developed the Northwestern Medicine CAT clinic in April 2020 to improve care by streamlining referrals for evaluation and management of CAT by a non-malignant hematologist. Patients were referred for either acute management of new VTE or for ongoing management of previously known VTE. Goal time-to-appointment for acute referrals was within 24 hours and for ongoing management within two weeks. Initial evaluations were completed by advanced practice providers with review by an attending classical hematologist and clinical pharmacist. We manually reviewed electronic health records of patients seen in the CAT clinic since its inception. Data collected included demographic, cancer diagnosis and cancer-directed therapy, CAT clinic recommendations, and recurrent VTE, bleeding and death within 6 months of initial CAT clinic appointment. We used descriptive statistics to assess referral and treatment patterns. Results: One hundred twenty-two patients (N=122) were seen by CAT clinic clinicians between April 2020 - April 2022, including 63 (51%) in the first year. Patients had a median age of 63 years and 56.4% were female. Appointments occurred in nearly equal proportion via telehealth (50.8%) and in-office visits (49.2%) during these two years; however, 78% of visits were telehealth during the first year, and only 25.4% during the second. Forty-three (35.2%) referred for acute management were seen at a median time of two days, and the remainder for ongoing management were seen at a median time of 10 days. Referrals were predominantly for PE (25.4%), concurrent PE/DVT (23.0%), and proximal lower extremity DVT (18.9%); however, consults included thrombi of the cerebral, pulmonary, and splanchnic veins, as well as tumor thrombi, arterial thrombi, and need for primary prophylaxis. Tumor types were categorized into nine groups, with the largest proportion consisting of gastrointestinal (25.4%), gynecologic (17.2%), and hematologic (17.2%) malignancies (Figure 1). DOACs were recommended in 47.5%, and LMWHs in 41% (Figure 2), with a similar proportion of DOACs prescribed between year one (47.5%) and year two (47.6%). Primary reasons for choosing LMWHs over DOACs were perceived bleeding risk (40%), tumor type (22%), and prior DOAC failure (20%). Twelve (9.8%) patients were advised to stop anticoagulation, due to lack of indication for 11 (91.7%) and perceived bleeding risk for one (8.3%). Four were referred for inferior vena cava (IVC) filter retrieval. At the time of evaluation, 16 (13.1%) patients were noted to have platelet counts <150,000/µL, but none had platelet counts <50,000/µL. Within 6 months of initial evaluation, 11 (9.0%) patients developed progressive or recurrent VTE. Fourteen (11.5%) patients experienced bleeding: eight (57.1%) had major bleeding episodes as defined by the International Society on Thrombosis and Hemostasis, and six (42.9%) had clinically-relevant non-major bleeding. Among major bleeding events, six (75%) were gastrointestinal and two (25%) intraabdominal in origin, with no identified intracranial hemorrhages. Twenty (16.4%) died during the follow up period. Seventy-six (61.8%) patients were seen for a follow up visit after initial consultation. Conclusion: Building the CAT clinic led to improved access to classical hematologists with thrombosis expertise to manage CAT. Historical wait times for this specialty have exceeded 90 days, while those referred to the CAT clinic had a median time-to-appointment of only nine days. Highlighting the complexity of CAT management, more than 40% of patients were not treated with DOAC, primarily related to perceived bleeding risk. Four patients were identified for IVC filter removal, suggesting there may be additional benefits to non-malignant hematologists beyond anticoagulant management. Decisions regarding treatment of individual patients with CAT remain complex, and access to thrombosis specialists provides additional expertise to optimize care. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Inferior Vena Cava Filter Use at a Large Community Hospital: A Cross-Sectional Analysis

Introduction: Inferior vena cava (IVC) filters are considered among patients who have sustained a recent lower extremity deep vein thrombosis (DVT) and/or pulmonary embolism (PE) with a contraindication to anticoagulation. IVC filter use has risen in recent decades despite a lack of data on the effectiveness of IVC filters in reducing venous thromboembolism (VTE)-related mortality. Moreover, IVC filters may be associated with significant morbidity, including filter migration, IVC thrombosis, and fatal bleeding. Prolonged insertion of an IVC filter risks endothelialization which renders later attempts at removal ineffective, and raises the risk of complications. In this study, we aimed to characterize the pattern of IVC filter use at a large community-based hospital. Specifically, we characterized the indications for IVC filter insertion, rates of IVC filter removal, and filter-associated complications. Methods: A retrospective cohort study of adult patients (>18 years) who received an IVC filter between January 1, 2005 - February 28, 2022 at Windsor Regional Hospital (WRH), which is a large community-based hospital with academic affiliations in Southwestern Ontario, Canada. Data were collected using RedCAP software and analyzed using descriptive methods. Results: To date, we have reviewed 89 patient charts from 2019-2022. Patients with IVC filters inserted through WRH were most often male (58.4%) with a median age of 68 years. The most common indications for IVC filters included recent VTE (DVT and/or PE within 3 months) and active bleeding (43.8%), and recent VTE with a need for anticoagulation interruption for surgery (32.6%). Approximately 21% (19 patients) of IVC filters were inserted for indications outside recommended guidelines, including: need for interruption of anticoagulation in patients with a remote history of VTE (31.6%) or prior to surgery (15.8%), recent VTE & active bleed but anticoagulant therapy not discontinued (21.1%), surgical prophylaxis (10.5%), recent VTE & risk of bleeding with no active bleed (10.5%), failure of anticoagulation (5.3%), and massive PE with residual DVT (5.3%). Only 34.8% of patients had successful removal of their IVC filter with an average of 1.2 attempts at filter removal per patient. At least 4 patients (4.5%) have experienced complications relating to their IVC filter, including IVC thrombotic occlusion (50%) and IVC filter migration (50%). Conclusions: Approximately 21% of IVC filters were inserted for indications that fall outside of current guidelines at a large community-based hospital in Ontario, Canada. Moreover, 65% of IVC filters were not removed which is consistent with rates reported in other studies, and significantly raises the risk of IVC filter complications. Given that the majority of patient care occurs in the community setting, further efforts are needed to understand patterns of IVC filter use at other community hospitals. As well, our findings further support the need for development of concrete guidelines on indications for IVC filter use and monitoring practices. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Abstract 15627: Inferior Vena Cava Filter Strut Fracture and Migration to the Right Ventricle in Post-COVID Patient With Intractable Cough

Background: Inferior vena cava (IVC) filter fracture and migration of the fractured strut is a rare but potentially dangerous complication. We report a case of fractured IVC strut migrated to the right ventricle (RV) in a patient who was evaluated for persistent cough. Clinical Case: A 69-year-old male presented to his primary care physician for the evaluation of intractable cough and shortness of breath. Past medical history was significant for recurrent unprovoked deep vein thromboses treated with an IVC filter 15 years ago. He had COVID19 infection six months prior to current presentation. A computed tomography (CT) scan of the chest was ordered to screen for underlying pulmonary disease. CT scan showed no pulmonary process, but revealed a linear radiopaque foreign body in the RV of the heart. His cough was considered to be a sequela of his prior COIVD19 infection. Decision-making: To better characterize this foreign body in RV, a transesophageal echocardiogram was performed. This showed a prominent linear echo density on the tricuspid valve chord in the RV. On careful review of the CT scan of the chest and comparison with prior CT scans, it was found that one of the IVC filter strut at 9 o’ clock position was missing. The ‘foreign body’ in the RV had the same size as the remaining struts of the IVC filter. Given that the patient did not have any symptoms or complications from the incidentally found fractured strut, decision was made to not retrieve it with a percutaneous or surgical intervention. Conclusion: Significant variations in the intra-abdominal pressure may contribute to metal fatigue potentially leading to IVC filter strut fracture and migration to the RV. This underscores the importance of timely removal of IVC filters. Uncomplicated migrated IVC filter struts may be left unretrieved and patients can be followed clinically.

Stenting across inferior vena cava filters can be a safe and effective alternative to complex retrieval

ObjectiveVenous stenting for acute and chronic venous disease has been increasingly used as more evidence has accumulated on the efficacy and durability of these interventions for symptomatic patients. Inferior vena cava (IVC) filters that could have been present for years will often be implicated in the obstructive pathology and removal can be challenging. The purpose of the present study was to evaluate whether stenting across an indwelling IVC filter is a safe and effective alternative to removal. MethodsConsecutive patients who had undergone iliocaval stenting at our institution from 2007 to 2020 were identified and divided into groups stratified by the presence of an IVC filter. The operative notes, venography findings, and the electronic health records were queried to obtain the operative details, patient characteristics, postoperative outcomes, stent patency, and survival outcomes. The primary end point was iliocaval stent patency. The patients were divided into two groups according to the presence of an IVC filter with or without overstenting. We used the χ2 test and survival analysis as appropriate. ResultsA total of 224 consecutive patients were identified, of whom 71 were found to have undergone iliocaval stenting (age, 48 ± 18 years; 47.9% male; body mass index, 31 ± 9 kg/m2). Of the 71 patients, 15 had had stents placed across an indwelling IVC filter (overstented group) and 56 had not had an IVC filter present (non-overstented group). No differences were found in presentation between the overstented group (acute occlusion, 4 of 15 [26.7%]; chronic occlusion, 8 of 15 [53.3%]; and nonocclusive lesions, 3 of 15 [20%]) and the non-overstented group (acute occlusion, 29 of 56 [52%]; chronic occlusion, 18 of 56 [32%]; nonocclusive lesions, 9 of 56 [16%]; P = .2). Comparisons between the two groups revealed no differences in the baseline characteristics except for age (overstented, 57 ± 15 years; non-overstented, 46 ± 18 years; P = 0.03), preoperative anticoagulation therapy (overstented, 66.6%; non-overstented, 26.9%; P = .01), and bilateral leg symptoms (overstented, 86.7%; non-overstented, 23.2%; P < .001). Primary patency at 30 months was 85.6% in the overstented group and 86.1% in the non-overstented group (P = .78). At follow-up, no adverse events related to filter crushing were reported, and no differences were found in 30-month survival. ConclusionsIn our single-center, retrospective study of iliocaval stenting, patients who had undergone overstenting across an indwelling IVC filter had had patency rates similar to those whose stents had been placed with no IVC filter in place. Thus, complex IVC filter removal, when not possible or when the risk of operative complications is too high, can be forgone in favor of stenting across the IVC filter, with no implications on midterm patency or adverse events.

Implications for patient follow-up of changes in inferior vena cava filter removal plan practices

To assess the improvements during patient follow-up after implementing a proactive plan for retrieval of inferior vena cava (IVC) filters. A retrospective study was undertaken including all patients who had a temporary IVC filter inserted over a 10-year period. Patient demographics, insertion dates, retrieval dates, retrieval rates, and complications were recorded. Patients were categorised into three groups as follows: group A, no intervention where retrieval was not suggested; group B, passive intervention where retrieval was suggested but no appointment made; and group C, proactive intervention where a retrieval date was booked by the radiologist. Five hundred and nine patients had a temporary IVC filter inserted at Royal Liverpool University Hospital over the study period. One per cent of patients in group C were lost to follow-up compared to 41% and 29% in groups A and B respectively (p<0.001). The number of patients who had an IVC retrieval attempt also increased to 80% in group C compared to 53% and 64% in groups A and B (p<0.001). Incorporation of a proactive retrieval booking system has significantly reduced the number of patients lost to follow-up to 1%, leading to an increased number of IVC filter retrieval attempts.

Complex filter removal using forceps from combined transfemoral and transjugular approach unhooking the filter apex using forceps and dual access: Two case reports

Modern inferior vena cava filters (IVCFs) are intended to be retrieved once a thrombotic process or risk of pulmonary embolism has resolved independent of administration of anticoagulation. IVCF removal can be challenging with the risk of complications including venous perforation, filter migration, and device fracture. IVCFremoval has been described using the nomenclature of routine versus advanced retrieval. Routine retrieval is defined as accessing the filter hook with a loop snare device before advancing a sheath over the filter. Advanced retrieval techniques are employed when routine retrieval fails and can refer to a variety of approaches, including filter realignment with loop snare, stiff wire-displacement, use of a wire and snare with dual access, angioplasty balloon advanced over a guidewire, single access sling approach, the sandwich technique, the endobronchial forceps dissection and removal, photothermic ablation with excimer laser, and the filter eversion technique among others.Successful routine retrieval of IVCF has been reported at 74% and IVCF retrieval with advanced techniques has a success rate of nearly 95%. The complication rate with advanced techniques is higher when compared with routine techniques (5.3% vs. 0.4%; p < .05) and, as expected, requires fluoroscopic time. We report two cases of advanced filter retrieval using endobronchial forceps simultaneously or sequentially through the transfemoral and trans-jugular approach.

Classification System for Inferior Vena Cava (IVC) Appearance Following Percutaneous IVC Filter Retrieval.

There is no classification system for describing inferior vena cava (IVC) injuries. The objective of this study was to develop a standardized grading system for venographic appearance of the IVC following percutaneous IVC filter retrieval. A classification system for the appearance of the IVC on cavograms following percutaneous IVC filter removal was developed consisting of two grading elements; luminal characteristics and extravasation. Luminal narrowing from 0% up to 50% from any cause is grade 1; narrowing between 50 and 99% is grade 2; occlusion is grade 3; and avulsion is grade 4. Absence of extravasation is grade A, contained extravasation is grade B, and free extravasation is grade C. This system was then applied retrospectively to pre- and post-IVC filter retrieval cavograms performed at a single institution from October 2004 through February 2019. 546 retrieval attempts were identified with 509 (93.2%) filters successfully retrieved. 449 cases (88.2%) had both pre-retrieval and post-retrieval imaging appropriate for application of the proposed classification system. Inter-rater reliability was 0.972 for luminal characteristics, 0.967 for extravasation, and 0.969 overall. Consensus grading demonstrated a distribution of 97.3% grade 1, 1.3% grade 2, 1.3% grade 3, and 0.0% grade 4 for post-retrieval luminal characteristics. For extravasation classification, 96.4% of the cases were classified as grade A, 2.7% grade B, and 0.9% grade C. A classification system was developed for describing IVC appearance after IVC filter retrieval, and retrospectively validated using a single center dataset.

Abstract No. 162 Medium and long-term outcomes of single session inferior vena cava filter removal, recanalization and endovenous reconstruction for filter-related chronic iliocaval thrombosis

Endovascular management of inferior vena cava filter (IVCF)-related chronic iliocaval thrombosis historically consisted of stent placement across an obstructed IVCF; however, there are data that suggest that this may result in compromised patency and higher rates of reintervention. Stent placement across an obstructed IVCF may result in incomplete stent expansion. Furthermore, IVCF displacement can result in adverse events (AE) including pericaval filter component perforation. We present medium and long-term outcomes following the single-session endovenous reconstruction of IVCF-related chronic iliocaval thrombosis with simultaneous IVCF retrieval.

Developing and optimizing a computable phenotype for incident venous thromboembolism in a longitudinal cohort of patients with cancer

BackgroundResearch on venous thromboembolism (VTE) that relies only on the International Classification of Diseases (ICD) can misclassify outcomes. Our study aims to discover and validate an improved VTE computable phenotype for people with cancer. MethodsWe used a cancer registry electronic health record (EHR)–linked longitudinal database. We derived three algorithms that were ICD/medication based, natural language processing (NLP) based, or all combined. We then randomly sampled 400 patients from patients with VTE codes (n = 1111) and 400 from those without VTE codes (n = 7396). Weighted sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated on the entire sample using inverse probability weighting, followed by bootstrapped receiver operating curve analysis to calculate the concordance statistic (c statistic). ResultsAmong 800 patients sampled, 280 had a confirmed acute VTE during the first year after cancer diagnosis. The ICD/medication algorithm had a weighted PPV of 95% and a weighted sensitivity of 81%, with a c statistic of 0.90 (95% confidence interval [CI], 0.89–0.91). Adding Current Procedural Terminology codes for inferior vena cava filter removal or early death did not improve the performance. The NLP algorithm had a weighted PPV of 80% and a weighted sensitivity of 90%, with a c statistic of 0.93 (95% CI, 0.92–0.94). The combined algorithm had a weighted PPV of 98% at the higher cutoff and a weighted sensitivity of 96% at the lower cutoff, with a c statistic of 0.98 (95% CI, 0.97–0.98). ConclusionsOur ICD/medication‐based algorithm can accurately identify VTE phenotype among patients with cancer with a high PPV of 95%. The combined algorithm should be considered in EHR databases that have access to such capabilities.

A single center 9-year experience in IVC filter retrieval - the importance of an IVC filter registry

BackgroundTo evaluate Inferior vena cava (IVC) filter retrieval practices over a 9-year period at an academic hospital with a prospectively maintained IVC filter registry.MethodAn IVC filter registry was maintained prospectively within our institution. We reviewed cases between August 2011 and June 2020, following filter status, retrieval plans, and eventual retrieval date. The validity of the database was cross referenced with a Picture Archiving and Communication System and patient records.ResultsThree hundred forty-three patients had IVC filters inserted. Three filter types were used, Celect (Cook Medical) in 189, Gunther Tulip (GT) (Cook Medical) in 65, ALN (ALN) in 89. 196 (57%) filters were retrieved, 108 (31.5%) were made permanent, 36 (10.5%) died before retrieval, and 3 (1%) were yet to be retrieved.Retrieval rates were 92.5% overall (86% for GT, 93% for Celect and 94.5% for ALN). The mean dwell time for successful retrieval was 59 days with the majority of insertions (85%) removed in under 100 days. Failed initial retrieval occurred in 23 patients, 10 (43%) were retrieved at second attempt, 13/23 filters remained in-situ and were deemed permanent.ConclusionThe removal of IVC filters, when indication for insertion has past, is no longer the sole responsibility of the referring physician but also the responsibility of the Interventionalist. Our retrieval rates of 92.5% of eligible IVC filters highlights the value of maintaining a prospective IVC filter registry.

Analysis of Costs and Payments for Inferior Vena Cava Filter Retrieval in the Medicare Population

Over the past decade, inferior vena cava (IVC) filter retrieval has been increasing, in part due to Food and Drug Administration recommendations and legal pressure. The costs and margin of IVC filter removal are poorly understood. Medicare claims data from 2016 for the 103 highest volume centers for IVC filter retrieval were examined. Pooled mean charges, costs, payments, and margin were calculated by institution. Mean ± SD charges, costs, and payments were $14,138.00 ± $8,400.48, $3,693.28 ± $2,294.27, and $1,949.82 ± $702.91, respectively. Average (range) margin was −$1,706.18 (−$7,509.93 to $362.77). The margin was negative in 99 of the 103 (96%) institutions evaluated. The most significant contributors to the total procedure cost were operating room, supplies, and recovery (44.5%, 23.5%, and 10.4%, respectively). While IVC filter retrieval is often medically indicated, it is typically associated with a financial loss under current reimbursement structure.

Stability of Retained Inferior Vena Cava Filter Fragments after Filter Removal

PurposeTo assess the stability and outcome of fractured inferior vena cava (IVC) filter fragments that are retained in patients after IVC filter removal. Materials and MethodsA retrospective analysis was conducted on all patients at a single tertiary referral center between May 2005 and June 2020 with fractured IVC filters where fragment(s) were retained after removal of the main filter body. IVC filter fragment stability was assessed by a clinician review of computed tomography images, chosen from available radiologic studies, to best visualize the fragments. Data collected included filter type, fragment location, duration of fragment follow-up, fragment stability in location, and further fragment fracture or clinical sequelae. ResultsSeventy-seven patients with retained IVC filter fragment(s) after complex filter removal were identified. Of this, 37 patients (14 men, 23 women) were deemed to have adequate imaging follow-up to assess positional stability of the retained fragments, whereas the remainder were excluded from further analysis. Excluding fractured foot processes, 51 separate filter fragments were retrospectively identified and followed for a median duration of 726 days (interquartile range, 843 days; range, 28–3353 days). Filter designs producing the studied fragments included Celect, G2, Recovery, Günther, OptEase, Meridian, and G2X/Eclipse. In all, 50 of 51 (98%) fragments were found to be unchanged in position during their respective intervals of observation. One fragment displayed a rotational change without migrating from its original location. No further fragment fractures or clinical sequelae were observed among the group. ConclusionsWhen asymptomatic, retained IVC filter fragments are predominantly stable and can be safely followed on an intermediate-term basis.

Making Invaluable Changes: Assessing Appropriateness for IVC Filter Insertion and Reasons for Non-Retrieval

Background:Inferior vena cava (IVC) filters are commonly placed in patients with contraindications to anticoagulation including bleeding concurrent with venous thromboembolism (VTE). Retrievable IVC filters have been preferred over permanent filters for their flexibility to be removed once anticoagulation can be resumed. Published reports show that the retrieval rate of the filters is around 34%. Non-retrieved filters can result in significant complications such as filter migration, embolization, filter fracture, vena cava thrombosis, and IVC perforation.Objective:The primary objective of this study is to assess IVC filter insertion indications, retrieval rate and factors prohibiting timely retrieval.Methods:A retrospective chart review was conducted on patients with a history of IVC filter placement and/or removal between January 2012 and January 2017. Data collected included demographics, indications for filter placement, referring and placement services and the reasons for non-retrieval.Results:A total of 573 patients were identified of which 343 patients had IVC filters inserted without retrieval, 200 patients had placement followed by retrieval and 30 patients who had retrieval alone. Reasons for placement included VTE with active bleed in 29.48%, trauma, surgery, or immobilization in 22.01%, VTE with planned surgery in 19.22%, history of VTE with planned surgery in 11.94%, and extensive clot burden in 9.33%, VTE with elevated bleeding risk in 3.92%, PE with thrombolysis therapy in 0.19%, and other in 3.92% of patients. Internal medicine had ordered IVC filters in 44.44% of patients compared to 27.16% in surgical services with (p-value of 0.0028). This indicates that a significantly greater proportion of IVC filters were placed due to VTE with active bleeding in internal medicine as opposed to all other departments. In addition, Internal medicine ordered IVC filters for immobilization from trauma in 4.23% of patients compared to 24.73% by other departments (p-value <0.0001), indicating that other departments order IVC filters for immobilization or bleeding from trauma at a significantly higher rate than does internal medicine.For those 343 patients who had IVC filters placed but not retrieved, reasons for non retrieval by Interventional radiology(IR) included lost to follow up in 39.80% compared to 58.97% in vascular surgery, decided to use as permanent IVC filter in 20.72% in IR compared to 12.82% in vascular surgery, ongoing thrombosis in 4.93% in IR compared to 7.69% in vascular surgery, trapped clots in 1.32% in IR compared to 0% in vascular surgery, died within 3 months in 31.58% in IR compared to 15.38% in vascular surgery, filter removed locally in 0.99% in IR compared to 5.13% in vascular surgery, and scheduled to be removed in 0.66% in IR compared to 0% vascular surgery.To further investigate the rates of patients that were “lost to follow up” we dichotomized the reasons into “lost to follow up” in comparison to all other reasons. This showed that the reason for non-retrieval was lost to follow up in 39.80% compared to 58.97% of patients in vascular surgery (p-value 0.0224). This indicates that the proportion of patients that were “lost to follow up” in vascular surgery is significantly higher than in interventional radiology.Conclusion:Only one-third of IVC filters were ordered in compliance to current evidence based guidelines. There was also a significantly greater proportion of “lost to follow up” patients in vascular surgery compared to interventional radiology, indicating room for improvement regarding patient follow up. To improve the appropriateness of IVC filter insertion and overall retrieval rate, we plan to implement best practice alerts and institutional guidelines along with hematology referral upon patient discharge to aid in timely retrieval. We plan to reevaluate our practice in 6 months following the implementation of these guidelines. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Inferior Vena Cava Filter Utilization at Kingston Health Sciences Centre: A Comparison of Practice with Guidelines

Background: Inferior vena cava (IVC) filters offer mechanical protection against pulmonary embolism in high risk patients. Guidelines have recommended their use be limited. “Don't use inferior IVC filters routinely in patients with acute venous thromboembolism” (ASH Choosing Wisely, 2013). “For patients with acute VTE who are treated with anticoagulation, the guideline recommends against the use of an inferior vena cava filter.” (CHEST Antithrombotic Therapy and Prevention of Thrombosis, 2016) IVC filters implanted for longer than 100 days confer a significantly higher risk of complications (Odds Ratio 2.3, Dinglasan et al. 2013). We sought to determine compliance with these recommendations at Kingston Health Sciences Center (KHSC), an academic tertiary referral center with 440 inpatient beds at Queen's University in Kingston, Ontario, Canada.Methods: Approval was obtained from the Queen's Health Services Research Ethics Board.Consecutive patients with IVC filter implantation at KHSC from August 1st, 2013 to August 1st, 2016 were identified through Interventional Radiology records. All charts were retrospectively reviewed in depth by one investigator followed by review and discussion. Data extracted included: patient demographics and disposition, details surrounding IVC filter insertion and removal, and IVC filter related complications. The indication for filter implantation was classified as clearly consistent or not clearly consistent with CHEST guidelines. The category ‘lesser indication’ was subsequently added for cases of a more subjective nature where definitive categorization was challenging.Results: Between August 2013 and August 2016, 95 IVC filters were implanted at KHSC. Among these, 42 (44.2%) patients were male and the median age was 67 (ages ranged from 17 to 91). The most responsible services ordering IVC filter implantation were Critical Care Medicine (37.9%), Internal Medicine (32.6%), Surgery (12.6%) and other services such as Neurology, Family Medicine and Emergency Medicine (16.9%).Complications arose in 21 patients (22.1%) including filter-associated thrombosis (11), filter migration or tilt (8), IVC penetration (5), IVC perforation (2), and one instance of suspected IVC filter seeding with methicillin sensitive Staphylococcus aureus (MSSA) leading to bacteremia. The mean dwell time of filters that were successfully removed (n=52, 54.7%) was 69.2 days, with thirteen (18.1%) remaining indwelling beyond 100 days. Of those in whom the filter was not removed (n=43), unsuccessful retrieval attempts were made in eight, 23 patients died with their filters in situ within 100 days of implantation, and in 12 patients no record of an attempt to retrieve the device was found.Indication for IVC filter insertion was clearly consistent with CHEST guidelines in 58 (61.1%) patients. Insertion alongside therapeutic anticoagulation/thrombolysis or for prophylaxis in patients without VTE occurred in 26 patients (27.4%) and was considered not consistent with current recommendations. In 8 (8.4%) patients, a ‘lesser indication’ was identified. Lesser indications included cases where there was a need to withhold anticoagulation for less than 24 hours for procedures or surgeries, such as endoscopic retrograde cholangiopancreatography (ERCPs) or ankle open reduction internal fixations (ORIFs). Three charts had insufficient information to determine compliance.Discussion: The main limitation of this study is its retrospective nature with reliance on chart documentation. In addition, it is recognized that guidelines surrounding IVC filter use do not apply to all possible clinical scenarios. Nonetheless, restricting the use of IVC filters to appropriate indications is an important endeavour. These devices are costly, can cause harm, and do not have a strong evidentiary basis. Educational initiatives are underway to optimize use of IVC filters at KHSC. Additional interventions under consideration include development of a specific requisition form listing recommended indications, and creation of an IVC filter insertion database as a prompt for timely removal. DisclosuresHay:Celgene: Research Funding; Roche: Research Funding; Abbvie: Research Funding; Kite: Research Funding; Amgen: Research Funding; Janssen: Research Funding; Novartis: Research Funding.