Tulip Inferior Vena Cava Filter Research Articles

Abstract No. 143 Gunther tulip filter strut penetration: benign long-term follow-up

IVC filter strut penetration of the caval wall is often cited as an indication for filter removal (1). Though a common finding on CT images, associated clinical manifestations are reported in < 1% of cases (2–5). Nonetheless, the observation of a conical filter strut that appears to penetrate the caval wall remains a concern long-term because it is common, may be progressive, and there are case reports of serious strut-related symptomatic complications. This study was designed to assess the incidence, magnitude, and natural history of vena cava wall penetration by struts of the Gunther Tulip inferior vena cava filter.

Lateral tilt during IVC filter placement does not predict the need for advanced filter retrieval techniques.

We aimed to determine if lateral inferior vena cava (IVC) filter tilt at placement predicts the need for subsequent advanced retrieval techniques. A retrospective chart review was performed of all Gunther Tulip IVC filter placements with subsequent retrievals between February 2015 and October 2017. Chart and imaging review was performed for patient, filter placement, and filter retrieval demographics/characteristics. Degree of agreement between two measurement sets was evaluated with the intraclass correlation (ICC) analysis. Categorical variables were compared with chi-square or Fisher exact test, as appropriate. Kendall rank correlation was used to measure correlation between categorical variables. There was poor agreement between filter tilt angle at the time of placement and retrieval (ICC coefficient, 0.54). Mean difference ± standard deviation between tilt angle at the time of placement and retrieval was 4.6°±4.3° (p = 0.35). Among patient- or procedure-related factors, a common femoral vein access on placement (regression coefficient, -2.90; p = 0.039) was associated with a lower difference between placement and retrieval filter tilt angles compared to internal jugular vein access. Higher filter tilt angle measured at the time of retrieval (OR: 1.19, p = 0.025), hook embedment (OR: 77.3, p < 0.001), and a longer dwell time (OR: 1.25, p = 0.002) were associated with the need for advanced retrieval techniques. However, in univariate and multivariate analysis filter tilt angle at the time of placement was not associated with the subsequent need for advanced retrieval technique (p = 0.16). Lateral tilt at the time of placement is poorly associated with lateral tilt at the time of retrieval and does not correlate with the need for advanced retrieval technique.

Safety and Efficacy of the Gunther Tulip Retrievable Vena Cava Filter: Midterm Outcomes

To evaluate of the medium-term integrity, efficacy, and complication rate associated with the Gunther Tulip vena cava filter. A retrospective study was performed of 369 consecutive patients who had infrarenal Gunther Tulip inferior vena cava filters placed over a 5-year period. The mean patient age was 61.8 years, and 59% were men. Venous thromboembolic disease and a contraindication to or complication of anticoagulation were the indications for filter placement in 86% of patients; 14% were placed for prophylaxis in patients with a mean of 2.3 risk factors. Follow-up was obtained by review of medical and radiologic records. Mean clinical follow-up was 780 days. New or recurrent pulmonary embolus occurred in 12 patients (3.3%). New or recurrent deep-vein thrombosis occurred in 53 patients (14.4%). There were no symptomatic fractures, migrations, or caval perforations. Imaging follow-up in 287 patients (77.8%) at a mean of 731 days revealed a single (0.3%) asymptomatic fracture, migration greater than 2 cm in 36 patients (12.5%), and no case of embolization. Of 122 patients with CT scans, asymptomatic perforations were identified in 53 patients (43.4%) at a mean 757 days. The Gunther Tulip filter was safe and effective at 2-year follow-up. Complication rates were similar to those reported for permanent inferior vena cava filters.

Thrombectomy and cavocavostomy for inferior vena cava thrombosis and torsion after piggyback liver transplantation

Inferior vena cava (IVC) complications after orthotopic liver transplantation continue to be rare but serious concerns.1,2 Although numerous surgical and percutaneous techniques have been suggested for the management of different IVC complications, there is no consensus about a standard method of treatment. Here we describe a unique case in which a liver allograft caused kinking of the recipient's IVC and subsequent thrombosis after piggyback liver transplantation. Our case involves a 48-year-old male with end-stage liver disease secondary to hepatitis C. He underwent piggyback liver transplantation in which the suprahepatic allograft IVC was anastomosed with 3 recipient hepatic veins. On postoperative day 3, the patient developed significant hemodynamic instability and was re-explored through the same bilateral subcostal incision. An intraoperative Doppler examination revealed patent hepatic veins with pulsatile flow but also a nearly occlusive thrombus in the recipient's IVC extending from the suprarenal IVC to the retrohepatic IVC inferior to the piggyback anastomosis. The absence of an outflow obstruction was confirmed by the lack of a pressure gradient across the piggyback anastomosis, which was demonstrated by the direct measurement of the pressures of the recipient's suprahepatic IVC and the donor's IVC. Graft rotation and IVC kinking inferior to the piggyback anastomosis were also observed to be causing IVC stenosis. The decision was made to perform a thrombectomy through a venotomy on the suprarenal IVC with Fogarty balloons. Once an adequate caval flow was obtained, vascular clamps were applied inferior to the piggyback anastomosis and slightly superior to the renal veins. The lower aspect of the donor's IVC was untied and anastomosed to the opening on the recipient's IVC (the site of the thrombectomy) in an end-to-side fashion (Fig. 1). By anchoring the donor's IVC in 2 separate locations, we were able to relieve the kinking of the IVC. End-to-side cavocavostomy. Reprinted with permission from Transplantation Proceedings.3 Copyright 2001, Elsevier Science, Inc. Three days after the re-exploration, a Doppler ultrasound examination revealed normal directional flow and patency of the hepatic vasculature. A retrievable Gunther Tulip IVC filter was inserted to prevent any further risk of a pulmonary embolism. The patient's remaining postoperative course was unremarkable. The laboratory values on April 2011 were as follows: total bilirubin, 1.4 mg/dL; aspartate aminotransferase, 41 U/L; alanine aminotransferase, 32 U/L; and creatinine, 1.5 mg/dL. Recent abdominal magnetic resonance imaging demonstrated the patency of the cavocavostomy (Fig. 2). Magnetic resonance imaging (May 2011) demonstrating the patency of the cavocavostomy (black arrows). It is well known that graft rotation is an infrequent but serious complication after orthotopic liver transplantation because of its potential association with IVC obstructions. Our patient developed graft rotation and subsequent IVC kinking because of a size discrepancy between the graft and the recipient's right upper quadrant cavity. In addition, we believe that the construction of a significant portion of the piggyback anastomosis in the anterior wall of the IVC (where a substantial separation existed between the right hepatic vein and the confluence of the middle and left hepatic veins) may have further contributed to the graft rotation, which led to the IVC kinking and the subsequent caval flow obstruction and thrombosis. Although cavocaval anastomoses after piggyback liver transplantation have been reported, they have been used primarily to address IVC outflow obstructions.3, 4 We addressed graft rotation and kinking of the recipient's IVC by anchoring the donor's IVC in 2 separate locations. By using both IVC thrombectomy and an additional cavocaval anastomosis, we were able to successfully provide stability to the graft and re-establish adequate blood flow through the piggyback anastomosis. Our patient was still alive and doing well more than 3 years after liver transplantation. The utilization of IVC thrombectomy and infrahepatic cavocavostomy provided excellent management of graft rotation, IVC kinking, and retrohepatic/infrahepatic IVC thrombosis. In our view, this should be considered another option for the treatment of patients with similar complications after orthotopic liver transplantation. Aaron M. Williams B.A.*, Jonathan C. Hundley M.D.*, Michael F. Daily M.D.*, Malay B. Shah M.D.*, James T. Lee M.D.*, Roberto Gedaly M.D.*, * Division of Transplantation Department of Surgery College of Medicine University of Kentucky Lexington, KY.

Evaluation of migration forces of a retrievable filter: Experimental setup and finite element study

The aim of this paper is to provide a computational study of migration forces of a retrievable filter (Günther Tulip inferior vena cava filter). Using an experimental setup and finite element simulation, the migration forces and stress at the end of the anchored hooks in the struts were estimated. After that, the estimation value of migration stress (τrup) was used to analyze the effect of different mechanical factors (strut thickness, vena cava diameter) in the migration of the IVC filter.Our results show that the migration stress is τrup=4.37N/mm2. Using this value we obtain that the filter with higher strut diameter (ϕstrut=0.45mm) shows the maximal migration forces in every cava diameter. On the other hand, the value of the migration force decreases when the cava diameter increases. In addition, the finite element simulations also show that there are contact between the struts of the filter and the vein in regions close to the anchors.

Lumbar Artery Pseudoaneurysm Caused by a Gunther Tulip Inferior Vena Cava Filter

Inferior vena cava (IVC) filters are widely used to decrease the risk of pulmonary embolism in patients with contraindications to anticoagulation. Complications include local hematoma, access site deep venous thrombosis (DVT), filter migration and embolization, leg penetration through the IVC wall, IVC occlusion, and filter fracture with embolization. Other rare complications include leg penetration into adjacent organs including duodenum and ureter. Lumbar artery pseudoaneurysms are rare and may be spontaneous, iatrogenic, or traumatic. To date, there have been 3 case reports of lumbar artery pseudoaneurysms caused by IVC filters. We present an additional case of a lumbar artery pseudoaneurysm caused by a Gunther Tulip IVC filter treated successfully with selective embolization.

Techniques Used for Difficult Retrievals of the Günther Tulip Inferior Vena Cava Filter: Experience in 32 Patients

To retrospectively review experience with difficult retrievals of Günther Tulip filters (GTFs) in which various techniques were used. From December 2004 to December 2006, 32 patients were referred to a single radiology department for GTF retrieval (25 women and seven men; mean age, 40 years; range, 21-60 y). All patients were evaluated, and 22 of these patients had undergone unsuccessful filter retrieval attempts elsewhere. In the remaining patients, significant tilt of the filter (n = 8) or difficult internal jugular vein access (n = 2) discouraged retrieval attempts. There were a total of 38 filters. Twenty-five patients had a filter in the infrarenal inferior vena cava (IVC). Among the remaining seven patients, six had bilateral iliac filters and one had a left iliac filter. Retrievals were performed via conventional technique-ie, by snaring the hook of the filter without additional maneuvers-or other techniques. Thirty-seven of 38 filters were successfully removed, for a success rate of 97%. Successful retrievals were performed with conventional (n = 4), catheter twist (n = 3), modified snare (n = 15), loop snare (n = 14), and balloon dilation (n = 1) techniques. The average dwell time for filters successfully removed was 58 days (range, 22-258 d). One failure occurred in a patient who had undergone unsuccessful retrieval previously. The hook of the filter and a displaced secondary strut, which had migrated superiorly, were incorporated into the IVC wall in this case. Additional maneuvers were useful in these difficult retrievals of GTFs that might not otherwise be retrievable with the conventional method.

Factors Associated with Failed Retrieval of the Günther Tulip Inferior Vena Cava Filter

To identify potential factors associated with failed retrieval of the Günther Tulip inferior vena cava (IVC) filter. A retrospective review was performed of patients who underwent placement of the Günther Tulip filter with at least one attempt at filter retrieval over a 3-year period. Patient demographics, filter dwell time, filter angulation, and filter leg protrusion were analyzed. A total of 188 patients were included in the study. Primary retrieval success was achieved in 166 patients (88.3%), for an overall retrieval success rate of 94.2%. The overall mean dwell time was 63 days, whereas the mean dwell time in cases of retrieval failure was 95.4 days. A total of seven filters were in place for longer than 6 months, four of which were successfully retrieved. The degree of filter tilt was not found to be significantly related to retrieval success (P = .36), even though filter angulation was commonly cited as a reason for retrieval failure. On venography, 90.9% of filters that could not be retrieved showed leg protrusion beyond the lumen of the IVC. Finally, increasing patient age also correlated with retrieval failure (P = .01). Prolonged dwell time and increasing patient age are associated with failed filter retrieval. However, even filters in place for extended periods can be safely removed.

Migration of the Günther Tulip Inferior Vena Cava Filter to the Chest

The authors describe two cases in which Günther Tulip inferior vena cava filters migrated to the chest, necessitating open-heart surgery for retrieval. In the first case, a 52-year-old man was transferred to their hospital from an outside facility after the filter migrated to the main pulmonary artery during attempted filter placement. In the second case, a 72-year-old man, a Günther Tulip filter was found to have migrated to the tricuspid valve after cardiopulmonary arrest and subsequent resuscitation, including emergent central venous line placement. The authors present the relevant details of both cases, discuss possible preventive strategies, and review the available literature about migration of the Günther Tulip filter.

Retrievability of the Günther Tulip Vena Cava Filter after Dwell Times Longer Than 180 days in Patients With Multiple Trauma

To evaluate the retrieval feasibility of the Günther Tulip inferior vena cava filter (IVCF) after dwell times >180 days in patients with multiple trauma. A retrospective study was conducted of 117 multiple-trauma patients (70 men; mean age 36 years, range 17 to 64) who underwent prophylactic placement of Günther Tulip retrievable IVCFs between December 1, 2003 and October 1, 2006. Prior to IVCF retrieval, all patients had vena cavography to identify possible IVCF thrombus entrapment. Filter retrieval was performed in the catheterization laboratory under sterile conditions from a right internal jugular vein approach. After IVCF retrieval, repeat vena cavography was performed to evaluate the IVC for contrast extravasation, intraluminal defects, or IVC narrowing. Twelve (10.3%) filters were not retrieved as the patients died of their injuries (no deaths related to IVCF placement or retrieval). Forty-one (35.0%) filters had dwell times >180 days (mean 261.5 days, range 182-403). Of these, 31 (76%) were uneventfully retrieved; 10 were left in place permanently. Pre-retrieval vena cavography identified filter tilting in 13 filters: 9 had a mild tilt < or =10 degrees, and 4 had severe tilting > or =25 degrees. All of the 10 filters that could not be retrieved were tilted (4 severe and 6 mild). In comparison to the 64 (54.7%) filters in place for <180 days (mean 51 days, range 42-180), 4 (6.2%) could not be retrieved (p = 0.367). No filter had trapped thrombus identified by vena cavography at the time of retrieval. None of the retrieved filters had structural fracture or collapse, and none had migrated. Post-retrieval vena cavograms demonstrated no contrast extravasation, intraluminal defects, or impingement on adjacent organs. If retrieval of a Gunther Tulip filter with an dwell time >180 days is considered, the patient should be ambulatory and a candidate for anticoagulation if indicated; notably, the filter should have a <25 degrees tilt. Under these circumstances, retrieval of the Günther Tulip filter after 180 days of dwell time appears justified and safe.

Retrieval of Trapped Günther Tulip Inferior Vena Cava Filters: Snare–over–Guide Wire Loop Technique

The Günther Tulip inferior vena cava (IVC) filter is designed for transjugular retrieval with use of a sheath and snare device. This report describes a technique for removal of difficult-to-retrieve Günther Tulip IVC filters when the standard method fails. In a series of four patients, each with an IVC filter refractory to capture by snare alone, the use of a snare-over-guide wire loop technique succeeded in retrieving the filter in all cases.

Gunther Tulip Inferior Vena Cava Filter Placement During Treatment for Deep Venous Thrombosis of the Lower Extremity

To evaluate the efficacy and safety of Gunther tulip retrievable vena cava filter (GTF) implantation to prevent pulmonary embolism during intravenously administered thrombolytic and anticoagulation therapy and interventional radiological therapy for occlusive or nonocclusive deep venous thrombosis (DVT) of the lower extremity. We evaluated placement of 55 GTFs in 42 patients with lower extremity DVT who had undergone various treatments including those utilizing techniques of interventional radiology. Worsening of pulmonary embolism in patients with existing pulmonary embolism or in those without pulmonary embolism at the time of GTF insertion was avoided in all patients. All attempts at implantation of the GTF were safely accomplished. Perforation and migration experienced by one patient was the only complication. Mean period of treatment for DVT under protection from pulmonary embolism by the GTF was 12.7 +/- 8.3 days (mean +/- SD, range 4-37 days). We attempted retrieval of GTFs in 18 patients in whom the venous thrombus had disappeared after therapy, and retrieval in one of these 18 cases failed. GTFs were left in the vena cava in 24 patients for permanent use when the DVT was refractory to treatment. The ability of the GTF to protect against pulmonary embolism during treatment of DVT was demonstrated. Safety in both placement and retrieval was clarified. Because replacement with a permanent filter was not required, use of the GTF was convenient when further protection from complicated pulmonary embolism was necessary.

In Vitro Study of Guide Wire Entrapment in Currently Available Inferior Vena Cava Filters

Guide wire entrapment by some older inferior vena cava (IVC) filters is known to occur, particularly with J-tipped wires. Three new IVC filters have recently been approved for use in the United States. An in vitro study was performed to compare the risk of engaging and entrapping guide wires in eight of the IVC filters currently available in the United States. Titanium Greenfield, over-the-wire stainless-steel Greenfield, Simon nitinol, Bird's Nest, Vena Tech LGM, Vena Tech LP, TrapEase, and Günther Tulip IVC filters were deployed separately in an in vitro IVC flow model. Four different wires (15-mm, 3-mm, and 1.5-mm J-tipped, and straight) were passed 100 times each through the filters (50 from a jugular approach and 50 from a femoral approach). The frequency and specific patterns of engagement of the wires by the filters were recorded. Engagement was defined as a filter/wire interaction that caused either the filter or the wire to be deformed. The second part of the experiment measured the force (in pounds) that was required to release wires that became engaged in the filters with use of an electromechanical test stand with a specially designed low-capacity load cell of 20 pounds. Entrapment was defined as inability to separate an engaged wire from the filter without damage to either the wire or filter. Guide wire engagement occurred in all filters tested with the 15-mm, 3-mm, and 1.5-mm J-tipped wires. The straight wire did not engage any of the filters. The wires engaged the TrapEase filter with the greatest frequency overall (72.8%; 291 of 400). The 15-mm J wire engaged the filters more often than the other wires (98.5%; 788 of 800), but never became entrapped in a filter. The Vena Tech LP and Günther Tulip filters did not entrap any of the wires. The TrapEase filter, the stainless-steel Greenfield filter, and the Vena Tech LGM filter entrapped the 3-mm and 1.5-mm J wires. The force required to disengage the wires from these filters exceeded 4 pounds and resulted in structural damage to the wire and/or filter. Among the IVC filters recently approved by the Food and Drug Administration, the TrapEase filter entrapped 3-mm and 1.5-mm J-tipped guide wires, whereas the Vena Tech LP and Günther Tulip filters did not. This study corroborates previously described wire entrapment by the stainless-steel Greenfield and Vena Tech LGM devices.