Clinical case Case Presentation: IVC Retrievable and Permanent Filters Antonios P Gasparis, MD Professor of Surgery Director, Center for Vein Care Stony Brook Medicine

72 year-old male with chronic atrial fibrillation not on anticoagulation presented with aphasia and right-sided hemiplegia. CT (computed tomography) head showed left medial cerebral artery (MCA) infarct. Patient underwent t-PA and mechanical thrombectomy.

Which of the following options would be the most appropriate for post-procedure Deep Vein Thrombosis (DVT) prophylaxis? Intermittent pneumatic compression Elastic compression stockings Chemical prophylaxis Surveillance ultrasounds Inferior vena cava (IVC) filter

Which of the following options would be the most appropriate for post-procedure Deep Vein Thrombosis (DVT) prophylaxis? Intermittent pneumatic compression Elastic compression stockings Chemical prophylaxis Surveillance ultrasounds Inferior vena cava (IVC) filter

On day #4 of admission, a CT pulmonary angiogram (CTPA) was ordered to evaluate a lesion in the right upper lobe that was seen in a previous chest x ray (CXR).

Polo mint sign CTPA shows multiple filling defects within the pulmonary vasculature consistent with acute pulmonary embolism (PE)

What is the next step?

Bilateral lower extremity duplex ultrasound (DUS) to rule out DVT was ordered.

DUS shows lack of compressibility, filling defects and minimum flow in the right popliteal vein (POP V).

DUS shows lack of compressibility, filling defects and minimum flow in the left POP V.

A follow-up CT head showed evolving left basal ganglia and corona radiata MCA territory infarct with interval development of petechial hemorrhage along the periventricular white matter.

How would you manage this patient’s DVT/PE? Systemic anticoagulation IVC filter insertion Catheter-directed thrombolysis (CDT) Mechanical thrombectomy Follow-up ultrasound

How would you manage this patient’s DVT/PE? Systemic anticoagulation IVC filter insertion Catheter-directed thrombolysis (CDT) Mechanical thrombectomy Follow-up ultrasound

What type of filter and access site?

A Cook Tulip IVC filter was inserted via right femoral approach.

4 - week follow-up CT head reported “evolving late subacute to chronic left basal ganglia infarction with no evidence of intracranial hemorrhage”. Warfarin (VKA) was started.

Any imaging prior to retrieval? 8 - week follow-up Referred to vascular surgery for IVC filter retrieval Any imaging prior to retrieval?

8 - week follow-up DUS shows lack of compressibility, filling defects and absence of flow in the right POP V (no change from initial DUS).

DUS shows new filling defect in the left external iliac vein (EIV).

DUS shows lack of compressibility, filling defects and absence of flow in the left common femoral vein (new).

DUS shows lack of compressibility, filling defects and absence of flow in the left femoral vein (new).

Now what?

Cavogram for IVC filter retrieval at 8 weeks after VKA being started shows IVC filter thrombosis.

What would be the most appropriate next step? Thrombolysis for IVC thrombus Angiovac Continue anticoagulation Supra-renal IVC filter Retrieve the IVC filter

What would be the most appropriate next step? Thrombolysis for IVC thrombus Angiovac Continue anticoagulation Supra-renal IVC filter Retrieve the filter

Discussion Although IVC filters reduce the risk of PE, they can increase the risk of other complications such as IVC thrombosis. Decousus H., Leizorovicz A., Parent F., Page Y., Tardy B.,Girard P., et al. 1998. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep‐vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group. N. Engl. J. Med. 338:409–415.  The incidence of IVC filter thrombosis ranges from 13-30%. Group PS . 2005. Eight‐year follow‐up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d'Embolie Pulmonaire par Interruption Cave) randomized study. Circulation 112:416–422 Pan Y, Zhao J, Mei J, et al. Retrievable Inferior Vena Cava Filters in Trauma Patients: Prevalence and Management of Thrombus Within the Filter. Eur J Vasc Endovasc Surg. 2016 Sep 27

Discussion Highest risk factors for IVC filter thrombosis include age, type of filter and lack of anticoagulation therapy Tardy B., Mismetti P., Page Y., Décousus H. Da Costa A., Zeni F., et al. 1996. Symptomatic inferior vena cava filter thrombosis: clinical study of 30 consecutive cases. Eur. Respir. J. 9:2012–2016. Retrieval rates of inferior vena cava (IVC) filters in US hospitals range from 11 - 70%. The most common reason for failure in retrieval was filter thrombus. Peterson EA, Yenson PR, Liu D, at al. Predictors of attempted inferior vena cava filters retrieval in a tertiary care centre. Thromb Res. 2014 Aug;134(2):300-4.

Discussion Various techniques for retrieval of a thrombosed IVC filter has not been reported including: CDT, mechanical thrombectomy, laser-assisted removal, or combination of different modalities. The retrieval rate for IVC filter thrombosis ranges from 75 – 100% in different series. Jiang J, Tu J, Jia Z, at al. Incidence and Outcomes of Inferior Vena Cava Filter Thrombus during Catheter-directed Thrombolysis for Proximal Deep Venous Thrombosis. Ann Vasc Surg. 2016 Aug 12. Branco BC, Montero-Baker MF, Espinoza E, et al. Pharmacomechanical thrombolysis in the management of acute inferior vena cava filter occlusion using the Trellis-8 device.J Endovasc Ther. 2015 Feb;22(1):99-104.

764 patients having filters implanted were referred for filter removal Discussion 764 patients having filters implanted were referred for filter removal The incidence of infra-filter thrombus was 30.9% (236 cases), and occlusion of the filter bearing IVC was seen in 2.4% (18) of cases 121 cases with small clots – retrieval with snare and sheath technique 116 cases with massive thrombus – CDT and/or negative pressure aspiration 213 cases (90.3%) of thrombus in the filter were removed successfully without PE Pan Y, Zhao J, Mei J, et al. Retrievable Inferior Vena Cava Filters in Trauma Patients: Prevalence and Management of Thrombus Within the Filter. Eur J Vasc Endovasc Surg. 2016 (In Press)