IVC Filter Placement Which and How Mark C. Bates MD, DSc, FACC, FSVM CAMC Health Education and Research Institute Charleston West Virginia

Mark C, Bates, MD, DSc, FACC, FSVM Disclosure Slide Mark C, Bates, MD, DSc, FACC, FSVM   Consultant: W. L. Gore and Associates Vascular Dynamics, Inc Inventor Shareholder: Nexeon MedSystems, Inc Pulsus Medical, Inc Touchstone Alpha, LLC Speaker: Maquet Medical

IVC Filter Placement Which and How Mark C. Bates MD, DSc, FACC, FSVM CAMC Health Education and Research Institute Charleston, West Virginia

History: We have come a long way 2008 Chirurgicaux 2008 Option (Angiotech) 2007 G2x Eclipse (Bard) 2007 Celect (Cook) 2003 Recovery (Bard) 2002 OptEase (Cordis) 2002 Gunther Tulip (cook) 1990b Simon NiTi (Bard) 1989 Vena Tech LGM (B Braun) 1989 Titanium Greenfield (Boston Sci) 1982 Bird Nest (Cook Medical) 1969 Stainless steel Greenfield 1967 Mobin-Uddin Modified from Data presented by Matthew Johnson, MD FSIR (Society of Interventional Radiology Meeting 2013)

BUT… Proximal Laser sheath Distal Laser sheath Example(30 year old with back pain 10 years post filter)

Dense IVC thrombus inside filter apex Preventing 16 Fr laser sheath capture Cheese cutter approach to remove limbs Thrombosis Migration and Thrombosis Endojunk

Filter Types Closed cell or “Double Basket” Conical Hybrid

Most Important consideration  ”A patient should be referred for IVC filter removal when the risk/benefit profile favors removal and the procedure is feasible given the patient’s health status” Best filter: (Temporary that you are confident can be easily removed). Best Technique: Don’t leave the lab with a filter tilt or position that will impede retrieval

‘Retrieveability’ Signals on ease of retrieval BUT numbers are too small to be conclusive

Picking a filter based on complication risks and anatomy MAUDE Database 1,063 Filter complications reported J Vasc Interv Radiol 2014; 25: 1181 -1185

Buyers guide Endovascular today 2017 Company Name Product Name Indicated Caval Diameter (mm) (Based on average caval diameter) Maximum Deployed Length (mm) Catheter Carrier System ID (F) Material Design Approach Permanent/Retrievable ALN ALN Optional Filter 32 55 7 Stainless steel Conical Femoral/jugular/brachial Optional (permanent or temporary) ALN Optional Filter With Hook 59 Argon Medical Devices, Inc. OptionElite Up to 30 56.5 5 Nitinol Femoral/jugular/antecubital/popliteal, standard, or OTW Optional (permanent or retrievable) B. Braun Interventional Systems, Inc. Vena Tech Convertible Filter 28 60 12.9 Cobalt chromium Femorial, jugular Convertible B. Braun Interventional Systems/Vena Tech Vena Tech LP Filter 43 Phynox wire Femoral/jugular Permanent Bard Peripheral Vascular, Inc. Denali Filter 50 (unconstrained) 8.4 Bilevel, conical Bio2 Medical, Inc. Angel Catheter 15–30 50 9 OD; 8 ID Femoral Retrievable Boston Scientific Corporation Stainless Steel Over-the-Wire Greenfield Filter (SGF) 12 316L surgical stainless steel Titanium Greenfield Filter (TGF) Beta III titanium alloy Cook Medical Bird's Nest Filter 40 80 Biocompatible stainless steel Varying unique design Celect Platinum 30 51 Conichrome Günther Tulip Filter Cordis, a Cardinal Health company OptEase Retrievable Vena Cava Filter 54 6 Double basket Femoral/jugular/antecubital TrapEase Permanent Vena Cava Filter Buyers guide Endovascular today 2017

Numbers too small in each subgroup

Kaiser Permanente National IVC Registry 96 patients (39 permanent and 57 retrievable) Mean dwell time 61 months Fracture rate overall 13.5% TrapEase (23% incidence) Partial or complete IVC occlusion 12.5% IVC Perforation 47.9% Higher in retrievable (70%) than permanent (15.4%) Perforation involving retroperitoneal structures 68% in retrievable versus 5% in permanent JVIR Scientific Sessions

IVC Size 28 to 31 mm most filters work depending on the IFU. Large IVCs (32 to 40 mm) the only option is the Gianturco-Roehm Birds Nest filter. Note: when measuring diameter you can use the Heyt / Diaz equation (below) or do what I do – just measure the diameter from AP angio

Sheath Positioned above bifurcation and device introduced After IVC Angiogram and Sizing… Rt Renal vein Lt Renal vein Sheath and filter retracted until Apex slightly above lowest renal vein Sheath retracted while pusher held perfectly stationary (Focus on Apex RO marker and do not let it move) Note: Renal vein flow (in theory) may enhance apex clearing and reduce thrombosis Sheath Positioned above bifurcation and device introduced

Single sheath IVUS Guided Filter advanced to end of sheath based on measured distance IVUS used to define lowest renal vein and sheath positioned Pin – pull to release zr zr zr zr zr zr

Conclusions There is inadequate comparative data to say ANY filter or deployment approach is better than another. However, here are my selection tips If the IVC is large (> 31mm and < 40mm) then the Birds Nest is the only option. If follow-up is a concern then perhaps a non-nitinol removable filter may be beneficial to reduce long-term fracture risk??? (e.g. Elgiloy, stainless steel,…) In pregnant patients conceder filter placement above the renal vein and use a filter with lower reported risk of perforation. If the patient has a small IVC OR is hypercoagulable then perhaps avoid use of the Optize or VenaTech filters (Seem to have higher thrombosis rate) Bard filters may be easier to retrieve but also trend towards higher fracture risk. Cook filters may have less fracture risk but tend to be more likely to tilt (Confirm hook is not embedded prior to leaving lab) Make sure you have an app or system to remind the team to contact the patient and ensure retrieval is done as soon as safely possible

Thanks! Thanks! New River Bridge West Virginia

Approach Fluoroscopy Guided Right IJ or antecubital Ultrasound Guided Access preferred IVC measurements using marker pigtail or marker sheath (20 cc/sec X 2 seconds). Mark level of lowest renal vein. Note: If IVC smaller than expected or a contrast inflow defect is noted below left renal vein exclude duplicate IVC (0.3% of patients)? Station sheath 1.5 X filter length below the lowest renal vein Position proximal RO filter marker at level of lowest renal vein and hold pusher stationary while sheath is retracted. Note: This is not a “push / pull” maneuver rather ”Pin / pull” Focus on avoiding forward movement of the pusher will reduce tilt and embedding of apex. Repeat angiogram (with spin if available). If the apex is tenting the IVC it is worth taking the time to snare and reposition