MY STORY WITH I.V.C FILTER 5/29/2018 MY STORY WITH I.V.C FILTER Mr.Mohamed Omar El-Farok M.Sc FRCSENG ,FRCSED ,IME Mr.Mohamed Omar El-Farok M.SC, FRCS

Topics to be covered: Basic facts on IVC filter Some tips and tricks Few situations you see in your carrer Summary

VTE is common

Indications of IVC filter (absolute) Recurrent VTE despite therapeutic AC Contraindication to AC Complication of AC Poorly controlled on AC Recurrent PE-IVC filter in place In concert with pulmonary embolectomy

Indications of IVC filter (Relative) Large free floating iliofemoral/caval thrombus Propagating thrombus despite adequate AC Thromboembolic disease w/limited reserve Poor compliance w/Rx Septic PE Severe ataxia /fall risk DVT thrombolysis Renal cell Ca w/renal vein or IVC involvement Prophylaxis :high risk pts,trauma, orthopedic, bariatric

Technique of IVC filter placement: Pre-operative workup Venous access puncture Pass GW to IVC then IVC filter sheath Check venogram Filter deployment Completiong venogram Followup-plan

IVC filters and DVT (ACCP) For patients w/DVT or PE no role for routine IVC filter in add,to AC (grade 1 A) If AC is contraindicated an IVC filter is recommended (Grade 1c) If IVC filter inserted as alternative to AC when bleeding risk resolves , can restart AC (Grade 1c)

FDA warning regarding IVC filters

FDA warning •“…implanting physicians and clinicians responsible for the ongoing care of patients with retrievable IVC filters consider removing the filter as soon as protection from pulmonary embolism is no longer needed.” •“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.” http://www.fda.gov/MedicalDevices/Safety/Aler tsandNotices/ucm396377.htm

Filter law .com Mr.Mohamed Omar El-Farok M.Sc, FRCSENG ,FRCSED ,IME

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Increase in IVC filter use medicare

Difficulties in venous access Always do venous duplex scan to both femoral veins and internal jugular veins Some filters can be deployed through femoral , jugular and cephalic route One can use occluded vein as an access for IVC filter placement if you have to

Complications of IVC filter IVC perforation Filter migration Erosion (25-86% on CT Visceral injury 1% Fracture Thrombosis 5 % Infection 0.1 % IVC stenosis 0.1% Embolization0.1% Recurrent DVT10% Pulmonary embolism 4.2 %

Operative removal of IVC filter

Indication of operative removal of IVC filter Severely tilted & eroding surrounding structures Unable to retrieve endovacularly with - Abdominal or chest pain -back pain - GIT bleeding Data is limited , mostly case records

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IVC filter planning sheet

How and where to implant the IVC Bony landmark Venography guided (selective , non selective) Duplex guided IVUS guided

Bony landmark 12-20 % variable venous anatomy Should be discouraged Place filter at L@ is 53.8% correct

What I do ? Review CT scan for IVC diameter Duplex guided vein puncture ½ strength contrast 6 F sheath C2 cath Renal venography 6 cc Filter insertion Completion venography 15 cc Total contast 22 cc , fluro time 2 min

Steps in Ultrasound Guided Venous Puncture (Access) Examine planned access vein with ultrasound If one cannot work through thrombosed/occluded vein, consider another access site Prep and drape site of access vein Localize skin entry point over vein access point Anesthetize skin and make incision large for tools to pass through and blunt dissect soft tissues tract Enter vein with access needle under ultrasound Can use syringe with suction to look for blood flashback to confirm vein entry It may be helpful to use a Valsalva maneuver to distend the vein Pass guidewire via needle into vein Troubleshoot as needed

Duplex guided vein puncture:

Troubleshooting Guidewire Difficulties If the guidewire does not pass easily : Double wall puncture (bevel beyond back wall). Ultrasound may show this. Pull wire back into needle. Pull needle back into lumen. Readvance guidewire Single puncture of front wall. Ultrasound may show this (bevel indenting front wall) Advance needle until it penetrate into lumen and advance guidewire Bevel partially in lumen. This can give blood return. Advance needle marginally and try readvancing guidewire

Resistance after advancing guidewire a short distance Guidewire in side branch (Fluoroscopy reveals unexpected course of guidewire) Pull back guidewire and redirect under fluoroscopy Guidewire against unexpected stenosis/occlusion (Fluoroscopy shows guide looping back on itself/deflected into unexpected course) Advance sheath or catheter over wire and perform venogram to define anatomy/pathology

Some IVC filters permanent Type of Filter Implant Route Max Allowable IVC Diameter (mm) Delivery System Size (OD (F)) Max Implant Time before Retrieval Retrieval Route Bird's NestC Fem/IJ 40 13.8 NA TrapEaseJ 30 8.5 Vena Tech LPN 28 (35 in Europe) 9 Vena Tech LGMN 28 12.9 12F GreenfieldS 15

Some IVC filters temporary Type of Filter Implant Route Max Allowable IVC Diameter (mm) Delivery System Size (OD (F)) Max Implant Time before Retrieval Retrieval Route Gunther TulipC Fem/IJ 30 10 NS IJ OptEaseJ 8.5 Fem RecoveryB 28 9 IJ (with recovery cone)

Preoperative Workup and Planning Review the clinical data to determine which group of filters to use (see the later section on filters) and examine the patient to determine what access site is available for use. It is good to match the access site to the filter required. Any available imaging should be reviewed, such as an abdominal CT scan, to get some information relating to possible variant IVC anatomy. In a morbidly obese patient, where the fluoroscopy table weight limit is exceeded, plan to use IVUS guidance for placement.

Different Scenarios of IVC placement If thrombus in IVC What to do ? Suprarenal filter (if no room in infrarenal IVC), or infrarenal filter above the clot

Duplicate IVC what to do ? 1. One infrarenal filter in each IVC, or   2. Suprarenal filter.

1. Place filter in main IVC and embolize the accessory IVC with coils. Accessory IVC (small IVC forming venous ring from level of iliac veins to renal veins) 1. Place filter in main IVC and embolize the accessory IVC with coils.

Circumaortic left renal vein (forming venous ring from normal renal vein via hilum into inferior aspect of infrarenal IVC) 1. If room permits place filter below IVC opening of circumaortic vein, or   2. Suprarenal filter.

1. Infrarenal IVC filter below vein orifice if there is room, or Retro aortic renal vein (single left renal vein that empties lower in IVC) 1. Infrarenal IVC filter below vein orifice if there is room, or   2. Filter in each iliac vein.

Mega-Cava (IVC diameter >28 mm) 1. Place a bird's nest filter in infrarenal IVC, or   2. One filter in each common iliac vein.

Pregnant woman 1. Suprarenal filter

SVC filter needed (points to keep in mind) Keep apex of filter out of RA Position legs of filter above azygos if possible Avoid bird's nest filter (components will prolapse into RA)

Occluded filter what to do? Filter occlusion (no intervention in asymptomatic patient)

Symptomatic IVC filter thrombosis Pharmacologic thrombolysis/anticoagulation Mechanical thrombolysis (especially if AC contraindicated) to restore flow Suprarenal IVC filter

Filter migration inferiorly into iliac veins Place second filter above in IVC

Filter migration superiorly into RA/PA If possible attempt percutaneous filter retrieval/repositioning or Consult cardiac surgery for removal

Filter failure Place second filter below 1st if there is room, or Suprarenal IVC filter, or SVC filter (if upper extremity source)

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