CRT 2012 Primer for Endovascular Interventions

IVC Filters: When? Which Ones? And How?

Anthony C. Venbrux, MD Professor of Radiology and Surgery Director, Vascular and Interventional Radiology The George Washington University Medical Center Washington, DC

Anthony Venbrux, MD Cook, Inc. Cordis Endovascular Honoraria received for medical lectures: Cook, Inc. Cordis Endovascular Bard Peripheral Vascular Terumo Interventional Systems Medrad-Possis Interventional Rex Medical Consultant - Bard Peripheral Vascular Consultant - ArtVentive Medical

Special Thanks To: Shawn N. Sarin, MD Andrew S. Akman, MD Albert K. Chun, MD Amy P. Harper, ACNP-BC Noel Clay Haskins, MD Frank Lynch, MD John Kaufman, MD Shundra D. Dinkins

Objectives 2) Techniques of deployment 3) Clinical applications 1) Background 2) Techniques of deployment 3) Clinical applications 4) Complications

Ideal Caval Filter Easily deployed Percutaneous approach Small puncture site Biocompatible

Nonthrombogenic Ideal Caval Filter Stress resistant Percutaneously removed

Greenfield Meditech-Boston Scientific

When ?

Classic Filter Indications Thrombo-embolic disease (TED) with Contraindication for anticoagulation. Complication of anticoagulation. Failure of anticoagulation. Massive pulmonary embolism. Chronic, recurrent pulmonary embolism.

Extended Indications - Off Label DVT/PE with poor compliance. “Widow maker” thrombus. Poor respiratory/pulmonary reserve. Unsteady patient (fall risk). No DVT/PE but at high risk for development.

Which Filter ?

Vena Cava Filters

Current U.S. Optional Filter Designs Meridian™ OptEase™ Tulip™ ALN Celect™ Option™

How ?

Cook Inc.

Removal of optional filters using currently available percutaneous techniques

What do you need?

Favorable anatomy

IVC Filter Removal Straight forward and Complex

Equipment Sheaths Directional catheters Directional guidewires Loop snares Grasping devices Baskets

ev3

Amplatz GOOSE NECK® Snare Kit (ev3) Nitinol cable with gold plated tungsten loop & platinum-iridium marker band. 90 degree snare loop. Wide range of loop diameters: 5 mm – 35 mm. Catheter length = 102 cm. Snare length = 120 cm.

EN Snare® (Angiotech / Hatch Medical) Three nitinol loops with interwoven platinum strands for radiopacity and radiopaque band. Angled catheter tip (15°) Wide range of loop diameters: 6 mm. – 45 mm. Catheter length = 100 cm. Snare length = 120 cm.

EXPRO Elite™ Snare (Radius Med. Tech.) Helical shaped loop made from cobalt chromium makes loop and tip radiopaque. Wide range of loop diameters: 5 mm – 35 mm. Snare & catheter length = 150 cm. (integrated system). Distributed by both Vascular Solutions and by Abbott.

Removal of an “Intravascular Foreign Body” Straight forward Loop snare Grasping device Complex Multiple devices used including angioplasty balloons, bronchoscopy forceps, and the“in situ” snare technique.

Retrieval with a snare and a long sheath or guiding catheter Günther Tulip (Cook) Celect (Cook) Opt Ease (Cordis Endovascular) Option (Angiotech) G 2 X, Eclipse, Meridian (Bard)

Retrieval with a “grasping”device Recovery Filter, G 2 (Bard Peripheral Vascular) Aln (Aln Implants)

Snare Retrieval EnSnare

G 2 Filter Cone Bard Peripheral Vascular.

Bard Peripheral Vascular.

Recovery (G 2) Retrieval

Can a Permanent IVC Filter be Removed?

Take Home Points