1. IVC Filter Tracking and Retrieval
February 26, 2016
Karie Schmidt, RN MSN APNP
Division of Interventional Radiology
Department of Radiology
University of Wisconsin- Madison

2. Objectives Overview of Interventional Radiology
What exactly is Interventional Radiology?
Examples of services provided
Explain what an IVC filter is.
Retrieval process in place at UW

3. What is Interventional Radiology?
A subspecialty of Radiology that involves minimally invasive, targeted treatments performed using CT, ultrasound, fluoroscopy for guidance.
In general, these procedures have less risk, less pain and less recovery time compared to open surgery.

4. IR Team at UWHC Players Areas of Coverage Doctors
Staff physicians
Fellow
Resident
Advanced Practice Providers
Registered Nurses
Radiology Techs
Medical Assistant
CNA
Prep/recovery
Intra Procedure
IR Clinic
Call triage
In patient consults
Out patient consults

5. Patient work-up Initial consultation by MD and/or NP staff NP staff
Evaluate images - candidate for procedure or not
NP staff
Clinical evaluation
Targeted history and physical examination
Medications, appropriate anesthesia, contraindications
Patient education and counseling
Labs
Coagulation profile
Renal Function – creatinine
CBC, CMP
RN staff
Pre-procedure instructions

6. Procedures Preformed by IR
Drainage of abscess
Transcutaneous
Transrectal
Transvaginal

7. Procedures Preformed by IR
Biopsy
CT guidance
US guidance
Transjugular liver biopsy

8. Procedures Preformed by IR
GI Tract
Gastrostomy tube
Transgastric tube
Gastrojejunostomy tube
Jejunostomy tube changes

9. Procedures Preformed by IR
GU Tract
Nephrostomy tube
Ureteral stents

10. Procedures Preformed by IR
Biliary Tract
Percutaneous Transhepatic Cholangiogram with biliary drain placement. (PTC)
Cholecystostomy tube placement
Biliary stenting
Brush biopsy
Stone removal

11. Procedures Preformed by IR
Central venous access procedures including
PICC lines
Tunneled line placement
Powerline
Dialysis/pheresis catheters
Port placement/removal
Fibrin sheath stripping

12. Procedures Preformed by IR
Embolization: treatment for bleeding or some types of cancer by deliberately blocking blood vessels
Uterine Artery Embolization for fibroids
Varicocele
GI Bleeding
Trauma
Tumors
Liver (HCC)
Kidney (AML)
Embolization to cut off blood supply

13. Procedures Preformed by IR
TIPS – transjugular intrahepatic portosystemic shunt placement
Fistulogram
Chest tube placement
Thrombolysis
Angiograms
Venograms
Sclerotherapy
Lymphatic malformations
Venous malformations
Arterial malformations
TIPS indications: Refractory ascites, portal hypertension with variceal bleeding that has failed endoscopic intervention

14. Procedures Preformed by IR
Inferior vena cava (IVC) filter placement
Patient tracking
IVC filter removal

15. What is an IVC Filter?
A inferior vena cava filter is a device inserted into the inferior vena cava to prevent a blood clot from entering the lungs.
Purpose is to prevent pulmonary embolism (PE).

16. Indications for IVC Filters
Contraindication to anticoagulation
Active bleeding
Complication of anticoagulation
Develop bleed
poor INR control
Failed anticoagulation
DVT formation even on anticoagulation
History of failure

17. Types of IVC Filters Permanent- unable to remove
Temporary- able to remove, but can become permanent

18. What type of filter to place?
Indication for placement
How long is the filter needed
Life expectancy of patient
Indication:
Off anticoagulation for surgery
Failed anticoagulation

19. Case Study #1
52 Y old male POD#2 left total hip knee replacement, now c/o chest pain with deep breathing
Contrast-enhanced CT was obtained

20. Case study #1
Bilateral pulmonary emboli

21. Case Study #1 Patient was started on LMWH and transitioned to Coumadin
Now returns with intramuscular (psoas) hematoma
Anticoagulation stopped
What would you recommend to prevent recurrent VTE?

22. Case Study #1 Temporary IVC filter placement
Place on the IVC filter tracking list

23. Case Study #2 73 yr old male with mantle cell lymphoma
Hx PE & DVT on anticoagulation
Now with physical decline and needing brain biopsy
After family meeting pt wanting to be transferred to comfort cares
Life expectancy of 3-6 months

24. What type of filter should be placed?
Case Study #2
What type of filter should be placed?

25. Case Study #2
Permanent IVC filter placement indicated

26. IVC Filter Placement Conscious sedation is used for procedure
Usually the IVC filter is inserted through a small tube placed in either femoral vein or IJ vein. The doctor will numb the entry site with lidocaine. Once the small tube is placed, the doctor will advance a catheter to the site where the IVC filter will be placed. Contrast dye and x-ray imaging are used to guide the way.
The IVC filter is released through the catheter and positioned in IVC below the renal veins. Then the catheter will be removed and pressure will be held at the entry site to minimize any bleeding.

27. IVC Filter Placement

28. Now What?
Review of current data provides a national IVC filter removal rate for temporary IVC filter rates to be:
20-50% in centers without a patient tracking system (most closer to 20%)
60-86% in centers with a dedicated patient tracking system

29. IVC Filter Tracking Team
Advanced Practice Provider (NP/PA) RN
IR Tech
Once monthly-IR tech runs list of IVC filter pts with MR#’s, RN compares list with excel list, F/u discussed with APP

30. Tracking List Date Placed Filter Type Indication APP Status
NAME
MR#
Date Placed
Filter Type
Indication MD
APP
Status
Planning notes

31. Follow up schedule 3 month f/u US to evaluate for BLE DVT’s
IR clinic visit with APP to discuss findings and plan moving forward
Status of clot burden
Is patient on anticoagulation?
Safe for IVC filter removal?

32. IVC Filter Removal Procedure Criteria
INR to be 2.5 or Less
Plts 50,000 or greater
Able to lay flat or semi-flat
Conscious sedation used for procedure
Need a driver upon discharge

34. Look at the Data Data from January 1, 2013-December 31,2014
Total number of filters (permanent and retrievable) placed: 123
17 of the 123 filters were permanent
Left with 106 retrievable filters placed
Started tracking pts on data base on 1/1/2012

35. Look at the Data 38 of the 106 retrievable filters became permanent
Failure of anti-coagulation
Change in patient condition
Death

36. Look at the Data 68 retrievable filters available for removal
55 have been removed
80.9% removal rate

37. Look at the Data 13 remaining retrievable filters 8 transferred care
4 still being followed
1 refused follow up care

38. Conclusion
The inception of dedicated database by an IR advanced practice provider has resulted in tracking all IR IVC filter placement patients and documented the successful removal of 80.9% of retrievable filters when deemed appropriate.
This current process of IVC Filter tracking is now being discussed with our Trauma Surgical, General Surgical and Cardiology Colleagues with the hope of institutionally capturing, tracking and monitoring all IVC Filters placed at University of Wisconsin Hospital and Clinics

39. Current Data
Effect of a retrievable IVC filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolization.
No difference in reduction of symptomatic recurrent pulmonary embolism at 3 or 6 months between groups
Anticoagulation alone is sufficient in pts whom are able to be anticoagulated.
Mismetti, P., Laporte, S., Pellerin, O., Et all, (2015). Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism. JAMA, Vol 313 (16),

40. You Decide…

42. References
Angel, L., Tapson, V., Galgon, R., Restrepo, M., & Kaufman, J. (2011). Systematic review of the use of retrievable inferior vena cava filters. Journal of Vascular and Interventional Radiology, 22 (11),
Gasparis, A., Spentzouris, G., Meisner, R., Elitharp, D., Labropoulos, N., & Tassiopoulos, A., (2011). Improving retrieval rates of temporary inferior vena cava filters. Journal of Vascular Surgery, 54 (19S), 34S-38S.
Lynch, F. (2011). A method of following patients with retrievable inferior vena cava filters: results and lessons learned from the first 1,100 patients. Journal of Vascular and Interventional Radiology, 22,
Mismetti, P., Laporte, S., Pellerin, O., Et all, (2015). Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism. JAMA, Vol 313 (16),
Ni, H., & Lei, L. (2013). Retrievable inferior vena cava filters for venous thromboembolism. ISRN Radiology, vol 2013 (2013), Article ID , 8 pages.
Sarosiek, S., Crowther, M., & Sloan, M. (2013). Indications, complications, and management of inferior vena cava filters. Journal of the American Medical Association Internal Medicine, Vol 173 (7),