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

2. 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

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

4. 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)

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

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

7. Filter Types
Closed cell or “Double Basket”
Conical
Hybrid

8. 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

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

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

11. 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

12. Numbers too small in each subgroup

13. 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

14. 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

15. 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

16. 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

17. 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

18. Thanks!
Thanks!
New River Bridge West Virginia

19. 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