1. 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

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

3. VTE is common

4. 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

5. 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

6. 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

7. 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)

8. FDA warning regarding IVC filters

9. 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.”
tsandNotices/ucm htm

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

11. Official website

13. Increase in IVC filter use medicare

14. 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

15. 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 %

16. Operative removal of IVC filter

17. 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

18. Please Doc ?

19. IVC filter planning sheet

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

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

22. 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

23. 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

24. Duplex guided vein puncture:

25. 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

26. 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

27. 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

28. 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)

29. 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.

30. 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

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

32. 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.

33. 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.

34. 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.

35. 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.

36. Pregnant woman
1. Suprarenal filter

37. 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)

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

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

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

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

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

43. Thank you
Thank You