IVC Filter Retrieval Dr Steven Abramowitz Med Star

IVC Filter – Retrieval Dr. Steven Abramowitz Med. Star Washington Hospital Center Washington, DC

Steven Abramowitz, MD I have no relevant financial relationships

IVC Filters • Permanent filters developed in 1990’s – US ~50, 000 implanted in 1999 • Development of retrievable filters led to increased utilization – 250, 000 in 2012

IVC Filters

IVC Filter Retrieval

IVC Filter Retrieval

Causes of Difficult Removals • • • Mis-aligned filter and retrieval device Filter tilt Tissue overgrowth apex/hook Tissue growth through filter elements Extensive wall contact Operator experience

Principles of Complex Retrieval • • • Assess need for removal Pre-procedure imaging - CT Review of prior attempts Anti-coagulate during procedure Oblique/lateral views Sequential increase in aggressiveness

Importance of Perspective

Filter Tilt • • • Anatomic Angulation Filter Tilt at Placement Migration Thrombus Shift Iatrogrentic Manipulation

Wire Guided Centering Use wire to keep sheath& filter aligned

Wire Guided Centering

Balloon Assisted Centering

Duel Snare Centering

Tissue Overgrowth - Apex

Guided Separation “Hangman” technique

Endobronchial Forceps • Rigid bronchoscopy forceps – 3 mm shaft – 60 cm working length – Bryan Co, Woburn MA – #4162 • 12 Fr sheath • Visual and tactile

”Hangman” Technique

”Hangman” Technique

Tissue Ingrowth

Snare Flip

Dual Sheath Technique

Laser-Assisted Removal • • CVX-300 system 308 nm Excimer laser Ultraviolet 50 micron penetration 12 F, 14 F, 16 F 50 cm length Kuo et al. JVIR 2010; 21: 1896 -9

Complications • • • Entanglement of snare & filter Entanglement of filter legs Filter fx IVC tear IVC thrombosis

Conclusion • • Multiple Approaches for Filter Retrieval Risk Assessment must be performed Anticoagulation strongly encouraged Consent must include risk of laceration