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Vena Cava Filter Placement and Retrieval
Nathan Saucier, MD; Gloria M. Salazar, MD
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        TERMINOLOGY

        • Abbreviations

          • Vena cava filter (VCF)
        • Definitions

          • VCF: Endovascular medical device implanted percutaneously in vena cava
            • Designed to mechanically trap venous emboli
            • Mechanical prophylaxis for pulmonary embolus (PE)
            • Multiple indications for placement
          • Permanent filter: Designed for permanent caval interruption
            • Indicated for long-term contraindication to anticoagulation
            • Not designed/approved for retrieval
              • Increasingly fewer insertions; nonpermanent filters preferred
            • Multiple proprietary designs
              • Gianturco-Roehm Bird's Nest (Cook Medical; Bloomington, IN)
                • V-shaped struts support random tangle of wires
                • May place in inferior vena cava (IVC) with diameters of up to 40 mm
                • Produces marked MR susceptibility artifacts
              • Greenfield (Boston Scientific; Natick, MA)
                • Cone-shaped design; can fill 70-80% of device with clot without affecting IVC blood flow
                • Titanium and over-the-wire (OTW) configurations
              • Simon Nitinol (Bard; Covington, GA)
                • 2-level filter design: Upper level cone-shape/lower level self-centering legs
                • Produces minimal MR artifact
              • TrapEase (Cordis; Bridgewater, NJ)
                • Nitinol; self-centering double-basket design
                • Approved for IVC diameters of up to 30 mm
              • Vena Tech (B. Braun; Bethlehem, PA)
                • Made from Phynox: Nonferromagnetic alloy; excellent MR compatibility
                • Conical design; 6 longitudinal anchoring side rails to improve device centering
          • Nonpermanent filter: Designed for temporary caval interruption
            • Retrievable (optional) filters
              • Designed for removal after risk of PE resolved
              • Can remain permanently: < 50% of filters removed
              • Retrievability period: Variable (device specific)
              • Short-term contraindication for anticoagulation
            • Temporary filters
              • Not designed for permanent placement
              • Must remove before filter/tether adheres to IVC
              • Not available in USA
            • Convertible (optional) filters
              • Permanent device that can be structurally altered to no longer function as filter
              • If not converted, provides permanent protection
            • Available nonpermanent filters
              • Crux Vena Cava Filter System (Volcano; San Diego, CA)
                • Self-centering, no tilt spiral design
                • Caudal and cephalad retrieval hooks
                • Allows jugular or femoral placement (and retrieval)
              • Denali (Bard; Covington, GA)
                • 2 levels of filtration: 6 primary legs with anchors, 6 secondary legs
                • Conical self-centering design with retrieval hook at apex
                • Previous iterations no longer available (e.g., G-2, Meridian, Eclipse)
              • Günther Tulip (Cook Medical; Bloomington, IN)
                • Conical design with retrieval hook at apex
                • 4 primary legs with anchors
                • Each primary leg has 2 secondary legs for filtration/stabilization
              • Celect (Cook Medical; Bloomington, IN)
                • Conical design with retrieval hook at apex
                • Upper self-centering tier/lower tier hooks
              • Option ELITE (Angiotech; Vancouver, BC)
                • Conical design with retrieval hook at apex; 6 struts with anchors
                • 5-Fr internal diameter delivery sheath
                • May be placed via popliteal or antecubital veins
                • OTW placement for stability and precise placement
              • OptEase (Cordis; Bridgewater, NJ)
                • Similar to TrapEase; caudal retrieval hook
              • SafeFlo (Rafael Medical; Dover, DE)
                • Nitinol double-ring anchoring mechanism; alternative to strut-based filter designs
                • FDA approval only for permanent insertion; European approval as retrievable
          • Anatomical filter placement locations/indications
            • Infrarenal IVC: Ideal/preferred VCF location
              • Normal IVC and renal veins
                • Immediately below lowest renal vein level
              • Circumaortic left renal vein
                • Place filter below this level or suprarenal
            • Suprarenal IVC: Location indicated when infrarenal VCF placement problematic
              • Anatomic variants
                • Duplicated infrarenal IVC (1-2% incidence): Left IVC drains into normal left renal vein; joins right IVC; forms single normal suprarenal IVC
                • Left IVC (0.5% incidence): IVC enters left renal vein; courses right to form single normal suprarenal IVC
                • Low insertion of renal veins
              • Pregnancy
              • Thrombus in IVC/gonadal/renal veins
              • Pelvic mass compressing infrarenal IVC
              • Presurgical placement followed by surgery in which IVC manipulation may occur
            • Bilateral common iliac veins: Alternative location to suprarenal IVC filter placement
              • Anatomic variants
                • Duplicated IVC
                • Low insertion of renal veins
                • Megacava
              • Surgery in which IVC manipulation may occur
            • Superior vena cava (SVC): May be considered for upper extremity deep venous thrombosis (DVT)
              • Not routinely done
              • Literature suggests benefit in select subgroup of patients
              • Unique risks include
                • SVC thrombosis
                • Migration to heart (closer)
                • SVC perforation
          • Intravascular ultrasound (IVUS): Specially designed catheter; miniaturized distal US probe
            • Provides 360° intravascular field of view
              • Visualizes endothelium, venous confluences
              • Adjacent arterial/venous structures visualized
            • Provides image guidance if cannot use fluoroscopy
              • Bedside IVC filter placement
              • Contraindication to contrast

        PREPROCEDURE

        • Indications

          • Contraindications

            • Preprocedure Imaging

              • Getting Started

                PROCEDURE

                • Patient Position/Location

                  • Procedure Steps

                    • Alternative Procedures/Therapies

                      POST PROCEDURE

                      • Things to Do

                        OUTCOMES

                        • Complications

                          Selected References

                          1. Kearon C et al: Antithrombotic therapy for VTE disease: CHEST Guideline and Expert Panel Report. Chest. 149(2):315-52, 2016
                          2. Kalva SP et al: Long-term safety and effectiveness of the "OptEase" vena cava filter. Cardiovasc Intervent Radiol. 34(2):331-7, 2011
                          3. Oh JC et al: Removal of retrievable inferior vena cava filters with computed tomography findings indicating tenting or penetration of the inferior vena cava wall. J Vasc Interv Radiol. 22(1):70-4, 2011
                          4. Van Ha TG et al: Use of retrievable filters in alternative common iliac vein location in high-risk surgical patients. J Vasc Interv Radiol. 22(3):325-9, 2011
                          5. Nicholson W et al: Prevalence of fracture and fragment embolization of Bard retrievable vena cava filters and clinical implications including cardiac perforation and tamponade. Arch Intern Med. 170(20):1827-31, 2010
                          6. Kalva SP et al: Suprarenal inferior vena cava filters: a 20-year single-center experience. J Vasc Interv Radiol. 19(7):1041-7, 2008
                          7. Stavropoulos SW et al: Embedded inferior vena cava filter removal: use of endobronchial forceps. J Vasc Interv Radiol. 19(9):1297-301, 2008
                          8. Kaufman JA et al: Guidelines for the use of retrievable and convertible vena cava filters: report from the Society of Interventional Radiology multidisciplinary consensus conference. J Vasc Interv Radiol. 17(3):449-59, 2006
                          9. PREPIC Study Group.: Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d'Embolie Pulmonaire par Interruption Cave) randomized study. Circulation. 112(3):416-22, 2005
                          10. Ebaugh JL et al: Bedside vena cava filter placement guided with intravascular ultrasound. J Vasc Surg. 34(1):21-6, 2001
                          11. Grassi CJ et al: Quality improvement guidelines for percutaneous permanent inferior vena cava filter placement for the prevention of pulmonary embolism. SCVIR Standards of Practice Committee. J Vasc Interv Radiol. 12(2):137-41, 2001
                          12. Levy JM et al: Inferior vena cava filter placement. American College of Radiology. ACR Appropriateness Criteria. Radiology. 215 Suppl:981-97, 2000
                          Related Anatomy
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                          Related Differential Diagnoses
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                          References
                          Tables

                          Tables

                          KEY FACTS

                          • Terminology

                            • Preprocedure

                              • Procedure

                                TERMINOLOGY

                                • Abbreviations

                                  • Vena cava filter (VCF)
                                • Definitions

                                  • VCF: Endovascular medical device implanted percutaneously in vena cava
                                    • Designed to mechanically trap venous emboli
                                    • Mechanical prophylaxis for pulmonary embolus (PE)
                                    • Multiple indications for placement
                                  • Permanent filter: Designed for permanent caval interruption
                                    • Indicated for long-term contraindication to anticoagulation
                                    • Not designed/approved for retrieval
                                      • Increasingly fewer insertions; nonpermanent filters preferred
                                    • Multiple proprietary designs
                                      • Gianturco-Roehm Bird's Nest (Cook Medical; Bloomington, IN)
                                        • V-shaped struts support random tangle of wires
                                        • May place in inferior vena cava (IVC) with diameters of up to 40 mm
                                        • Produces marked MR susceptibility artifacts
                                      • Greenfield (Boston Scientific; Natick, MA)
                                        • Cone-shaped design; can fill 70-80% of device with clot without affecting IVC blood flow
                                        • Titanium and over-the-wire (OTW) configurations
                                      • Simon Nitinol (Bard; Covington, GA)
                                        • 2-level filter design: Upper level cone-shape/lower level self-centering legs
                                        • Produces minimal MR artifact
                                      • TrapEase (Cordis; Bridgewater, NJ)
                                        • Nitinol; self-centering double-basket design
                                        • Approved for IVC diameters of up to 30 mm
                                      • Vena Tech (B. Braun; Bethlehem, PA)
                                        • Made from Phynox: Nonferromagnetic alloy; excellent MR compatibility
                                        • Conical design; 6 longitudinal anchoring side rails to improve device centering
                                  • Nonpermanent filter: Designed for temporary caval interruption
                                    • Retrievable (optional) filters
                                      • Designed for removal after risk of PE resolved
                                      • Can remain permanently: < 50% of filters removed
                                      • Retrievability period: Variable (device specific)
                                      • Short-term contraindication for anticoagulation
                                    • Temporary filters
                                      • Not designed for permanent placement
                                      • Must remove before filter/tether adheres to IVC
                                      • Not available in USA
                                    • Convertible (optional) filters
                                      • Permanent device that can be structurally altered to no longer function as filter
                                      • If not converted, provides permanent protection
                                    • Available nonpermanent filters
                                      • Crux Vena Cava Filter System (Volcano; San Diego, CA)
                                        • Self-centering, no tilt spiral design
                                        • Caudal and cephalad retrieval hooks
                                        • Allows jugular or femoral placement (and retrieval)
                                      • Denali (Bard; Covington, GA)
                                        • 2 levels of filtration: 6 primary legs with anchors, 6 secondary legs
                                        • Conical self-centering design with retrieval hook at apex
                                        • Previous iterations no longer available (e.g., G-2, Meridian, Eclipse)
                                      • Günther Tulip (Cook Medical; Bloomington, IN)
                                        • Conical design with retrieval hook at apex
                                        • 4 primary legs with anchors
                                        • Each primary leg has 2 secondary legs for filtration/stabilization
                                      • Celect (Cook Medical; Bloomington, IN)
                                        • Conical design with retrieval hook at apex
                                        • Upper self-centering tier/lower tier hooks
                                      • Option ELITE (Angiotech; Vancouver, BC)
                                        • Conical design with retrieval hook at apex; 6 struts with anchors
                                        • 5-Fr internal diameter delivery sheath
                                        • May be placed via popliteal or antecubital veins
                                        • OTW placement for stability and precise placement
                                      • OptEase (Cordis; Bridgewater, NJ)
                                        • Similar to TrapEase; caudal retrieval hook
                                      • SafeFlo (Rafael Medical; Dover, DE)
                                        • Nitinol double-ring anchoring mechanism; alternative to strut-based filter designs
                                        • FDA approval only for permanent insertion; European approval as retrievable
                                  • Anatomical filter placement locations/indications
                                    • Infrarenal IVC: Ideal/preferred VCF location
                                      • Normal IVC and renal veins
                                        • Immediately below lowest renal vein level
                                      • Circumaortic left renal vein
                                        • Place filter below this level or suprarenal
                                    • Suprarenal IVC: Location indicated when infrarenal VCF placement problematic
                                      • Anatomic variants
                                        • Duplicated infrarenal IVC (1-2% incidence): Left IVC drains into normal left renal vein; joins right IVC; forms single normal suprarenal IVC
                                        • Left IVC (0.5% incidence): IVC enters left renal vein; courses right to form single normal suprarenal IVC
                                        • Low insertion of renal veins
                                      • Pregnancy
                                      • Thrombus in IVC/gonadal/renal veins
                                      • Pelvic mass compressing infrarenal IVC
                                      • Presurgical placement followed by surgery in which IVC manipulation may occur
                                    • Bilateral common iliac veins: Alternative location to suprarenal IVC filter placement
                                      • Anatomic variants
                                        • Duplicated IVC
                                        • Low insertion of renal veins
                                        • Megacava
                                      • Surgery in which IVC manipulation may occur
                                    • Superior vena cava (SVC): May be considered for upper extremity deep venous thrombosis (DVT)
                                      • Not routinely done
                                      • Literature suggests benefit in select subgroup of patients
                                      • Unique risks include
                                        • SVC thrombosis
                                        • Migration to heart (closer)
                                        • SVC perforation
                                  • Intravascular ultrasound (IVUS): Specially designed catheter; miniaturized distal US probe
                                    • Provides 360° intravascular field of view
                                      • Visualizes endothelium, venous confluences
                                      • Adjacent arterial/venous structures visualized
                                    • Provides image guidance if cannot use fluoroscopy
                                      • Bedside IVC filter placement
                                      • Contraindication to contrast

                                PREPROCEDURE

                                • Indications

                                  • Contraindications

                                    • Preprocedure Imaging

                                      • Getting Started

                                        PROCEDURE

                                        • Patient Position/Location

                                          • Procedure Steps

                                            • Alternative Procedures/Therapies

                                              POST PROCEDURE

                                              • Things to Do

                                                OUTCOMES

                                                • Complications

                                                  Selected References

                                                  1. Kearon C et al: Antithrombotic therapy for VTE disease: CHEST Guideline and Expert Panel Report. Chest. 149(2):315-52, 2016
                                                  2. Kalva SP et al: Long-term safety and effectiveness of the "OptEase" vena cava filter. Cardiovasc Intervent Radiol. 34(2):331-7, 2011
                                                  3. Oh JC et al: Removal of retrievable inferior vena cava filters with computed tomography findings indicating tenting or penetration of the inferior vena cava wall. J Vasc Interv Radiol. 22(1):70-4, 2011
                                                  4. Van Ha TG et al: Use of retrievable filters in alternative common iliac vein location in high-risk surgical patients. J Vasc Interv Radiol. 22(3):325-9, 2011
                                                  5. Nicholson W et al: Prevalence of fracture and fragment embolization of Bard retrievable vena cava filters and clinical implications including cardiac perforation and tamponade. Arch Intern Med. 170(20):1827-31, 2010
                                                  6. Kalva SP et al: Suprarenal inferior vena cava filters: a 20-year single-center experience. J Vasc Interv Radiol. 19(7):1041-7, 2008
                                                  7. Stavropoulos SW et al: Embedded inferior vena cava filter removal: use of endobronchial forceps. J Vasc Interv Radiol. 19(9):1297-301, 2008
                                                  8. Kaufman JA et al: Guidelines for the use of retrievable and convertible vena cava filters: report from the Society of Interventional Radiology multidisciplinary consensus conference. J Vasc Interv Radiol. 17(3):449-59, 2006
                                                  9. PREPIC Study Group.: Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d'Embolie Pulmonaire par Interruption Cave) randomized study. Circulation. 112(3):416-22, 2005
                                                  10. Ebaugh JL et al: Bedside vena cava filter placement guided with intravascular ultrasound. J Vasc Surg. 34(1):21-6, 2001
                                                  11. Grassi CJ et al: Quality improvement guidelines for percutaneous permanent inferior vena cava filter placement for the prevention of pulmonary embolism. SCVIR Standards of Practice Committee. J Vasc Interv Radiol. 12(2):137-41, 2001
                                                  12. Levy JM et al: Inferior vena cava filter placement. American College of Radiology. ACR Appropriateness Criteria. Radiology. 215 Suppl:981-97, 2000