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Friday, November 18, 2016

5-Year Results of Laser-Assisted Vena Cava Filter Removal


Inferior vena cava (IVC) filters with prolonged implantation are associated with increased risk of filter-related complications. Prolonged dwell time is also associated with an increased risk of the filter embedding in the vessel wall increasing the likelihood of failed retrieval using standard retrieval methods. Kuo et al. recently published their 5-year results of laser-assisted removal of embedded IVC filters in the journal CHEST. A total of 251 patients were enrolled prospectively in the study after failure of standard retrieval methods. Indications for filter retrieval included symptomatic IVC thrombosis, chronic IVC occlusion, pain from filter penetration and/or reduction of risk from prolonged implantation. Success was defined as complete filter detachment and removal. Major procedure-related complications were assessed. Laser-assisted retrieval was successful in 249/251 (99.2%) with a mean dwell time of 979 days (range 37-9098). Less measured force was needed for laser-assisted retrieval compared to failed standard retrieval attempts (3.8 lbs compared to 6.7 lbs). They report a major complication rate of 1.6%. This included 2 patients who developed IVC thrombus during the procedure that was successfully treated with catheter-directed thrombolysis and 2 patients who suffered IVC injury with retroperitoneal hemorrhage and hypotension requiring endovascular stentgraft placement. Retrieval permitted a cessation of anticoagulation in 45/46 (98%) patients. Filter associated morbidity was relieved in 55/57 (96%) patients. Authors conclude the excimer laser-sheath technique is safe and effective for removing embedded IVC filters that have failed standard retrieval attempts.

Commentary

This article reports favorable results for the use of the excimer laser sheath for IVC filter retrieval that has failed standard techniques. The laser sheath is FDA approved for removal of embedded venous pacemaker leads and any use for embedded IVC filters is off-label. Failed laser-assisted retrieval occurred with cylindrical-shaped filters (1 Optease and 1 Trapease) that contained a large amount of chronic thrombus that could not be captured within the sheath. In subsequent cases, authors reduced large amounts of chronic thrombus with a separate atherectomy catheter and/or angioplasty balloon allowing for laser-assisted filter removal. Not included in the major complications were 25 patients that developed a small (<2.5 cm) pseudoaneursym and 3 patients with small focal hemorrhage. All were self-limited or treated with temporary occlusion balloon inflation with resolution on immediate follow-up venography. Pseudoaneurysms larger than 2.5 cm were followed with cross sectional imaging and found to be resolved within 2-3 months. Data for this study was collected over a 5-year time period and authors do admit to a learning curve with laser sheath usage. Prior to routine force gauge use there were 4 cases of laser sheath cracking external to the patient with application of excessive force. Additionally, the major complications reported occurred earlier in their experience. The encouraging overall safety and efficacy, therefore, may not be transferable to early experience.

Click here for abstract

Kuo WT, Odegaard JI, Rosenberg JK, Hofmann LV, Laser-Assisted Removal of Embedded Vena Cava Filters: A 5-Year First-in-Human Study, CHEST (2016), doi: 10.1016/j.chest.2016.09.029.

Post Author:
Jennifer Montgomey, MD, PhD
Assistant Professor
Cleveland Clinic

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