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Monday, July 23, 2018

Endovascular Removal of Fractured Inferior Vena Cava Filter Fragments: 5-Year Registry Data with Prospective Outcomes on Retained Fragments


Summary



This is a recent review of IVC filter fragment removal from Stanford University by Kuo and his collegues. The study included 82 patients as part of a prospective registry. The investigators reviewed outcomes of residual fragment removal after the main filter was removed. They included fragments that were intravascular per pre-procedure CT, procedural cone beam CT and/or intravascular US. 185 filter fragments were identified excluding the ones lodged in distal pulmonary artery. Eighty-seven of 185 fragments (47%) were deemed amenable to attempted removal: 65 IVC, 11 PA, 8 cardiac, 2 hepatic, and 1 aortic. Authors successfully removed 78 of 87 fragments (89.7%). There were 6 minor complications and 1 major complication (a cardiac tamponade that was successfully treated). Nineteen patients with retained cardiopulmonary fragments, 81% remained asymptomatic during long-term clinical follow-up of 845 days. Authors concluded that percutaneous removal of filter fragments had high technical success rate and low complication rate, except when fragments are intracardiac. Most residual fragments not amenable for retrieval remained asymptomatic and followed clinically.



Figure 3. Images from a 41-year-old patient who presented for complex retrieval of an indwelling Bard Recovery filter (2,505 d). (a,b) Axial and coronal CT images show multifocal filter penetration, with one component penetrating into the aorta (arrows) and fractured within the lumen. (c,d) Spot image of the filter and subsequent cavogram show the extracaval component (arrows). (e) Following main filter body removal, an aortogram also confirms fragment location within the aortic lumen (arrow). (f–h) Fluoroscopic images show successful percutaneous fragment removal via transfemoral arterial access.

Commentary


The paper represents outcomes of attempted and retained filter fragments at a high volume clinically oriented academic interventional radiology practice with a dedicated IVC filter clinic. Of note senior author Dr. Kuo has described first in man utilization of laser for IVC filter removal. IVC filter removal has become an increasing trend during the past 5-10 years fueled by associated law suits related to fracture and migration of filters and broken fragments. As many of us witness commonly, it is not uncommon for existing commercial filters to have broken fragments that migrate into different locations in venous system as well as to extra-venous locations. Unfortunately, there is very limited data on potential complications related to those fragments. This is the first article reviewing a large cohort of filter fragment retrieval. Authors demonstrated that most of intravascular components (confirmed by imaging) can be removed using various techniques at a highly specialized center, but at the same time there were no significant clinical negative outcomes among the filter fragments that were left behind.

After review of this manuscript and through personal experience I would recommend retrieval of intravascular fragments especially if they have the risk for eventual migration to the heart. Intracardiac fragments carry higher risk of complication during retrieval but they also pose higher risk of complications when left alone (cardiac tamponade, arrhythmias, etc). Again, when feasible with cardiac surgery support these fragments should be managed at experienced centers. Low risk fragments can be monitored with imaging and confirm stability. Thanks to the authors for providing guidance in this difficult topic.

Click here for abstract

Andrew J. Kesselman, MD, Nam Sao Hoang, BA, Alexander Y. Sheu, MD, and William T. Kuo, MD Endovascular Removal of Fractured Inferior Vena Cava Filter Fragments: 5-Year Registry Data with Prospective Outcomes on Retained Fragments J Vasc Interv Radiol. 2018 Jun;29(6):758-764. doi: 10.1016/j.jvir.2018.01.786. Epub 2018 Apr 26.

Post Author:
Bulent Arslan, MD, FSIR
Associate Professor and Associate Chair of Radiology
Division Director, Vascular and Interventional Radiology
Department of Radiology and Nuclear Medicine
Rush University Medical Center
Chicago, IL
@arslanmd

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