Pictorial review of IVC filters and their complications

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1 Pictorial review of IVC filters and their complications Poster No.: C-1353 Congress: ECR 2014 Type: Educational Exhibit Authors: J. A. Vossen, J. S. Golia, L. Miller, D. Fedele, N. Velasco; Bridgeport, CT/US Keywords: Veins / Vena cava, CT, Plain radiographic studies, Fluoroscopy, Filter insertions, Outcomes DOI: /ecr2014/C-1353 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 22

2 Learning objectives To review the imaging features of inferior vena cava (IVC) filter complications. To outline both early and late occurring complications. To discuss management strategies. Background Deep vein thrombosis (DVT) and pulmonary embolism (PE) are associated with significant morbidity and mortality. IVC filters have gained acceptance for use in patients in whom standard anticoagulation therapy is contraindicated or ineffective. IVC filters are relatively safe to deploy and effective in most patients, however, there have been several reports of short- and long-term complications. A major complication rate of approximately 0.3% has been reported. Reported complications from IVC filters include: Deployment complications: Filter tilt Deployment outside target area Access site thrombosis and infection Venous anomalies Post deployment complications: Filter penetration of caval wall PE and IVC or lower limb thrombosis Filter fracture Filter migration Retrieval complications: Caval tear Findings and procedure details Page 2 of 22

3 Filter Tilt (Fig. 16 on page 4) Filter tilt: angulation of the filter >15-30 from the longitudinal axis of the IVC. Slight filter angulation after insertion is common and insignificant. Might reduce the filtration efficiency and predispose to caval perforation and pulmonary emboli. Deployment outside target area (Fig. 1 on page 4, Fig. 2 on page 5, Fig. 3 on page 7 and Fig. 4 on page 9) Misplaced IVC filters in the iliac veins, right renal vein, hepatic veins, lumbar veins, gonadal veins, aorta and spinal canal have been reported. Optional filters can be retrieved and repositioned. Venous anomalies; double IVC with single filter (Fig. 5 on page 11) Congenital anomalies of the IVC and its tributaries originate from a defective embryogenesis of three paired embryonic veins. Reported incidence of IVC duplication: 2-3%. Recognizing IVC defects is crucial before IVC filter placement. Venography currently appears to be the best way to study IVC anomalies. Duplication of the IVC on cavography can be recognized by lack of visualization of the left iliac inflow and increased left renal vein inflow. If a double IVC is identified before filter placement, options for filter placement include: - filter placement in each IVC - filter placement in the unpaired suprarenal IVC - filter placement in the right IVC with concurrent embolization of the left IVC Filter penetration of caval wall (Fig. 6 on page 11) Filter penetration = penetration of the caval wall #3 mm by a filter strut or hook. Reported incidence: 70-85%. Clinical presentation: the majority of perforations are asymptomatic. Complications associated with caval penetration by IVC filters include pancreatitis, aortic pseudoaneurysm, aortocaval fistula, duodenal perforation, retroperitoneal hemorrhage, and chronic pain. Treatment: retrieval of the filter should be performed in a symptomatic patient if the filter permits and is of the retrievable type. IVC thrombus (Fig. 7 on page 12, Fig. 8 on page 13, Fig. 9 on page 14, Fig. 10 on page 15 and Fig. 11 on page 16) IVC thrombus = occluding thrombus in the IVC after filter placement. Reported incidence: 2-30%. Asymptomatic in approximately 50% of the cases. Page 3 of 22

Symptoms include lower extremity swelling, PE, and renal failure. Treatment options include: systemic anticoagulation, thrombolytic agents, and balloon angioplasty and stent placement.

4 Symptoms include lower extremity swelling, PE, and renal failure. Treatment options include: systemic anticoagulation, thrombolytic agents, and balloon angioplasty and stent placement. Filter migration (Fig. 12 on page 16) Filter migration= movement of the filter > 1-2 cm in either the caudal or the cephalad direction. Reported incidence: 2-13%. (More common with early type filters due to lack of hooks). Usually without clinical sequelae, but can result in complications, including death (due to migration into the heart and pulmonary arteries). Risk factors include: inappropriate filter size, inadequate hooking of the filter struts into the caval wall, large thrombus within the filter, guidewire entanglement during intravascular procedure. Treatment: retrieval of filter endovascularly or surgically. Filter fracture (Fig. 13 on page 17, Fig. 14 on page 18 and Fig. 15 on page 19) Filter fractures are fairly rare and have been reported in 1-10% of cases. The mechanism of fracture may be related to tilting of the filter, continuous strain on the engaged strut resulting in repetitive flexion, and eventual fracture caused by metal fatigue. Free fragments migrate into hepatic veins and pulmonary artery branches. Treatment: Percutaneous retrieval of filters with arm fracture or arm migration is recommended. Images for this section: Fig. 16: Abdominal radiograph and axial and coronal CT images showing a tilted filter leading to (asymptomatic) perforation of the medial and posterior IVC wall. Page 4 of 22

5 Fig. 1: Abdominal radiograph and axial and coronal CT images showing an unopened IVC filter within the lumbar vein (arrow) and an open IVC filter within the inferior vena cava. Page 5 of 22

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7 Fig. 2: Abdominal radiograph and axial and coronal CT images showing an unopened IVC filter within the lumbar vein (arrow) and an open IVC filter within the inferior vena cava. Page 7 of 22

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9 Fig. 3: Abdominal radiograph and axial and coronal CT images demonstrating low placement of the filter in the right common iliac vein instead of the inferior vena cava. Page 9 of 22

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Fig. 4: Abdominal radiograph and axial and coronal CT images demonstrating low placement of the filter in the right common iliac vein instead of the inferior vena cava. Fig.

11 Fig. 4: Abdominal radiograph and axial and coronal CT images demonstrating low placement of the filter in the right common iliac vein instead of the inferior vena cava. Fig. 5: 51 year old male presenting with PE after IVC filter placement. Coronal and axial CT images demonstrating a double IVC. The left sided IVC does not contain a filter (arrow). Page 11 of 22

12 Fig. 6: Axial (A+C) and coronal (B+D) CT images showing (asymptomatic) perforation of the medial and posterior IVC wall. One of the struts is in close relationship with the abdominal aorta (arrow). Page 12 of 22

13 Fig. 7: Axial and coronal CT images and venogram showing a large venous thrombus within the inferior vena cava, deforming the IVC filter. Page 13 of 22

14 Fig. 8: Axial and coronal CT images and venogram showing a large venous thrombus within the inferior vena cava, deforming the IVC filter. Page 14 of 22

15 Fig. 9: Venogram, abdominal radiographs and axial and coronal CT images demonstrating a large thrombus within the IVC extending through the filter (arrow). A second filter is placed superiorly. Page 15 of 22

Fig. 10: Venogram, abdominal radiographs and axial and coronal CT images demonstrating a large thrombus within the IVC extending through the filter (arrow). A second filter is placed superiorly. Fig.

16 Fig. 10: Venogram, abdominal radiographs and axial and coronal CT images demonstrating a large thrombus within the IVC extending through the filter (arrow). A second filter is placed superiorly. Fig. 11: Venogram, abdominal radiographs and axial and coronal CT images demonstrating a large thrombus within the IVC extending through the filter (arrow). A second filter is placed superiorly. Page 16 of 22

17 Fig. 12: Axial and coronal CT image demonstrating cephalad migration of filter (white arrow). A single strut remains in the original position (black arrow). Page 17 of 22

18 Fig. 13: Frontal chest X-ray 5 years after IVC filter placement showing two linear metallic foreign bodies within the right lung parenchyma. Page 18 of 22

19 Fig. 14: Axial CT image (A) demonstrating the six intact upper arms of the Recovery filter. Axial CT image obtained 3 years later (B) demonstrating a missing arm. Axial CT images obtained 4 yrs and 5 yrs later (C+D), respectively, demonstrating two missing arms. Page 19 of 22

Fig. 15: Coronal reformatted CT image demonstrating flexion of one of the upper arms of the Recovery filter 3 years after initial filter placement.

20 Fig. 15: Coronal reformatted CT image demonstrating flexion of one of the upper arms of the Recovery filter 3 years after initial filter placement. Subsequent coronal reformatted CT image obtained 1 year later demonstrating the previously flexed arm now to be missing. Final coronal reformatted CT image obtained 6 months later showing another arm flexed upward. Page 20 of 22

21 Conclusion IVC filters reduce the risk of pulmonary embolism in patients with proximal deep venous thrombosis and contraindication to anticoagulation. IVC filters should not be considered a substitute for anticoagulation. Filters do not prevent propagation of DVT, and long-term sequelae of DVT. Anatomic variations of the inferior vena cava and its tributaries must be recognized before IVC filter placement. The risk of these long-term complications of IVC filters increases with prolonged in-dwell time. The development of retrievable filters could avoid some of the long-term complications. Vigilance on the part of the implanting physician is needed to improve rates of patient follow-up for retrieval of the filters when indicated. Personal information References Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008 Jun;133(6 Suppl):454S-545S. Greenfield LJ. The 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. Perspect Vasc Surg Endovasc Ther 2006 Jun;18(2): Brountzos EN, Kaufman JA, Venbrux AC, Brown PR, Harry J, Kinst TF, Kleshinski S, Ravenscroft AC. A new optional vena cava filter: retrieval at 12 weeks in an animal model. J Vasc Interv Radiol 2003 Jun;14(6): Joels CS, Sing RF, Heniford BT. Complications of inferior vena cava filters. Am Surg 2003 Aug;69(8): Owens CA, Bui JT, Knuttinen M, Gaba RC, Carrillo TC, Hoefling N, LaydenAlmer JE. Intracardiac migration of inferior vena cava filters: review of published data. Chest 2009 Sep;136(3): Page 21 of 22

22 6. Hull JE, Robertson SW. Bard Recovery filter: evaluation and management of vena cava limb perforation, fracture, and migration. J Vasc Interv Radiol 2009 Jan;20(1): Grande WJ, Trerotola SO, Reilly PM, Clark TWI, Soulen MC, Patel A, Shlansky-Goldberg RD, Tuite CM, Solomon JA, Mondschein JI, Fitzpatrick MK, Stavropoulos SW. Experience with the recovery filter as a retrievable inferior vena cava filter. J Vasc Interv Radiol 2005 Sep;16(9): Nicholson W, Nicholson WJ, Tolerico P, Taylor B, Solomon S, Schryver T, McCullum K, Goldberg H, Mills J, Schuler B, Shears L, Siddoway L, Agarwal N, Tuohy C. Prevalence of fracture and fragment embolization of Bard retrievable vena cava filters and clinical implications including cardiac perforation and tamponade. Arch. Intern. Med 2010 Nov;170(20): Uberoi R, Tapping CR, Chalmers N, Allgar V. British Society of Interventional Radiology (BSIR) Inferior Vena Cava (IVC) Filter Registry. Cardiovasc Intervent Radiol Dec;36(6): Shang EK, Nathan DP, Carpenter JP, Fairman RM, Jackson BM. Delayed complications of inferior vena cava filters: case report and literature review. Vasc Endovascular Surg Apr;45(3): Decousus H., Leizorovicz A., Parent F.,et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prevention du Risque d'embolie Pulmonaire par Interruption Cave Study Group. New Engl J Med 1998; 338: Page 22 of 22

Bail out strategies after accidental Wallstent dislocation into the right atrium in patients with superior vena cava syndrome

Bail out strategies after accidental Wallstent dislocation into the right atrium in patients with superior vena cava syndrome Poster No.: C-0613 Congress: ECR 2014 Type: Educational Exhibit Authors: P.