Image shows bronchial forceps retrieving embedded IVC filter

Interventional radiologists at Penn Medicine are performing retrieval of tip-embedded inferior vena cava (IVC) filters using rigid endobronchial forceps, a technique developed by Penn Interventional Radiology. The efficacy and safety of the technique has recently been confirmed in a clinical study published in the journal Radiology. [1]

The largest venous trunk in the body, the IVC is a conduit for thromboemboli originating in the legs. Among hypercoagulable individuals, particularly those with contraindications for anticoagulant therapy, caval blood clots are a primary cause of catastrophic pulmonary embolism. Percutaneous placement of permanent or retrievable IVC filters is an effective way to trap these clots before they reach the lungs.

Although the FDA recommends that IVC filters be removed when no longer needed, it is estimated that fewer than half of retrievable devices are taken out each year. This number includes the 5 to 10 percent of retrieval attempts that fail because the filter tip is embedded in the vessel wall.

Tip-embedded filters must be removed because they present a substantial risk for vessel occlusion, fracture, and further penetration through the IVC into bowel, bone, arteries and other structures. Standard retrieval of IVC filters involves capturing the devices with snares or cones. Neither technique is effective, however, when the filter tip is embedded in the vessel wall.

Every tip-embedded filter retrieval is considered a high-risk procedure. Incomplete, failed or overly aggressive removal of the filter can result in vessel damage and/or further distortion/fracture of the filter.

IVC Filter Retrieval at Penn

For more than a decade, interventional radiologists at Penn Medicine have been developing methods to improve the results of IVC filter retrieval and to optimize retrieval of tip-embedded caval filters.

The approach to these complex retrievals involves the use of rigid endobronchial forceps placed into the IVC from the right internal jugular vein through a sheath and dissecting away engulfing tissue, grasping the filter tip and removing the device. The technique incorporates several imaging modalities, including rotational venography, spot radiography, and CT venography.

In the aforementioned study at Penn, the endobronchial forceps approach was used successfully to retrieve 109 of 114 (96%) tip-embedded IVC filters. Three minor complications and one major complication occurred (the latter involved a patient in whom the struts as well as the tip were embedded), but these resulted in no permanent sequelae.

Case Study

Image of embedded inferior vena cava filter
Figure 1: A tip-embedded IVC filter appears on inferior vena cavagram. This filter has entered the vessel wall and cannot be retrieved by standard methods.

Mr. W, a 37-year-old man, presented to Penn Interventional Radiology with a filter embedded in the wall of his inferior vena cava (Figure 1). According to his medical records, he had a history of deep vein thrombosis, for which he’d been taking warfarin for some years. Recently, however, he’d experienced a bleeding ulcer, requiring him to temporarily cease taking the drug.

To protect Mr. W from pulmonary emboli in this interim, a retrievable filter was placed in his inferior vena cava at his community hospital. After Mr. W’s ulcer had healed and he re-started warfarin, he returned to the hospital to have the IVC filter removed. An inferior vena cavagram at this time showed the tip of the filter embedded in the vessel wall, however, and the retrieval attempt was abandoned. 

Mr. W was then referred to Penn Interventional Radiology, where he was scheduled for a complex IVC filter retrieval after an office consultation. His anticoagulation was not interrupted for the one-hour procedure, which was performed in an outpatient setting. Following access at the right internal jugular, endobronchial forceps were used to cut away the tissue surrounding the embedded tip, allowing the filter to be grasped and removed (Figure 2).

Image shows bronchial forceps retrieving embedded IVC filter
Figure 2: Endobronchial forceps grasping an IVC filter after freeing the embedded tip of the device.

Following the procedure, Mr. W was observed for two hours; he went home the same day. He had no adverse effects from the procedure and remains under the care of his family physician. 

Access

Penn Interventional Radiology

Hospital of the University of Pennsylvania

1 Silverstein

3400 Spruce Street Philadelphia, PA 19104

Penn Presbyterian Medical Center

4 Wright-Saunders Building

51 North 39th Street Philadelphia, PA 19104

Penn Radiology

Hospital of the University of Pennsylvania

Ground Dulles

3400 Spruce Street Philadelphia, PA 19104

Published on: June 23, 2017

References

1. Stavropoulos SW, Ge BH, Mondschien J, Shlansky-Goldberg RD, Sudheendra D, Trerotola SO. Retrieval of tip-embedded inferior vena cava filters by using the endobronchial forceps technique. Radiology 2015; 12:141420.

About Penn Interventional Radiology

The specialists with the Interventional Radiology Division at Penn Medicine offer the diagnosis and treatment of a variety of diseases using minimally invasive techniques. The Division is situated in six interventional radiology suites at the Hospital of the University of Pennsylvania, and has an active outpatient clinic, admitting and consulting service. 

Penn Faculty Team

Scott O. Trerotola, MD, FACR

Division Chief, Interventional Radiology

Vice Chair, Quality, Radiology

Stanley Baum Professor of Radiology

Professor of Radiology in Surgery

S. William Stavropoulos, MD

Modality Chief, Interventional Radiology

Vice Chair for Clinical Operations, Department of Radiology

Professor of Radiology at the Hospital of the University of Pennsylvania

Professor of Surgery

Timothy W.I. Clark, MD

Director of Interventional Radiology at Penn Presbyterian Medical Center

Associate Professor of Clinical Radiology

Mandeep S. Dagli, MD

Assistant Professor of Clinical Radiology

Raymond M. Fabrizio, MD

Director of Interventional Radiology at Pennsylvania Hospital

Assistant Professor of Clinical Radiology

Benjamin D. Hammelman, MD, MedED

Associate Program Director, Diagnostic Radiology Residency

Assistant Professor of Clinical Radiology

Stephen J. Hunt, MD, PhD, DABR

Director, Penn Image-Guided Interventions (PIGI) Laboratory

Maxim Itkin, MD

Director, Center for Lymphatic Imaging and Interventions Program

Associate Professor of Radiology at the Hospital of the University of Pennsylvania

Associate Professor of Pediatrics

Gregory J. Nadolski, MD

Assistant Professor of Radiology at the Hospital of the University of Pennsylvania

Jonas W. Redmond, MD

Assistant Professor of Clinical Radiology

Richard Shlansky-Goldberg, MD

Professor of Radiology at the Hospital of the University of Pennsylvania

Professor of Obstetrics and Gynecology

Professor of Radiology in Surgery

Michael C. Soulen, MD

Professor of Radiology at the Hospital of the University of Pennsylvania

Professor of Radiology in Surgery

Deepak Sudheendra, MD, RPVI

Assistant Professor of Clinical Radiology

Assistant Professor of Radiology in Surgery

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