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Abstract No. 433: IVC filter retrieval standard and alternative techiques
Poster Sessions 䡲 JVIR
S172
Conclusion: Although the utilization of SVC filters for prevention of PE in the setting of upper extremity DVT remains controversial, this single-center experience suggests both permanent and retrievable IVC filters may be used in the SVC with acceptable PE prevention rates and safety profile.
Educational Exhibit
Abstract No. 433
IVC filter retrieval standard and alternative techiques F. Aris1, R. Kodur1, A.A. Khankan2, G. McLennan1; 1 Interventional Radiology, Cleveland Clinic, Cleveland, OH; 2Diagnostic Radiology, Montreal, QC, Canada Learning Objectives: To illustrate and discuss the techniques of retrieving an IVC filter in the event of failure of conventional snare technique. Background: Standard filter removal techniques are unsuccessful in approximately 15% of cases. High failure rate is attributed to tilting or part of the filter becoming embedded into the IVC wall. The rationale for the use of retrievable filters is the fact that permanent filters are associated with higher risks of DVT. The poster will illustrate three techniques used for IVC filter removal: 1. Standard snare/cone retrieval 2. Loop and snare technique. 3. The recently described use of rigid bronchoscopy forceps Clinical Findings/Procedure Details: In all IVC filter removals right internal jugular venous access is obtained. A cavogram is performed to rule out thrombus in the filter/IVC. Access site is upgraded to the appropriately sized vascular sheath. Then the standard snare/retrieval cone is placed through the sheath and used to engage the cephalad end of the filter. With the tip secured, the sheath is advanced over the filter and is removed. Loop and snare technique:Right jugular access upgraded to a 16-F sheath. A 5-F RIM catheter is formed in the IVC engaging the filter struts towards the side of the tilt. Through the catheter, an exchange length wire is advanced and is snared. The filter is centralized by applying tension to the snared wire. A second snare is introduced alongside the snared wire to capture the centralized hook of the IVC filter. Holding tension on the snared filter and the wire the sheath is advanced over the filter and removed as a single unit. Rigid bronchoscopy forceps:14F vascular sheath is placed in the IVC cranial to the hook of the filter. Rigid bronchoscopy forceps is placed and directed towards the hook of the filter. Once grasped, the filter is gently repositioned in a favourable orientation. Ultimately, with the forceps grasping the filter, the sheath is advanced over the filter and removed as a single unit. Conclusion and/or Teaching Points: Many IVC filters which cannot be retrieved by conventional technique can be safely retrieved by using either the rigid bronchoscopy forceps technique or the loop and snare technique.
Poster Sessions
Educational Exhibit
Abstract No. 434
Fatal reperfusion injury following successful thrombolysis for phlegmasia cerulea dolens: a review and a warning M.L. Lessne, J.M. Bajwa; Radiology, Johns Hopkins, Baltimore, MD Learning Objectives: Review clinical features, pathophysiology, and treatment options of phlegmasia cerulea dolens (PCD).
Differentiate PCD from venous gangrene and warfarin-induced skin necrosis. Introduce the previously unreported risk for fatal reperfusion injury after successful catheter directed venous thrombolysis, and review reperfusion syndrome as it relates to interventional procedures. Additionally, a classification system to stratify patients with PCD is reviewed to help guide appropriate therapy. Background: Reperfusion injury following venous thrombolysis for PCD is not well described in the literature. The spectrum of clinical presentations of DVT is vast, and massive clot burden leading to PCD and venous gangrene can be rapidly fatal if not diagnosed accurately and treated early. Given the increased performance of catheter directed venous thrombolysis, awareness of PCD and possible adverse clinical sequelae following reperfusion is crucial for the interventionalist, though no widely accepted classification system exists to guide management of this morbid disease. We report two cases of fatal reperfusion injury following successful thrombolysis and review the presentation, pathophysiology, and treatment of PCD and reperfusion injury. Clinical Findings/Procedure Details: Clinical description of cases of fatal reperfusion syndrome following venous thrombolysis will be provided. Gross photos of physical exam findings of PCD and venous gangrene, mimicking warfarin-induced skin necrosis, along with angiographic images of massive venous thrombosis and successful thrombolysis will be exhibited. Suggested grading system of PCD will be displayed to correlate clinical presentation with severity of disease and guide therapy. Conclusion and/or Teaching Points: PCD represents a potentially reversible consequence of massive venous thrombosis and must be distinguished early from venous gangrene and warfarin-induced skin necrosis. Progression to venous gangrene heralds an irreversible process with poor prognosis despite adequate revascularization, which may be insufficient to stave off fatal complications from reperfusion injury. Early detection, severity stratification, and treatment of massive venous thrombosis is critical to limb and life salvage.
Educational Exhibit
Abstract No. 435
Simultaneous transvenous biopsy and stenting in malignant superior vena cava obstruction R. Bera1,2, Z. Zia1,2, O. Bashir1,2, J.G. Pollock2, P. Bungay2, P. Thurley2; 1Radiology, Queens Medical Centre Nottingham, Nottingham, United Kingdom; 2 Radiology, Royal Derby Hospital, Derby, United Kingdom Learning Objectives: We present our experience of simultaneous transvenous superior vena cavil mediastinal biopsy and stenting for malignant superior vena cava obstruction (SVCO). We describe our criteria for patient selection, technique, success and complication. Background: Malignant SVCO occurs in up to 12% of lung cancer patients at presentation. The central nature of these tumours in the presence of SVCO makes tissue biopsy hazardous. Superior vena cava (SVC) stenting is the preferred primary treatment of SVCO. Often there is no tissue diagnosis at the time of referral for stenting. We present our experience of simultaneous transvenous mediastinal biopsy and SVC stenting. Case notes and imaging of all patients referred for transvenous SVC mediastinal biopsy and stenting were reviewed. Clinical Findings/Procedure Details: Patients with SVCO were selected for this procedure if there was no percutaneous
S172
Conclusion: Although the utilization of SVC filters for prevention of PE in the setting of upper extremity DVT remains controversial, this single-center experience suggests both permanent and retrievable IVC filters may be used in the SVC with acceptable PE prevention rates and safety profile.
Educational Exhibit
Abstract No. 433
IVC filter retrieval standard and alternative techiques F. Aris1, R. Kodur1, A.A. Khankan2, G. McLennan1; 1 Interventional Radiology, Cleveland Clinic, Cleveland, OH; 2Diagnostic Radiology, Montreal, QC, Canada Learning Objectives: To illustrate and discuss the techniques of retrieving an IVC filter in the event of failure of conventional snare technique. Background: Standard filter removal techniques are unsuccessful in approximately 15% of cases. High failure rate is attributed to tilting or part of the filter becoming embedded into the IVC wall. The rationale for the use of retrievable filters is the fact that permanent filters are associated with higher risks of DVT. The poster will illustrate three techniques used for IVC filter removal: 1. Standard snare/cone retrieval 2. Loop and snare technique. 3. The recently described use of rigid bronchoscopy forceps Clinical Findings/Procedure Details: In all IVC filter removals right internal jugular venous access is obtained. A cavogram is performed to rule out thrombus in the filter/IVC. Access site is upgraded to the appropriately sized vascular sheath. Then the standard snare/retrieval cone is placed through the sheath and used to engage the cephalad end of the filter. With the tip secured, the sheath is advanced over the filter and is removed. Loop and snare technique:Right jugular access upgraded to a 16-F sheath. A 5-F RIM catheter is formed in the IVC engaging the filter struts towards the side of the tilt. Through the catheter, an exchange length wire is advanced and is snared. The filter is centralized by applying tension to the snared wire. A second snare is introduced alongside the snared wire to capture the centralized hook of the IVC filter. Holding tension on the snared filter and the wire the sheath is advanced over the filter and removed as a single unit. Rigid bronchoscopy forceps:14F vascular sheath is placed in the IVC cranial to the hook of the filter. Rigid bronchoscopy forceps is placed and directed towards the hook of the filter. Once grasped, the filter is gently repositioned in a favourable orientation. Ultimately, with the forceps grasping the filter, the sheath is advanced over the filter and removed as a single unit. Conclusion and/or Teaching Points: Many IVC filters which cannot be retrieved by conventional technique can be safely retrieved by using either the rigid bronchoscopy forceps technique or the loop and snare technique.
Poster Sessions
Educational Exhibit
Abstract No. 434
Fatal reperfusion injury following successful thrombolysis for phlegmasia cerulea dolens: a review and a warning M.L. Lessne, J.M. Bajwa; Radiology, Johns Hopkins, Baltimore, MD Learning Objectives: Review clinical features, pathophysiology, and treatment options of phlegmasia cerulea dolens (PCD).
Differentiate PCD from venous gangrene and warfarin-induced skin necrosis. Introduce the previously unreported risk for fatal reperfusion injury after successful catheter directed venous thrombolysis, and review reperfusion syndrome as it relates to interventional procedures. Additionally, a classification system to stratify patients with PCD is reviewed to help guide appropriate therapy. Background: Reperfusion injury following venous thrombolysis for PCD is not well described in the literature. The spectrum of clinical presentations of DVT is vast, and massive clot burden leading to PCD and venous gangrene can be rapidly fatal if not diagnosed accurately and treated early. Given the increased performance of catheter directed venous thrombolysis, awareness of PCD and possible adverse clinical sequelae following reperfusion is crucial for the interventionalist, though no widely accepted classification system exists to guide management of this morbid disease. We report two cases of fatal reperfusion injury following successful thrombolysis and review the presentation, pathophysiology, and treatment of PCD and reperfusion injury. Clinical Findings/Procedure Details: Clinical description of cases of fatal reperfusion syndrome following venous thrombolysis will be provided. Gross photos of physical exam findings of PCD and venous gangrene, mimicking warfarin-induced skin necrosis, along with angiographic images of massive venous thrombosis and successful thrombolysis will be exhibited. Suggested grading system of PCD will be displayed to correlate clinical presentation with severity of disease and guide therapy. Conclusion and/or Teaching Points: PCD represents a potentially reversible consequence of massive venous thrombosis and must be distinguished early from venous gangrene and warfarin-induced skin necrosis. Progression to venous gangrene heralds an irreversible process with poor prognosis despite adequate revascularization, which may be insufficient to stave off fatal complications from reperfusion injury. Early detection, severity stratification, and treatment of massive venous thrombosis is critical to limb and life salvage.
Educational Exhibit
Abstract No. 435
Simultaneous transvenous biopsy and stenting in malignant superior vena cava obstruction R. Bera1,2, Z. Zia1,2, O. Bashir1,2, J.G. Pollock2, P. Bungay2, P. Thurley2; 1Radiology, Queens Medical Centre Nottingham, Nottingham, United Kingdom; 2 Radiology, Royal Derby Hospital, Derby, United Kingdom Learning Objectives: We present our experience of simultaneous transvenous superior vena cavil mediastinal biopsy and stenting for malignant superior vena cava obstruction (SVCO). We describe our criteria for patient selection, technique, success and complication. Background: Malignant SVCO occurs in up to 12% of lung cancer patients at presentation. The central nature of these tumours in the presence of SVCO makes tissue biopsy hazardous. Superior vena cava (SVC) stenting is the preferred primary treatment of SVCO. Often there is no tissue diagnosis at the time of referral for stenting. We present our experience of simultaneous transvenous mediastinal biopsy and SVC stenting. Case notes and imaging of all patients referred for transvenous SVC mediastinal biopsy and stenting were reviewed. Clinical Findings/Procedure Details: Patients with SVCO were selected for this procedure if there was no percutaneous