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Failure of Filter Reexpansion during Unsuccessful Retrieval of Option Inferior Vena Cava Filter
Volume 24
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Number 7
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July
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2013
1065
2. Van Son JAM, Mierzwa M, Mohr FW. Resection of atherosclerotic aneurysm at origin of aberrant right subclavian artery. Eur J Cardiothorac Surg 1999; 16:576–579. 3. Tosenovsky P, Quigley F, Golledge J. Hybrid repair of an aberrant right subclavian artery with Kommerell’s diverticulum. EJVES 2010; 19:e31–e33.
4. Yang C, Shu C, Li M, Li Q, Kopp R. Aberrant subclavian artery pathologies and Kommerell’s diverticulum: a review and analysis of published endovascular/hybrid treatment options. J Endovasc Ther 2012; 19:373–382.
Failure of Filter Reexpansion during Unsuccessful Retrieval of Option Inferior Vena Cava Filter
and filter retrieval was aborted. Upon retracting the sheath, the filter did not return to form as expected but instead remained collapsed within the IVC lumen (Fig 1c). The patient was referred for laser-assisted filter retrieval, which was successfully performed 1 week later. No adverse events occurred during the interval to laserassisted removal. In the second case, a 54-year-old woman was initially admitted to an outside hospital for a strangulated ventral hernia requiring bowel resection. During a subsequent prolonged hospitalization, the patient was diagnosed with bilateral lower-extremity deep vein thrombosis. According to outside records, even though the patient was already receiving anticoagulation, an Option filter was placed given her history of anticoagulation failure and concern that a pulmonary embolism would carry substantial mortality risk. The patient presented to our institution for filter retrieval 11 months after placement. An initial cavogram demonstrated an infrarenal filter free of thrombus, with a single strut extending 3 mm beyond the caval margin (Fig 2a). With the use of a Cook retrieval set, the filter hook was successfully snared and the retrieval sheath was advanced over the filter. The struts were partially reduced into the sheath but remained adherent to the caval wall despite the application of traction. Upon releasing the filter, the struts remained predominantly collapsed except for their distalmost portions, with suggestion of helical twisting of the struts (Fig 2b). A repeat cavogram demonstrated new focal inward tenting of the caval wall at the level of the strut anchors (Fig 2c). A 14 40-mm angioplasty balloon (Cordis Europa/ Johnson and Johnson, Roden, The Netherlands) was then inflated within the remaining expanded portion of the filter in an attempt to reexpand the filter, yielding only minimal success. As there was still brisk antegrade flow beyond the point of narrowing, no further intervention was attempted at this time. Oral anticoagulation was resumed, and the patient was referred for laserassisted filter retrieval, which was successfully performed 2 weeks later. No adverse events occurred during the interval to laser-assisted removal. Here we describe two cases of failure of filter reexpansion during unsuccessful retrieval of the Option IVC filter. Each case was attempted by a different subspecialtycertified interventional radiology attending physician, both of whom have extensive experience in IVC filter retrieval. In neither case was there caval thrombus or a preexisting caval or pericaval abnormality.
From: Olufoladare G. Olorunsola, MD Maureen P. Kohi, MD Nicholas Fidelman, MD Jeanne M. LaBerge, MD Robert K. Kerlan, MD Department of Radiology and Biomedical Imaging University of California, San Francisco 505 Parnassus Ave. Room 391, Box 0628 San Francisco, CA 94143
Editor: We report two cases of unsuccessful filter removal involving the Option inferior vena cava (IVC) filter (Rex Medical, Conshohocken, Pennsylvania). In each case, the filter was partially sheathed but could not be removed because of firm attachment to the caval wall. After aborting the retrieval procedure and retracting the sheath, the filters did not reexpand to their normal configuration as expected, instead remaining collapsed within the IVC lumen. Approval was obtained from our institutional review board, with waiver of informed consent, for the description of the present two cases. In the first case, a 57-year-old woman underwent Option IVC filter placement for pulmonary embolism diagnosed 8 days after a traumatic hepatic laceration. Immediate postplacement fluoroscopy demonstrated an unusual appearance of the filter, with several of the struts clustered closely together along the right lateral border of the IVC (Fig 1a). A similar appearance was seen on computed tomography (CT) 73 days later (Fig 1b). As a result of discontinuous follow-up, retrieval was not attempted until 277 days (9.2 mo) after placement, with an initial cavogram again demonstrating the unusual configuration of the filter, which was free of thrombus. With the use of a Cook retrieval set (Cook, Bloomington, Indiana), the filter hook was snared, and the filter was nearly completely sheathed but remained adherent to the caval wall despite considerable traction. Subsequent forceful traction elicited abdominal pain, None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.03.026
1066
’
Letters to the Editor
Olorunsola et al
’
JVIR
Figure 1. (a) Postplacement anteroposterior fluoroscopic image demonstrates an unusual configuration of an Option IVC filter, with several of the struts clustered along the right lateral border of the IVC (arrowhead). (b) CT obtained 73 days following placement also demonstrates uneven clustering of the struts (arrow). (c) Oblique projection cavogram following unsuccessful attempted filter retrieval demonstrates retention of the collapsed filter within a patent IVC.
Figure 2. Anteroposterior-projection cavograms during attempted retrieval in the second case. (a) Infrarenal Option IVC filter before attempted retrieval shows 3-mm penetration of one of the struts (arrow). (b) After attempted sheathing and subsequent sheath retraction, the filter remained partially collapsed, with a suggestion of helical twisting of the struts. (c) New focal inward tenting of the caval wall is seen at the level of the strut anchors (arrowhead).
We may speculate as to potential mechanisms governing the observed sequence. The problem of tightly adherent struts to the caval wall is likely related to the prolonged dwell times in both cases (9 and 11 mo, respectively). In one case, there was evidence of strut penetration, possibly playing a role in strut adherence. The subsequent failure of filter reexpansion is the more unusual observation. The imaging appearance in both cases suggests that this may be attributable to entanglement of filter struts. In the first case, CT and venography before attempted sheathing demonstrate an unusual filter configuration, with uneven clustering of
several struts along the right lateral caval wall (Fig 1a, b). In the second case, there is suggestion of helical twisting of the struts following attempted sheathing (Fig 2b). Specific design features could theoretically predispose to limb clustering or entanglement in the Option filter. Its ultra–low-profile delivery system (6.5 F) necessitates thinner struts, which are perhaps more easily distorted. Additionally, the Option filter comprises six principal struts, which may be more conducive to interactions between the struts. Crossing of struts at the time of initial deployment of an Option filter has been reported (1).
Volume 24
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Number 7
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July
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2013
Another potential mechanism to explain the fixed filter collapse is fibrous tissue acting to constrain the struts. Histologic analyses have demonstrated dense fibrous tissue adherent to retrieved filter specimens (2). It is possible that a fibrous sheath could form in the filter hook region, which could in turn be pushed over the filter struts when advancing the retrieval sheath. The potential adverse consequences of this type of filter dysfunction could be severe. The result may be a filter left in unstable position with a possibility of filter embolization, as in the first case described here, in which most of the struts appeared to have been detached from the caval wall. A second potential problem is caval stenosis, as seen in the second case, which could result in flow limitation, caval thrombosis, or caval occlusion. Given the potentially serious consequences, it is the authors’ opinion that such occurrences warrant shortterm follow-up for repeat retrieval attempts by using
Durable Plug and Onyx Occlusion of a Refractory Bile Leak From: Kyle A. Wilson, BA Ziv J Haskal, MD Department of Radiology University of Maryland School of Medicine 22 S. Greene St., GK214 Baltimore, MD 21030
Editor: Bile leaks of iatrogenic or traumatic etiology are most commonly treated by biliary decompression, diversion of flow away from the leak, and drainage of adjacent bilomas. Persistent bile leaks have been treated with embolization with fibrin glue, n-butyl cyanoacrylate (NBCA), or microcoils, or with hepatic resection (1–3). Herein, we describe a case of persistent bile leak that was refractory to prolonged diversion and multiple liquid embolizations. A combination of metallic and liquid embolic agents was used to achieve long-term occlusion. This report was exempted from institutional review board approval. In 2009, a 49-year-old man underwent right hepatectomy for curative treatment of synchronous isolated liver metastases from a primary colorectal cancer. Two months later, he presented with a bile leak that was addressed by endoscopic biliary stent placement and percutaneous drainage of the perihepatic biloma. Z.JH. has royalty agreements with Cook (Bloomington, Indiana), is a paid consultant for W.L. Gore and Associates (Flagstaff, Arizona) and Bard Peripheral Vascular (Tempe, Arizona), has research funded by Bard Peripheral Vascular and W.L. Gore and Associates, and owns shares in AngioDynamics (Latham, New York). K.A.W. reports no disclosures. This letter includes Video E1 available online at www.jvir.org http://dx.doi.org/10.1016/j.jvir.2013.03.017
1067
specialized methods such as the laser-assisted retrieval technique. It is unknown with what frequency this complication occurs or whether it is unique to the Option filter. It is likely that previous such events have occurred with the Option filter and possibly filters of other types, but were not reported. Interventional radiologists who retrieve filters should be aware of this perplexing, alarming, and potentially dangerous problem.
REFERENCES 1. Johnson MS, Nemcek AA Jr, Benenati JF, et al. The safety and effectiveness of the retrievable option inferior vena cava filter: a United States prospective multicenter clinical study. J Vasc Interv Radiol 2010; 21:1173–1184. 2. Kuo WT, Cupp JS, Louie JD, et al. Complex retrieval of embedded IVC filters: alternative techniques and histologic tissue analysis. Cardiovasc Intervent Radiol 2012; 35:588–597.
The stent and drain were removed 1 month later. Within 3 months, he returned with a recurrent, large biloma, and was treated with repeat drainage and placement of a percutaneous internal external left biliary catheter for diversion. For the next 12 months, the leak continued, and the biloma drained approximately 100 mL per day. Fistula embolization with ethylene vinyl alcohol copolymer (Onyx; ev3, Plymouth, Minnesota) was performed at 1 month, followed by NBCA embolization at 3, 5, 6.5, and 8 months thereafter. We first met the patient 2 weeks later and considered a different approach (Fig 1, Video E1, available online at
Figure 1. Cholangiography through the percutaneous left biliary catheter demonstrates the leak (black arrow) flowing immediately into the right hepatectomy bed. The tip of the lockingloop biloma catheter is seen (white arrow)
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Number 7
’
July
’
2013
1065
2. Van Son JAM, Mierzwa M, Mohr FW. Resection of atherosclerotic aneurysm at origin of aberrant right subclavian artery. Eur J Cardiothorac Surg 1999; 16:576–579. 3. Tosenovsky P, Quigley F, Golledge J. Hybrid repair of an aberrant right subclavian artery with Kommerell’s diverticulum. EJVES 2010; 19:e31–e33.
4. Yang C, Shu C, Li M, Li Q, Kopp R. Aberrant subclavian artery pathologies and Kommerell’s diverticulum: a review and analysis of published endovascular/hybrid treatment options. J Endovasc Ther 2012; 19:373–382.
Failure of Filter Reexpansion during Unsuccessful Retrieval of Option Inferior Vena Cava Filter
and filter retrieval was aborted. Upon retracting the sheath, the filter did not return to form as expected but instead remained collapsed within the IVC lumen (Fig 1c). The patient was referred for laser-assisted filter retrieval, which was successfully performed 1 week later. No adverse events occurred during the interval to laserassisted removal. In the second case, a 54-year-old woman was initially admitted to an outside hospital for a strangulated ventral hernia requiring bowel resection. During a subsequent prolonged hospitalization, the patient was diagnosed with bilateral lower-extremity deep vein thrombosis. According to outside records, even though the patient was already receiving anticoagulation, an Option filter was placed given her history of anticoagulation failure and concern that a pulmonary embolism would carry substantial mortality risk. The patient presented to our institution for filter retrieval 11 months after placement. An initial cavogram demonstrated an infrarenal filter free of thrombus, with a single strut extending 3 mm beyond the caval margin (Fig 2a). With the use of a Cook retrieval set, the filter hook was successfully snared and the retrieval sheath was advanced over the filter. The struts were partially reduced into the sheath but remained adherent to the caval wall despite the application of traction. Upon releasing the filter, the struts remained predominantly collapsed except for their distalmost portions, with suggestion of helical twisting of the struts (Fig 2b). A repeat cavogram demonstrated new focal inward tenting of the caval wall at the level of the strut anchors (Fig 2c). A 14 40-mm angioplasty balloon (Cordis Europa/ Johnson and Johnson, Roden, The Netherlands) was then inflated within the remaining expanded portion of the filter in an attempt to reexpand the filter, yielding only minimal success. As there was still brisk antegrade flow beyond the point of narrowing, no further intervention was attempted at this time. Oral anticoagulation was resumed, and the patient was referred for laserassisted filter retrieval, which was successfully performed 2 weeks later. No adverse events occurred during the interval to laser-assisted removal. Here we describe two cases of failure of filter reexpansion during unsuccessful retrieval of the Option IVC filter. Each case was attempted by a different subspecialtycertified interventional radiology attending physician, both of whom have extensive experience in IVC filter retrieval. In neither case was there caval thrombus or a preexisting caval or pericaval abnormality.
From: Olufoladare G. Olorunsola, MD Maureen P. Kohi, MD Nicholas Fidelman, MD Jeanne M. LaBerge, MD Robert K. Kerlan, MD Department of Radiology and Biomedical Imaging University of California, San Francisco 505 Parnassus Ave. Room 391, Box 0628 San Francisco, CA 94143
Editor: We report two cases of unsuccessful filter removal involving the Option inferior vena cava (IVC) filter (Rex Medical, Conshohocken, Pennsylvania). In each case, the filter was partially sheathed but could not be removed because of firm attachment to the caval wall. After aborting the retrieval procedure and retracting the sheath, the filters did not reexpand to their normal configuration as expected, instead remaining collapsed within the IVC lumen. Approval was obtained from our institutional review board, with waiver of informed consent, for the description of the present two cases. In the first case, a 57-year-old woman underwent Option IVC filter placement for pulmonary embolism diagnosed 8 days after a traumatic hepatic laceration. Immediate postplacement fluoroscopy demonstrated an unusual appearance of the filter, with several of the struts clustered closely together along the right lateral border of the IVC (Fig 1a). A similar appearance was seen on computed tomography (CT) 73 days later (Fig 1b). As a result of discontinuous follow-up, retrieval was not attempted until 277 days (9.2 mo) after placement, with an initial cavogram again demonstrating the unusual configuration of the filter, which was free of thrombus. With the use of a Cook retrieval set (Cook, Bloomington, Indiana), the filter hook was snared, and the filter was nearly completely sheathed but remained adherent to the caval wall despite considerable traction. Subsequent forceful traction elicited abdominal pain, None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2013.03.026
1066
’
Letters to the Editor
Olorunsola et al
’
JVIR
Figure 1. (a) Postplacement anteroposterior fluoroscopic image demonstrates an unusual configuration of an Option IVC filter, with several of the struts clustered along the right lateral border of the IVC (arrowhead). (b) CT obtained 73 days following placement also demonstrates uneven clustering of the struts (arrow). (c) Oblique projection cavogram following unsuccessful attempted filter retrieval demonstrates retention of the collapsed filter within a patent IVC.
Figure 2. Anteroposterior-projection cavograms during attempted retrieval in the second case. (a) Infrarenal Option IVC filter before attempted retrieval shows 3-mm penetration of one of the struts (arrow). (b) After attempted sheathing and subsequent sheath retraction, the filter remained partially collapsed, with a suggestion of helical twisting of the struts. (c) New focal inward tenting of the caval wall is seen at the level of the strut anchors (arrowhead).
We may speculate as to potential mechanisms governing the observed sequence. The problem of tightly adherent struts to the caval wall is likely related to the prolonged dwell times in both cases (9 and 11 mo, respectively). In one case, there was evidence of strut penetration, possibly playing a role in strut adherence. The subsequent failure of filter reexpansion is the more unusual observation. The imaging appearance in both cases suggests that this may be attributable to entanglement of filter struts. In the first case, CT and venography before attempted sheathing demonstrate an unusual filter configuration, with uneven clustering of
several struts along the right lateral caval wall (Fig 1a, b). In the second case, there is suggestion of helical twisting of the struts following attempted sheathing (Fig 2b). Specific design features could theoretically predispose to limb clustering or entanglement in the Option filter. Its ultra–low-profile delivery system (6.5 F) necessitates thinner struts, which are perhaps more easily distorted. Additionally, the Option filter comprises six principal struts, which may be more conducive to interactions between the struts. Crossing of struts at the time of initial deployment of an Option filter has been reported (1).
Volume 24
’
Number 7
’
July
’
2013
Another potential mechanism to explain the fixed filter collapse is fibrous tissue acting to constrain the struts. Histologic analyses have demonstrated dense fibrous tissue adherent to retrieved filter specimens (2). It is possible that a fibrous sheath could form in the filter hook region, which could in turn be pushed over the filter struts when advancing the retrieval sheath. The potential adverse consequences of this type of filter dysfunction could be severe. The result may be a filter left in unstable position with a possibility of filter embolization, as in the first case described here, in which most of the struts appeared to have been detached from the caval wall. A second potential problem is caval stenosis, as seen in the second case, which could result in flow limitation, caval thrombosis, or caval occlusion. Given the potentially serious consequences, it is the authors’ opinion that such occurrences warrant shortterm follow-up for repeat retrieval attempts by using
Durable Plug and Onyx Occlusion of a Refractory Bile Leak From: Kyle A. Wilson, BA Ziv J Haskal, MD Department of Radiology University of Maryland School of Medicine 22 S. Greene St., GK214 Baltimore, MD 21030
Editor: Bile leaks of iatrogenic or traumatic etiology are most commonly treated by biliary decompression, diversion of flow away from the leak, and drainage of adjacent bilomas. Persistent bile leaks have been treated with embolization with fibrin glue, n-butyl cyanoacrylate (NBCA), or microcoils, or with hepatic resection (1–3). Herein, we describe a case of persistent bile leak that was refractory to prolonged diversion and multiple liquid embolizations. A combination of metallic and liquid embolic agents was used to achieve long-term occlusion. This report was exempted from institutional review board approval. In 2009, a 49-year-old man underwent right hepatectomy for curative treatment of synchronous isolated liver metastases from a primary colorectal cancer. Two months later, he presented with a bile leak that was addressed by endoscopic biliary stent placement and percutaneous drainage of the perihepatic biloma. Z.JH. has royalty agreements with Cook (Bloomington, Indiana), is a paid consultant for W.L. Gore and Associates (Flagstaff, Arizona) and Bard Peripheral Vascular (Tempe, Arizona), has research funded by Bard Peripheral Vascular and W.L. Gore and Associates, and owns shares in AngioDynamics (Latham, New York). K.A.W. reports no disclosures. This letter includes Video E1 available online at www.jvir.org http://dx.doi.org/10.1016/j.jvir.2013.03.017
1067
specialized methods such as the laser-assisted retrieval technique. It is unknown with what frequency this complication occurs or whether it is unique to the Option filter. It is likely that previous such events have occurred with the Option filter and possibly filters of other types, but were not reported. Interventional radiologists who retrieve filters should be aware of this perplexing, alarming, and potentially dangerous problem.
REFERENCES 1. Johnson MS, Nemcek AA Jr, Benenati JF, et al. The safety and effectiveness of the retrievable option inferior vena cava filter: a United States prospective multicenter clinical study. J Vasc Interv Radiol 2010; 21:1173–1184. 2. Kuo WT, Cupp JS, Louie JD, et al. Complex retrieval of embedded IVC filters: alternative techniques and histologic tissue analysis. Cardiovasc Intervent Radiol 2012; 35:588–597.
The stent and drain were removed 1 month later. Within 3 months, he returned with a recurrent, large biloma, and was treated with repeat drainage and placement of a percutaneous internal external left biliary catheter for diversion. For the next 12 months, the leak continued, and the biloma drained approximately 100 mL per day. Fistula embolization with ethylene vinyl alcohol copolymer (Onyx; ev3, Plymouth, Minnesota) was performed at 1 month, followed by NBCA embolization at 3, 5, 6.5, and 8 months thereafter. We first met the patient 2 weeks later and considered a different approach (Fig 1, Video E1, available online at
Figure 1. Cholangiography through the percutaneous left biliary catheter demonstrates the leak (black arrow) flowing immediately into the right hepatectomy bed. The tip of the lockingloop biloma catheter is seen (white arrow)