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Incorporation of the Gunther Temporary Inferior Vena Cava Filter into the Caval Wall
Case Report
Incorporation of the Gunther Temporary Inferior Vena Cava Filter into the Caval Wall1 Brent E. Burbridge, MD, FRCPC Doug R. Walker, MD, FRCPC Steven F. Millward, FRCPC, MB, ChB
Index terms: Interventional procedures, complications, 982,456,982,458,982,751 Venae cavae, filters, 982.1267 Venae cavae, interventional procedure, 982.1267 Venae cavae, thrombosis, 982,458,982,751
JVIR 1996; 7:289-290
PERMANENT inferior vena cava (IVC) filters are associated with a variety of complications (1).This problem, along with the lack of long-term scientific follow-up of patients with permanent IVC filters, has led to the development of retrievable permanent and temporary IVC filters. Retrievable IVC filters are similar to permanent filters except that they are designed to be potentially retrievable after repeated venous access a t a later date. Temporary IVC filters must remain tethered to a catheter or wire and are externalized a t the site of venous access to allow removal a t a later date. We recently described our preliminary experience with the Gunther temporary IVC filter (2); complications included insertion vein thrombosis and IVC occlusion. Patients had filters in situ for up to 14 days, and the filters were all easily removed. Here we describe a patient in whom the device became firmly incorporated into the vena cava wall after 12 days of implantation.
I CASE REPORT
F r o m the Department of Medical Imaging (B.E.B., D.W.), Royal University Hospital, 103 Hospital Dr, Saskatoon, Saskatchewan, Canada S7N 0W8; and the Department of Radiological Sciences, Ottawa Civic Hospital, Ottawa, Ontario, Canada (S.F.M.). Received September 5, 1995; revision requested September 28; revision received October 23; accepted October 26. Address correspondenceto B.E.B.
0SCVIR, 1996
Signs and symptoms of deep venous thrombosis developed in the right leg of a 70-year-old man 7 days after surgical evacuation of a left subdural hematoma. Duplex ultrasound (US) of the right leg revealed deep venous thrombosis extending from the popliteal vein to the proximal superficial femoral vein. Inferior vena cavography a t the time of filter placement showed a caval diameter of 20 mm, uncorrected for magnification. Images obtained before and after filter placement showed mild left lateral compression of the IVC by the adjacent aorta. A Gunther temporary IVC filter was successfully placed in an infrarenal location to help prevent pulmonary embolism before
the patient underwent anticoagulation. The left common femoral vein was used for filter insertion. The patient was brought to the interventional suite for removal of the temporary filter 12 days after insertion of the device. Thrombus was not detected in the IVC or the filter. When we attempted to remove the temporary filter, we found that it was firmly attached to the left wall of the IVC. Despite forcible attempts to extract the filter, including closing the filter in the sheath, pushing the device cranially, and rotating the filter, it could not be freed (Figure). When traction was applied to the filter, the calcified intima of the adjacent aorta could be seen to move. Removal of the filter was aborted. A subsequent attempt to remove the filter 1day later also failed. Staphylococcus aureus and Proteus mirabilis grew in blood culture specimens drawn from the filter sheath. During laparotomy a vertical inferior vena cavotomy was performed after the IVC was clamped upstream and downstream of the temporary filter. At visual inspection of the filter in situ, we found that two of the wires of the basket were imbedded in the left wall of the IVC, and a 2 cm3 thrombus was trapped inside the basket. The device could not be digitally extracted. The filter was grasped with a pair of forceps, and considerable force was required to detach it from the wall of the IVC. The filter and wire were successfully extracted 15 days after insertion, along with the thrombus and intima adherent to the basket wires. Cultures of the thrombus and the filter wires were negative. No complications occurred. Duplex US of the left leg 5 days after removal of the temporary filter revealed insertion vein thrombosis from the popliteal vein to the common fem-
290
Journal of Vascular and Interventional Radiology
March-April 1996
oral vein, presumably due to the temporary filter sheath. The patient and his family refused placement of a permanent IVC filter or any other venous intervention. The patient underwent full heparinization and his regimen was changed to warfarin to maintain full anticoagulation for 3 months.
(
DISCUSSION Retrievable IVC filters offer an advantage over temporary IVC filters in that they are permanent devices designed for potential retrieval during repeated venous access a t a later date. Temporary filters remain attached to a wire or catheter that protrudes from the site of venous access, thus necessitating eventual removal of the filter. It is difficult to know how long a temporary or retrievable IVC filter can be left implanted before simple, percutaneous removal becomes impossible; not enough data exist. Epstein et a1 (3) reported successful removal of Amplatz filters in five patients up to 16 days after implantation. Nakagawa et a1 (4) were able to easily remove nitinol wire temporary filters in two patients 5 and 7 days after implantation. ThCry et a1 (5) were able to remove the Prothia temporary filter (Prothia, Montrouge, France) in 174 patients 7 days after implantation, although all of these patients were given thrombolytic therapy, which could influence potential incorporation of the filter into the wall of the vena cava (5). Our own preliminary experience with the Gunther temporary filter indicated that the device could be safely removed 11or more days after implantation. We easily removed devices in three patients 11, 12, and 14 days after implantation. In two patients the filter was successfully removed after 6 days of implantation even though the vena cava and filter basket were occluded by thrombus (2). Temporary or retrievable vena cava filters have been left implanted and then successfully removed after longer periods in animals. The retrievability of filters is related to their design. Gunther and Schild (6) reported a n inability to remove their "basket" type of retrievable filter after 10 days. Neuerburg et a1 (7) were able to remove retrievable stainless steel half-basket
filters from seven dogs 2-3 weeks after insertion. They noted, however, that after 3 weeks of implantation, the filters were firmly fixed in the vein wall by fibrotic reaction (7). Subsequent animal research revealed t h a t t h i s device could be retrieved in 10 of 11 animals after 14 days of implantation (8). Kuszyk et a1 (9) were able to remove the Tempofilter (B Braun Celsa, Chasseneuil, France) from swine up to 6 weeks after implantation. Nevertheless, thrombus formation, subsequent pulmonary embolism, and caval stenosis did occur. No caval perforation occurred during removal. Irie et a1 (10) were able to remove a retrievable filter 4 weeks after implantation. Neointimal hyperplasia was found to occur around the struts of the device. In spite of this, removal was uncomplicated and no complications occurred during follow-up. A variety of factors affect the rate of formation of thrombus and neointimal hyperplasia on the struts of retrievable and temporary vena cava filters. These factors include device material and design, animal type, and the administration of drugs, including anticoagulants. Furthermore, the method of removal of a retrievable or temporary filter may have a bearing on whether it can be disengaged from thrombus or neointimal hyperplasia. Because retrievable filters can be left in situ if attempts to extract them fail, they offer a major advantage over temporary filters, which must be removed owing to the presence of a permanent external catheter or wire. In conclusion, we report a case in which a Gunther temporary IVC filter could not be removed percutaneously after only 12 days of implantation. Laparotomy was necessary for filter removal. This finding indicates that further research is necessary into the mechanism of incorporation of these devices into the IVC wall before retrievable or temporary vena cava filters can be recommended for widespread clinical use. References 1. Athanasoulis C. Complications of vena cava
filters. Radiology 1993; 188:614-615. 2. Millward SF, Bormanis J, Burbridge B, Markman S, Peterson R. Preliminary clinical experience with the Gunther temporary inferior vena cava filter. JVIR 1994; 5:863868.
Figure. Digital image of the abdomen coned down on the filter basket shows deformity of the basket during attempted removal.
3. Epstein DH, Darcy MD, Hunter DW, et al. Experience with the Amplatz retrievable vena cava filter. Radiology 1989; 172:105110. 4. Nakagawa N, Cragg AH, Smith TP, Castaneda F, Barnhart WH, DeJong SC. A retrievable nitinol vena cava filter: experimental and initial clinical results. JVIR 1994; 5:507-512. 5. Thery C, Bauchert J J , Lesenne M, et al. Predictive factors of effectiveness of streptokinase in deep venous thrombosis. Am J Cardio11992; 69:117-122. 6. Gunther R, Schild H. Basket filter for the prevention of pulmonary embolism. Semin Intervent Radiol 1986; 3:220-226. 7. Neuerberg J, Gunther RW, Vorwerk D, Handt S, Tonn K. New retrievable percutaneous vena caval filter: in vivo and in vitro studies (abstr). JVIR 1991; 2:51. 8. Neuerburg J , Gunther R, Rassmussen E, et al. New retrievable percutaneous vena cava filter: experimental in vitro and in vivo evaluation. Cardiovasc Intervent Radiol 1993; 16224-229. 9. Kuszyk BS, Baltimore MS, Venbmx AC, et al. Feasibility and pathologic effects on the caval wall of a new subcutaneously tethered temporary caval filter in swine (abstr). JVIR 1995; 62395-902. 10. Irie T, Yamauchi T, Makita K, Kusano S. Retrievable IVC filter: preliminary in vitro and in vivo evaluation. JVIR 1995; 6:449-454.
Incorporation of the Gunther Temporary Inferior Vena Cava Filter into the Caval Wall1 Brent E. Burbridge, MD, FRCPC Doug R. Walker, MD, FRCPC Steven F. Millward, FRCPC, MB, ChB
Index terms: Interventional procedures, complications, 982,456,982,458,982,751 Venae cavae, filters, 982.1267 Venae cavae, interventional procedure, 982.1267 Venae cavae, thrombosis, 982,458,982,751
JVIR 1996; 7:289-290
PERMANENT inferior vena cava (IVC) filters are associated with a variety of complications (1).This problem, along with the lack of long-term scientific follow-up of patients with permanent IVC filters, has led to the development of retrievable permanent and temporary IVC filters. Retrievable IVC filters are similar to permanent filters except that they are designed to be potentially retrievable after repeated venous access a t a later date. Temporary IVC filters must remain tethered to a catheter or wire and are externalized a t the site of venous access to allow removal a t a later date. We recently described our preliminary experience with the Gunther temporary IVC filter (2); complications included insertion vein thrombosis and IVC occlusion. Patients had filters in situ for up to 14 days, and the filters were all easily removed. Here we describe a patient in whom the device became firmly incorporated into the vena cava wall after 12 days of implantation.
I CASE REPORT
F r o m the Department of Medical Imaging (B.E.B., D.W.), Royal University Hospital, 103 Hospital Dr, Saskatoon, Saskatchewan, Canada S7N 0W8; and the Department of Radiological Sciences, Ottawa Civic Hospital, Ottawa, Ontario, Canada (S.F.M.). Received September 5, 1995; revision requested September 28; revision received October 23; accepted October 26. Address correspondenceto B.E.B.
0SCVIR, 1996
Signs and symptoms of deep venous thrombosis developed in the right leg of a 70-year-old man 7 days after surgical evacuation of a left subdural hematoma. Duplex ultrasound (US) of the right leg revealed deep venous thrombosis extending from the popliteal vein to the proximal superficial femoral vein. Inferior vena cavography a t the time of filter placement showed a caval diameter of 20 mm, uncorrected for magnification. Images obtained before and after filter placement showed mild left lateral compression of the IVC by the adjacent aorta. A Gunther temporary IVC filter was successfully placed in an infrarenal location to help prevent pulmonary embolism before
the patient underwent anticoagulation. The left common femoral vein was used for filter insertion. The patient was brought to the interventional suite for removal of the temporary filter 12 days after insertion of the device. Thrombus was not detected in the IVC or the filter. When we attempted to remove the temporary filter, we found that it was firmly attached to the left wall of the IVC. Despite forcible attempts to extract the filter, including closing the filter in the sheath, pushing the device cranially, and rotating the filter, it could not be freed (Figure). When traction was applied to the filter, the calcified intima of the adjacent aorta could be seen to move. Removal of the filter was aborted. A subsequent attempt to remove the filter 1day later also failed. Staphylococcus aureus and Proteus mirabilis grew in blood culture specimens drawn from the filter sheath. During laparotomy a vertical inferior vena cavotomy was performed after the IVC was clamped upstream and downstream of the temporary filter. At visual inspection of the filter in situ, we found that two of the wires of the basket were imbedded in the left wall of the IVC, and a 2 cm3 thrombus was trapped inside the basket. The device could not be digitally extracted. The filter was grasped with a pair of forceps, and considerable force was required to detach it from the wall of the IVC. The filter and wire were successfully extracted 15 days after insertion, along with the thrombus and intima adherent to the basket wires. Cultures of the thrombus and the filter wires were negative. No complications occurred. Duplex US of the left leg 5 days after removal of the temporary filter revealed insertion vein thrombosis from the popliteal vein to the common fem-
290
Journal of Vascular and Interventional Radiology
March-April 1996
oral vein, presumably due to the temporary filter sheath. The patient and his family refused placement of a permanent IVC filter or any other venous intervention. The patient underwent full heparinization and his regimen was changed to warfarin to maintain full anticoagulation for 3 months.
(
DISCUSSION Retrievable IVC filters offer an advantage over temporary IVC filters in that they are permanent devices designed for potential retrieval during repeated venous access a t a later date. Temporary filters remain attached to a wire or catheter that protrudes from the site of venous access, thus necessitating eventual removal of the filter. It is difficult to know how long a temporary or retrievable IVC filter can be left implanted before simple, percutaneous removal becomes impossible; not enough data exist. Epstein et a1 (3) reported successful removal of Amplatz filters in five patients up to 16 days after implantation. Nakagawa et a1 (4) were able to easily remove nitinol wire temporary filters in two patients 5 and 7 days after implantation. ThCry et a1 (5) were able to remove the Prothia temporary filter (Prothia, Montrouge, France) in 174 patients 7 days after implantation, although all of these patients were given thrombolytic therapy, which could influence potential incorporation of the filter into the wall of the vena cava (5). Our own preliminary experience with the Gunther temporary filter indicated that the device could be safely removed 11or more days after implantation. We easily removed devices in three patients 11, 12, and 14 days after implantation. In two patients the filter was successfully removed after 6 days of implantation even though the vena cava and filter basket were occluded by thrombus (2). Temporary or retrievable vena cava filters have been left implanted and then successfully removed after longer periods in animals. The retrievability of filters is related to their design. Gunther and Schild (6) reported a n inability to remove their "basket" type of retrievable filter after 10 days. Neuerburg et a1 (7) were able to remove retrievable stainless steel half-basket
filters from seven dogs 2-3 weeks after insertion. They noted, however, that after 3 weeks of implantation, the filters were firmly fixed in the vein wall by fibrotic reaction (7). Subsequent animal research revealed t h a t t h i s device could be retrieved in 10 of 11 animals after 14 days of implantation (8). Kuszyk et a1 (9) were able to remove the Tempofilter (B Braun Celsa, Chasseneuil, France) from swine up to 6 weeks after implantation. Nevertheless, thrombus formation, subsequent pulmonary embolism, and caval stenosis did occur. No caval perforation occurred during removal. Irie et a1 (10) were able to remove a retrievable filter 4 weeks after implantation. Neointimal hyperplasia was found to occur around the struts of the device. In spite of this, removal was uncomplicated and no complications occurred during follow-up. A variety of factors affect the rate of formation of thrombus and neointimal hyperplasia on the struts of retrievable and temporary vena cava filters. These factors include device material and design, animal type, and the administration of drugs, including anticoagulants. Furthermore, the method of removal of a retrievable or temporary filter may have a bearing on whether it can be disengaged from thrombus or neointimal hyperplasia. Because retrievable filters can be left in situ if attempts to extract them fail, they offer a major advantage over temporary filters, which must be removed owing to the presence of a permanent external catheter or wire. In conclusion, we report a case in which a Gunther temporary IVC filter could not be removed percutaneously after only 12 days of implantation. Laparotomy was necessary for filter removal. This finding indicates that further research is necessary into the mechanism of incorporation of these devices into the IVC wall before retrievable or temporary vena cava filters can be recommended for widespread clinical use. References 1. Athanasoulis C. Complications of vena cava
filters. Radiology 1993; 188:614-615. 2. Millward SF, Bormanis J, Burbridge B, Markman S, Peterson R. Preliminary clinical experience with the Gunther temporary inferior vena cava filter. JVIR 1994; 5:863868.
Figure. Digital image of the abdomen coned down on the filter basket shows deformity of the basket during attempted removal.
3. Epstein DH, Darcy MD, Hunter DW, et al. Experience with the Amplatz retrievable vena cava filter. Radiology 1989; 172:105110. 4. Nakagawa N, Cragg AH, Smith TP, Castaneda F, Barnhart WH, DeJong SC. A retrievable nitinol vena cava filter: experimental and initial clinical results. JVIR 1994; 5:507-512. 5. Thery C, Bauchert J J , Lesenne M, et al. Predictive factors of effectiveness of streptokinase in deep venous thrombosis. Am J Cardio11992; 69:117-122. 6. Gunther R, Schild H. Basket filter for the prevention of pulmonary embolism. Semin Intervent Radiol 1986; 3:220-226. 7. Neuerberg J, Gunther RW, Vorwerk D, Handt S, Tonn K. New retrievable percutaneous vena caval filter: in vivo and in vitro studies (abstr). JVIR 1991; 2:51. 8. Neuerburg J , Gunther R, Rassmussen E, et al. New retrievable percutaneous vena cava filter: experimental in vitro and in vivo evaluation. Cardiovasc Intervent Radiol 1993; 16224-229. 9. Kuszyk BS, Baltimore MS, Venbmx AC, et al. Feasibility and pathologic effects on the caval wall of a new subcutaneously tethered temporary caval filter in swine (abstr). JVIR 1995; 62395-902. 10. Irie T, Yamauchi T, Makita K, Kusano S. Retrievable IVC filter: preliminary in vitro and in vivo evaluation. JVIR 1995; 6:449-454.