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Inferior Vena Cava Filters and Ports
CHAPTER 33
Inferior Vena Cava Filters and Ports JESSE CHAIT, BS • ANIL HINGORANI, MD • ENRICO ASCHER, MD, FACS
CHAPTER OVERVIEW
Placement of inferior vena cava (IVC) filters (IVCFs) and totally implantable venous-access devices (TIVADs), like many other interventions covered in this text, are safely and effectively being performed in the office setting. This chapter will cover the officebased considerations of these procedures including indications, device selection, evidence-based technique, and postoperative care, including potential complications and their associated management. Since these aspects are unique to each intervention, they will be covered separately.
PREOPERATIVE EVALUATION All patients should undergo proper preoperative medical assessment and optimization before insertion of an IVCF or TIVAD. We recommend routine laboratory studies including a complete blood count, metabolic panel, prothrombin time, and an international normalized ratio (INR). In order to reduce bleedingrelated complications, all patients should have an INR <1.6 for TIVAD placement and <3.0 for IVCF insertion. In all cases, local anesthesia should be utilized to reduce pain associated with obtaining venous access. For patients undergoing TIVAD placement, we offer monitored anesthesia care (MAC) with intravenous sedation; however, the authors do not routinely employ this practice for uncomplicated IVCF insertions.
INFERIOR VENA CAVA FILTERS Overview In the past, the number of IVCF insertions performed in the United States experienced a marked increase often postulated to be due to an increase in retrievable filters placed for prophylactic indications.1,2 Contemporarily, due to questionable efficacy, negative views regarding long-term safety, and increased rates of litigation,3,4 IVCF placement has been decreasing. This overall
downward trend in filter insertion has been accompanied by increases in IVCF placement in the outpatient setting, a rise in the volume of insertions by nonsurgeon insertions, and increased retrieval rates.5,6
Indications for Filter Insertion IVCF placement is indicated for patients who have experienceddor are at high riskdpulmonary embolism (PE), who have an absolute contraindication or experienced complications to anticoagulation therapy, or who suffered from deep vein thrombosis (DVT) or PE despite maintaining therapeutic anticoagulation. IVCF insertion should be avoided unless absolutely indicated, as implantation increases incidence of DVT without proven mortality benefit.7,8 Furthermore, IVCFs should not be used as an adjunct to prevent recurrent PE in patients who are able to tolerate anticoagulation.9
Technique for Filter Insertion Ultrasound-guided percutaneous access is typically obtained via the common femoral vein; however, in cases where this is not feasible, the internal jugular and upper extremity veins remain viable options.10,11 A single access site is typically adequate for successful IVCF placement; however, some providers prefer two access sites when utilizing intravascular ultrasound (IVUS).12,13 The authors recommend an oversized (6 or 7Fr) sheath, as opposed to a typical 4Fr, in order to allow for rapid injection of contrast bolus without the need for an expensive power injector. Fluoroscopic guidance is used to identify bony landmarks that guide proper anatomic deployment, typically inferior to the renal veins. In most patients, the L2-L3 vertebral level marks the approximate level of the renal veins, and a 20-mL contrast bolus can be utilized to properly demarcate the renal veins. While an IVUS pullback technique from the right atrium can also be used to identify the renal veins,13 this may be cost-prohibitive in the office-based setting. Suprarenal filter placement is a safe alternative typically indicated when infrarenal
Office-Based Endovascular Centers. https://doi.org/10.1016/B978-0-323-67969-5.00033-2 Copyright © 2020 Elsevier Inc. All rights reserved.
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deployment is inadequate, such as in the presence of thrombus, compression, or pregnancy.14 Transabdominal ultrasound (TAUS) also remains a viable option for filter insertionda practice that has been utilized at the bedside for patients deemed too unstable for the operating room or interventional suite.14 This technique may also be used in the office-based setting. Proper probe positioning at the right flank to identify the confluence of the right renal vein (RRV) and IVC allows for safe and effective deployment.15 The authors recommend a postdeployment venogram to ensure proper filter deployment within the desired IVC segment and to identify any immediate complications such as filter malposition.16 Patients are encouraged to return to the office within 1 week of filter placement for follow-up examination with duplex ultrasonography (DUS). In order to increase filter retrieval rates and decrease complications related to prolonged dwell time, the authors recommend quarterly follow-up visits.
Complications of Filter Insertion Placement of IVCFs is a relatively low-risk intervention that can be safely performed in both hospital and office settings.17 As with any endovascular procedure, there is always a risk of access site complications; however, the majority of issues related to filters are attributed to the device itself. Filter complications can increase the risk of PE and prevent or complicate attempts at retrieval. Filter tilt is a common complication defined as >15 degrees angulation, which increases the risk for PE and some have suggested that this may be an indication for insertion of a second filter.16,18 Filter migration, defined as >2 cm movement from the initial deployment site, most commonly occurs >30 days after insertion.18 Struts can fracture and embolize, or pierce the caval wall. Thrombosis of the IVC can lead to edema, pain, PE, or even renal failure if the thrombus propagates to the level of the renal veins.18 Management of these complications is often complex, must be tailored to the exact needs of the patient, and therefore are out of the scope of this text.
Indications and Strategies for Filter Retrieval An increase in awareness of complications associated with long-standing IVCFs has led to widespread efforts to develop effective retrieval campaigns and techniques. All retrievable filters should be removed unless an indication for permanent filtration is present assuming there is no anticipated return to a high-risk status. Operator-dependent barriers to filter retrieval, such as
difficult anatomy or prolonged dwell time, should not be considered contraindications to a retrieval attempt. Risk factors for nonretrieval of retrievable filters include advanced age, presence of an acute bleed, and current malignancy.19 Patients are often unaware of the retrievable status of their filter, and some may not be aware one is present at all, and therefore healthcare providers must be vigilant in their follow-up.20 Development of a documented retrieval algorithm (Fig. 33.1), along with the creation of a multidisciplinary team or dedicated clinic, and access to an office-based endovascular center have all been shown to significantly increase filter retrieval rates.21e24
Technique for Filter Retrieval As with many endovascular interventions, a variety of tools are available for the retrieval of vena cava filters.25 Preoperatively, abdominal X-ray or computed tomography (CT) should be performed in order to determine filter location, degree of angulation, the presence of any strut fractures. Preintervention planning is paramount for efficient and safe filter retrieval, and DUS should be used liberally in order to confirm filter location and ensure access can be safely obtained. Typically, percutaneous access is obtained via the right IJV; however, some authors report the use of a femoral or upper extremity approach.26 In complex cases, multiple access sites may be utilized in order to facilitate the use of several retrieval devices. Unlike filter insertion, retrieval necessitates the use of fluoroscopic guidance, and complex scenarios may lead to both prolonged case times and increased radiation exposure. In simple cases, a combination of sheath and snare is used to hook, collapse, and remove the filter. This approach has a high success rate when attempting to retrieve filters with limited dwell time. However, retrieval of IVCFs that have remained in vivo for an extended period of time can often be complicated by filter malposition, wall penetration, endothelialization, or IVC thrombosis.25 In more complex cases, the use of endobronchial forceps and excimer lasers to dissect and free embedded filters and fractured components has been described with high levels of success.27 Adjunctive techniques such as grasping the hook with the endobronchial forceps, wire loop snare, and deflection of the filter hook with a balloon placed from the groin can also be helpful.
Rationale for Office-Based Placement and Retrieval The majority of IVCF insertion and retrieval procedures are simple, safe, and require a limited amount of equipment, making them ideal interventions to be performed
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IVC filter database updated monthly with patients from previous month
Discussion with referring physician
IVC filter retrieval indicated
IVC filter retrieval scheduled
IVC filter retrieval not indicated at this time
IVC filter is permanent (including patient dispositions of death and hospice)
1 month No further follow-up
Appropriateness of IVC filter retrieval is unclear
Patient lost to follow-up*
Referral to an hematologist
Attempts to contact patient by phone to follow-up with local physician
FIG. 33.1 Inferior vena cava (IVC) filter retrieval algorithm.23
in the office. Retrospective analyses have confirmed the safety and efficacy of both filter insertion17 and removal in the office-based setting, with an increased retrieval rate associated with access to an office endovascular center.24 Furthermore, the continuity of care, physicianpatient rapport, and presence of dedicated support staff associated with office-based centers make it an ideal environment for development of a culture dedicated to IVCF retrieval. All staff should be made aware of this effort and motivated to educate patients on their filter status. All patients who receive filter insertion in the office, report a history of filter placement, or have evidence of an IVCF on imaging should have their information placed in a registry that allows for continuous follow-up and evaluation of the necessity of the filter.
TOTALLY IMPLANTABLE VENOUS ACCESS DEVICES Overview TIVADs, commonly referred to as “ports,” provide reliable access for patients who require long-term,
intermittent intravenous therapy, typically in those with chronic hematologic disease and malignancy.28 While device selection and technique vary greatly between providers, the general principle of TIVAD placement is reliable central venous access through a subcutaneous port. Most modern ports are magnetic resonance imaging (MRI)-safe, able to endure thousands of repeat Huber needle punctures and can withstand high pressures and infusion volumes associated with intravenous contrast studies. The catheters attached to these ports may be double, single, or lumen, the latter allowing for simultaneous infusions, such as chemotherapy alongside total parenteral nutrition (TPN).29
Indications Ports are often necessary for those with chronic diseases, such as malignancy or hematologic disorders, who require intermittent infusion of venotoxic agents or exchange transfusions. The most common indications for TIVAD placement include solid and hematologic malignancies, and a long-term need for apheresis.
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In general, two options exist for long-term venous device-aided access: tunneled or subcutaneous catheters. Whereas a tunneled device is preferable when venous access is needed on a constant basis, TIVADs are better suited for intermittent access, such as for chemotherapy, TPN, or routine transfusions.28 Tunneled catheters are typically preferred for shortterm use, whereas TIVADs are more suitable for longterm access, such as in patients with chronic disease. The subcutaneous port aspect of the TIVAD design is the factor most associated with fewer complications, a lower infection rate, higher quality of life, and increased patient satisfaction, when compared with tunneled, nontunneled, and peripherally inserted central venous catheters.30,31
obtaining venous access via the femoral, subclavian, or internal jugular vein (IJV).38,39 In the office, highresolution DUS should be available for both diagnosis and image-guided intervention. US guidance allows for preprocedural identification of nonviable access sites, such as a thrombosed IJV, or a small caliber cephalic vein. Use of the routine US guidance reduces the incidence of iatrogenic PTX and prevents inadvertent arterial injury. Due to the lower incidence of hemopneumothorax, the authors prefer placement of TIVADs in the right IJV. This also eliminates the rare occurrence of “pinch off” syndrome with interaction and possible obstruction of the catheter due to compression at the costoclavicular junction with placement via the subclavian route.40e42
Technique
Follow-Up
We recommend routine administration of a prophylactic, preoperative antibiotic. Our preferred agent is cefazolin; however, for patients with allergy or sensitivity to beta lactam antibiotics, we utilize clindamycin or vancomycin. Initial venous access can be obtained percutaneously or via an open surgical approach. A recent metaanalysis showed a higher successful primary implantation rate with the Seldinger technique when compared with open venous cutdown; however, percutaneously placed subclavian catheters were more likely to experience complications. These complications, however, were not related to pneumothorax (PTX) or infection.32 Classically, a two-incision method has been the standard procedure for TIVAD placement33; however, a single-incision technique has also been described.34,35 Ultrasound-guided catheter placement into the internal jugular vein is preferred due to the ease of access and ability for direct visualization. Unless contraindicated due to prior surgery, wound, or history of ipsilateral device placement, some authors prefer insertion of the TIVAD catheter in the right subclavian or cephalic vein, as these options necessitate the shortest catheter length and least amount of angulation for proper positioning.36 Other options include branches of the thoracoacromial vein.37 The femoral vein is an alternative TIVAD site for patients with unsuitable upper extremity access, which can be due to central venous stenosis, thrombosis, inadequate vasculature, or superior vena cava syndrome. Regardless of insertion site, all office-based centers should have electrocautery available, as extensive axillary, pectoral, or femoral venous collaterals may cause bleeding during pocket creation. As with all percutaneous endovascular procedures, systematic reviews have demonstrated that ultrasound (US) guidance improves safety outcomes when
As with all intravascular devices and long-term access sites, frequent follow-up evaluation is paramount in order to maintain patency, prevent complications, and ensure removaldwhen indicated. We recommend evaluation with physical exam within 7 days of implantation, and every 3 months thereafter. New onset neck or upper extremity swelling should prompt a thorough DUS examination. If sonogram cannot identify a culprit lesion, a contrast port study may be indicated, especially since the tip of the catheterda common site of thrombusdis not able to be visualized due to its location at the caval-atrial junction.
Complications Pneumothorax Complications associated with TIVAD placement are rare. In many centers, routine postprocedural chest X-ray (CXR) is required after obtaining central venous access via the IJV and subclavian veins, in order to evaluate for iatrogenic PTX and proper catheter tip placement. However, some authors have suggested that this practice may be unnecessary due to a variety of reasons. First, the incidence of PTX is exceedingly low when utilizing US guidance to assist with TIVAD placement.43 Second, CXR has poor diagnostic capabilities in terms of both identifying postoperative PTX43 and catheter malposition.44 Third, postprocedure US can be used to assess for iatrogenic PTX and catheter malposition with similar or better efficacy when compared with CXR.45,46 Nevertheless, we still recommend a postinsertion chest radiograph following any type of central catheter placement. Some authors forgo formal radiographs in lieu of postinsertion fluoroscopic assessment; however, some infusion centers mandate confirmatory CXR prior to initial TIVAD access.
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Suspected postprocedure PTX is suggested by dyspnea, tachycardia, and decreased oxygen saturation and should be evaluated with prompt CXR or US and managed initially oxygen supplementation. The authors suggest having some type of pleural decompression device available in the office setting, such as a large gauge intravenous cannula, in the case of a tension PTX. All patients with suspected PTX should be sent to the nearest emergency department for further evaluation and monitoring.
The benefits of office-based TIVAD placement are multifaceted. Compared with implantation in the hospital setting, office-based placement results in fewer infections,51 decreased costs,52 and increased patient satisfaction. As healthcare expenditures continue to rise, providers should be cognizant of all options that reduce costs, especially for high-utilization patients, such as those with chronic disease who require TIVAD insertion or removal.
Infection
REFERENCES
As with the placement of any indwelling catheter, the risk of infection is of paramount concern. The strongest risk factors for TIVAD-associated infections include presence of a hematologic malignancy, frequent device utilization, young age, difficulty obtaining proper needle insertion, concomitant steroid use, and infusion of TPN through the port.47e49 Ports placed in the office have a lower incidence of infection and dehiscence when compared with those placed in the inpatient setting.50 Suspected port infection should be expeditiously evaluated, first by differentiating between local and bloodstream infection. Since local infections often occur due to extraluminal contamination, concomitant bloodstream infection is rare, and local signs are rarely seen with disseminated disease. Whereas local infection can be confirmed by tissue culture, bloodstream infection attributed to a contaminated TIVAD can be confirmed by positive, matching cultures withdrawn from both a native peripheral vein and the device itself. The management of TIVAD-related infection depends on location and severity. In some cases, local infections can be managed conservatively; however, in the majority of cases of catheter-associated bloodstream infection, the TIVAD should be explanted along with systemic antimicrobial therapy.47 In select scenarios, conservative management of systemic antimicrobial therapy with close observation and repeated cultures may be warranted.
Rationale for office-based placement and removal A large percentage of endovascular and vascular access procedures have migrated from the hospital to the outpatient and office setting,51 owing to reduced costs and increased preference by both patient and provider.52 As indications for port placement typically include chronic disease and cancer, TIVAD implantation is not emergent and can be scheduled as an elective, office-based procedure.
1. Duffett L, Carrier M. Inferior vena cava filters. J Thromb Haemost. 2017;15(1):3e12. 2. Duszak R, Parker L, Levin DC, Rao VM. Placement and removal of inferior vena cava filters: National trends in the medicare population. J Am Coll Radiol. 2011;8(7): 483e489. 3. Phair J, Denesopolis J, Lipsitz EC, Scher L. Inferior vena cava filter malpractice litigation: Damned if you do, Damned if you don’t. Ann Vasc Surg. 2018;50:15e20. 4. Oh K, Hingorani A. Outcomes and associated factors in malpractice litigation involving inferior vena cava filters. J Vasc Surg. 2018;6(4):541e544. 5. Morris E, Duszak R, Sista AK, Hemingway J, Hughes DR, Rosenkrantz AB. National trends in inferior vena cava filter placement and retrieval procedures in the medicare population over two decades. J Am Coll Radiol. 2018;15(8): 1080e1086. 6. Ahmed O, Wadhwa V, Patel K, Patel MV, Turba UC, Arslan B. Rising retrieval rates of inferior vena cava filters in the United States: insights from the 2012 to 2016 summary medicare claims data. J Am Coll Radiol. 2018;15(11): 1553e1557. 7. 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. N Engl J Med. 1998;338(7):409e416. 8. Jiang J, Jiao Y, Zhang X. The short-term efficacy of vena cava filters for the prevention of pulmonary embolism in patients with venous thromboembolism receiving anticoagulation: meta-analysis of randomized controlled trials. Phlebology. 2016;32(9):620e627. 9. Mismetti P, Laporte S, Pellerin O, et al. Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism. J Am Med Ass. 2015;313(16):1627e1635. 10. Lambe BD, Bedway JJ, Friedell ML. Percutaneous femoral vein access for inferior vena cava filter placement does not cause insertion-site thrombosis. Ann Vasc Surg. 2013; 27(8):1169e1172. 11. Stone PA, AbuRahma AF, Hass SM, et al. TrapEase inferior vena cava filter placement: use of the subclavian vein. Vasc Endovasc Surg. 2004;38(6):505e509. 12. Gunn AJ, Iqbal SI, Kalva SP, et al. Intravascular ultrasoundguided inferior vena cava filter placement using a single-
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puncture technique in 99 patients. Vasc Endovasc Surg. 2013;47(2):97e101. Passman MA, Dattilo JB, Guzman RJ, Naslund TC. Bedside placement of inferior vena cava filters by using transabdominal duplex ultrasonography and intravascular ultrasound imaging. J Vasc Surg. 2005;42(5):1027e1032. Kalva SP, Chlapoutaki C, Wicky S, Greenfield AJ, Waltman AC, Athanasoulis CA. Suprarenal inferior vena cava filters: a 20-year single-center experience. J Vasc Interv Radiol. 2008;19(7):1041e1047. Qin X, Lu C, Ren P, et al. New method for ultrasoundguided inferior vena cava filter placement. J Vasc Surg. 2018;6(4):450e456. Rajasekhar A. Inferior vena cava filters: current best practices. J Thromb Thrombolysis. 2015;39(3):315e327. Alsheekh A, Hingorani A, Marks N, Ascher E. The next frontier of office-based inferior vena cava filter placement. J Vasc Surg. 2016;4(3):283e285. Grewal S, Chamarthy MR, Kalva SP. Complications of inferior vena cava filters. Cardiovasc Diagn Ther. 2016;6(6): 632e641. Siracuse JJ, Al Bazroon A, Gill HL, et al. Risk factors of nonretrieval of retrievable inferior vena cava filters. Ann Vasc Surg. 2015;29(2):318e321. Aurshina A, Brahmandam A, Zhang Y, et al. Patient perspectives on inferior vena cava filter retrieval. J Vasc Surg. 2019. Article in press. Inagaki E, Farber A, Eslami MH, et al. Improving the retrieval rate of inferior vena cava filters with a multidisciplinary team approach. J Vasc Surg. 2016;4(3):276e282. Minocha J, Idakoji I, Riaz A, et al. Improving inferior vena cava filter retrieval rates: impact of a dedicated inferior vena cava filter clinic. J Vasc Interv Radiol. 2010;21(12): 1847e1851. Litwin RJ, Huang SY, Sabir SH, et al. Impact of an inferior vena cava filter retrieval algorithm on filter retrieval rates in a cancer population. J Vasc Surg. 2017;5(5):689e697. VanderVeen N, Friedman J, Rummel M, et al. Improving inferior vena cava filter retrieval and success rates utilizing an office endovascular center [Abstract]. J Vasc Surg. 2018; 67(6):e225. Kuyumcu G, Walker TG. Inferior vena cava filter retrievals, standard and novel techniques. Cardiovasc Diagn Ther. 2016;6(6):642e650. Posham R, Fischman AM, Nowakowski FS, et al. Transfemoral filter eversion technique following unsuccessful retrieval of option inferior vena cava filters: a single center experience. J Vasc Interv Radiol. 2017;28(6):889e894. Chen JX, Montgomery J, McLennan G, Stavropoulos SW. Endobronchial forceps-assisted and excimer laser-assisted inferior vena cava filter removal: the data, where we are, and how it is done. Tech Vasc Interv Radiol. 2018;21(2): 85e91. Walser EM. Venous access ports: indications, implantation technique, follow-up, and complications. Cardiovasc Interv Radiol. 2011;35(4):751e764. Teichgräber UK, Nagel SN, Kausche S, Streitparth F, Cho CH. Double-lumen central venous port catheters:
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simultaneous application for chemotherapy and parenteral nutrition in cancer patients. J Vasc Access. 2010; 11(4):335e341. Fang S, Yang J, Song L, Jiang Y, Liu Y. Comparison of three types of central venous catheters in patients with malignant tumor receiving chemotherapy. Patient Prefer Adherence. 2017;11:1197e1204. Coady K, Ali M, Sidloff D, Kenningham RR, Ahmed S. A comparison of infections and complications in central venous catheters in adults with solid tumours. J Vasc Access. 2014;16(1):38e41. Hsu CC, Kwan GN, Driel ML, Rophael JA. Venous cutdown versus the Seldinger technique for placement of totally implantable venous access ports. Cochrane Database Syst Rev. 2011. Funaki B, Szymski GX, Hackworth CA, et al. Radiologic placement of subcutaneous infusion chest ports for longterm central venous access. Am J Roentgenol. 1997; 169(5):1431e1434. Charles HW, Miguel T, Kovacs S, Gohari A, Arampulikan J, Mccann JW. Chest port placement with use of the singleincision insertion technique. J Vasc Interv Radiol. 2009; 20(11):1464e1469. Cheng H, Ting C, Chu Y, Chang W, Chan K, Chen P. Application of an ultrasound-guided low-approach insertion technique in three types of totally implantable access port. J Chin Med Assoc. 2014;77(5):246e252. Wei W, Wu C, Wu C, et al. The treatment results of a standard algorithm for choosing the best entry vessel for intravenous port implantation. Medicine (Baltim). 2015; 94(33):e1381. Su T, Wu C, Fu J, et al. Deltoid branch of thoracoacromial vein: a safe alternative entry vessel for intravenous port implantation. Medicine (Baltim). 2015;94(17). Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. Cochrane Database Syst Rev. 2015. Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. Cochrane Database Syst Rev. 2015. Aitken DR, Minton JP. The “pinch-off sign”: a warning of impending problems with permanent subclavian catheters. Am J Surg. 1984;148(5):633e636. Orsi F, Grasso RF, Arnaldi P, et al. Ultrasound guided versus direct vein puncture in central venous port placement. J Vasc Access. 2000;1(2):73e77. Tamura A, Sone M, Ehara S, et al. Is ultrasound-guided central venous port placement effective to avoid pinch-off syndrome? J Vasc Access. 2014;15(4):311e316. Brown JR, Slomski C, Saxe AW. Is routine postoperative chest X-ray necessary after fluoroscopic-guided subclavian central venous port placement? J Am Coll Surg. 2009; 208(4):517e519. Salimi F, Hekmatnia A, Shahabi J, Keshavarzian A, Maracy MR, Jazi AH. Evaluation of routine postoperative chest roentgenogram for determination of the correct
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position of permanent central venous catheters tip. J Res Med Sci. 2015;20(1):89e92. Smit JM, Raadsen R, Blans MJ, Petjak M, Ven PM, Tuinman PR. Bedside ultrasound to detect central venous catheter misplacement and associated iatrogenic complications: a systematic review and meta-analysis. Crit Care. 2018;22(1). Ablordeppey EA, Drewry AM, Beyer AB, et al. Diagnostic accuracy of central venous catheter confirmation by bedside ultrasound versus chest radiography in critically ill patients. Crit Care Med. 2017;45(4):715e724. Lebeaux D, Fernández-Hidalgo N, Chauhan A, et al. Management of infections related to totally implantable venous-access ports: challenges and perspectives. Lancet Infect Dis. 2014;14(2):146e159. Zhang S, Kobayashi K, Faridnia M, Skummer P, Zhang D, Karmel MI. Clinical predictors of port infections in adult
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patients with hematologic malignancies. J Vasc Interv Radiol. 2018;29(8):1148e1155. Wang TY, Lee KD, Chen PT, et al. Incidence and risk factors for central venous access port-related infection in Chinese cancer patients. J Formos Med Assoc. 2015;114(11): 1055e1060. Pandey N, Chittams JL, Trerotola SO. Outpatient placement of subcutaneous venous access ports reduces the rate of infection and dehiscence compared with inpatient placement. J Vasc Interv Radiol. 2013;24(6):849e854. Patel N, Hingorani A, Ascher E. Office-based surgery for vascular surgeons. Perspect Vasc Surg Endovasc Ther. 2008; 20(4):326e330. Feo CF, Ginesu GC, Bellini A, et al. Cost and morbidity analysis of chest port insertion in adults: outpatient clinic versus operating room placement. Ann Med Surg. 2017;21: 81e84.
Inferior Vena Cava Filters and Ports JESSE CHAIT, BS • ANIL HINGORANI, MD • ENRICO ASCHER, MD, FACS
CHAPTER OVERVIEW
Placement of inferior vena cava (IVC) filters (IVCFs) and totally implantable venous-access devices (TIVADs), like many other interventions covered in this text, are safely and effectively being performed in the office setting. This chapter will cover the officebased considerations of these procedures including indications, device selection, evidence-based technique, and postoperative care, including potential complications and their associated management. Since these aspects are unique to each intervention, they will be covered separately.
PREOPERATIVE EVALUATION All patients should undergo proper preoperative medical assessment and optimization before insertion of an IVCF or TIVAD. We recommend routine laboratory studies including a complete blood count, metabolic panel, prothrombin time, and an international normalized ratio (INR). In order to reduce bleedingrelated complications, all patients should have an INR <1.6 for TIVAD placement and <3.0 for IVCF insertion. In all cases, local anesthesia should be utilized to reduce pain associated with obtaining venous access. For patients undergoing TIVAD placement, we offer monitored anesthesia care (MAC) with intravenous sedation; however, the authors do not routinely employ this practice for uncomplicated IVCF insertions.
INFERIOR VENA CAVA FILTERS Overview In the past, the number of IVCF insertions performed in the United States experienced a marked increase often postulated to be due to an increase in retrievable filters placed for prophylactic indications.1,2 Contemporarily, due to questionable efficacy, negative views regarding long-term safety, and increased rates of litigation,3,4 IVCF placement has been decreasing. This overall
downward trend in filter insertion has been accompanied by increases in IVCF placement in the outpatient setting, a rise in the volume of insertions by nonsurgeon insertions, and increased retrieval rates.5,6
Indications for Filter Insertion IVCF placement is indicated for patients who have experienceddor are at high riskdpulmonary embolism (PE), who have an absolute contraindication or experienced complications to anticoagulation therapy, or who suffered from deep vein thrombosis (DVT) or PE despite maintaining therapeutic anticoagulation. IVCF insertion should be avoided unless absolutely indicated, as implantation increases incidence of DVT without proven mortality benefit.7,8 Furthermore, IVCFs should not be used as an adjunct to prevent recurrent PE in patients who are able to tolerate anticoagulation.9
Technique for Filter Insertion Ultrasound-guided percutaneous access is typically obtained via the common femoral vein; however, in cases where this is not feasible, the internal jugular and upper extremity veins remain viable options.10,11 A single access site is typically adequate for successful IVCF placement; however, some providers prefer two access sites when utilizing intravascular ultrasound (IVUS).12,13 The authors recommend an oversized (6 or 7Fr) sheath, as opposed to a typical 4Fr, in order to allow for rapid injection of contrast bolus without the need for an expensive power injector. Fluoroscopic guidance is used to identify bony landmarks that guide proper anatomic deployment, typically inferior to the renal veins. In most patients, the L2-L3 vertebral level marks the approximate level of the renal veins, and a 20-mL contrast bolus can be utilized to properly demarcate the renal veins. While an IVUS pullback technique from the right atrium can also be used to identify the renal veins,13 this may be cost-prohibitive in the office-based setting. Suprarenal filter placement is a safe alternative typically indicated when infrarenal
Office-Based Endovascular Centers. https://doi.org/10.1016/B978-0-323-67969-5.00033-2 Copyright © 2020 Elsevier Inc. All rights reserved.
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deployment is inadequate, such as in the presence of thrombus, compression, or pregnancy.14 Transabdominal ultrasound (TAUS) also remains a viable option for filter insertionda practice that has been utilized at the bedside for patients deemed too unstable for the operating room or interventional suite.14 This technique may also be used in the office-based setting. Proper probe positioning at the right flank to identify the confluence of the right renal vein (RRV) and IVC allows for safe and effective deployment.15 The authors recommend a postdeployment venogram to ensure proper filter deployment within the desired IVC segment and to identify any immediate complications such as filter malposition.16 Patients are encouraged to return to the office within 1 week of filter placement for follow-up examination with duplex ultrasonography (DUS). In order to increase filter retrieval rates and decrease complications related to prolonged dwell time, the authors recommend quarterly follow-up visits.
Complications of Filter Insertion Placement of IVCFs is a relatively low-risk intervention that can be safely performed in both hospital and office settings.17 As with any endovascular procedure, there is always a risk of access site complications; however, the majority of issues related to filters are attributed to the device itself. Filter complications can increase the risk of PE and prevent or complicate attempts at retrieval. Filter tilt is a common complication defined as >15 degrees angulation, which increases the risk for PE and some have suggested that this may be an indication for insertion of a second filter.16,18 Filter migration, defined as >2 cm movement from the initial deployment site, most commonly occurs >30 days after insertion.18 Struts can fracture and embolize, or pierce the caval wall. Thrombosis of the IVC can lead to edema, pain, PE, or even renal failure if the thrombus propagates to the level of the renal veins.18 Management of these complications is often complex, must be tailored to the exact needs of the patient, and therefore are out of the scope of this text.
Indications and Strategies for Filter Retrieval An increase in awareness of complications associated with long-standing IVCFs has led to widespread efforts to develop effective retrieval campaigns and techniques. All retrievable filters should be removed unless an indication for permanent filtration is present assuming there is no anticipated return to a high-risk status. Operator-dependent barriers to filter retrieval, such as
difficult anatomy or prolonged dwell time, should not be considered contraindications to a retrieval attempt. Risk factors for nonretrieval of retrievable filters include advanced age, presence of an acute bleed, and current malignancy.19 Patients are often unaware of the retrievable status of their filter, and some may not be aware one is present at all, and therefore healthcare providers must be vigilant in their follow-up.20 Development of a documented retrieval algorithm (Fig. 33.1), along with the creation of a multidisciplinary team or dedicated clinic, and access to an office-based endovascular center have all been shown to significantly increase filter retrieval rates.21e24
Technique for Filter Retrieval As with many endovascular interventions, a variety of tools are available for the retrieval of vena cava filters.25 Preoperatively, abdominal X-ray or computed tomography (CT) should be performed in order to determine filter location, degree of angulation, the presence of any strut fractures. Preintervention planning is paramount for efficient and safe filter retrieval, and DUS should be used liberally in order to confirm filter location and ensure access can be safely obtained. Typically, percutaneous access is obtained via the right IJV; however, some authors report the use of a femoral or upper extremity approach.26 In complex cases, multiple access sites may be utilized in order to facilitate the use of several retrieval devices. Unlike filter insertion, retrieval necessitates the use of fluoroscopic guidance, and complex scenarios may lead to both prolonged case times and increased radiation exposure. In simple cases, a combination of sheath and snare is used to hook, collapse, and remove the filter. This approach has a high success rate when attempting to retrieve filters with limited dwell time. However, retrieval of IVCFs that have remained in vivo for an extended period of time can often be complicated by filter malposition, wall penetration, endothelialization, or IVC thrombosis.25 In more complex cases, the use of endobronchial forceps and excimer lasers to dissect and free embedded filters and fractured components has been described with high levels of success.27 Adjunctive techniques such as grasping the hook with the endobronchial forceps, wire loop snare, and deflection of the filter hook with a balloon placed from the groin can also be helpful.
Rationale for Office-Based Placement and Retrieval The majority of IVCF insertion and retrieval procedures are simple, safe, and require a limited amount of equipment, making them ideal interventions to be performed
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IVC filter database updated monthly with patients from previous month
Discussion with referring physician
IVC filter retrieval indicated
IVC filter retrieval scheduled
IVC filter retrieval not indicated at this time
IVC filter is permanent (including patient dispositions of death and hospice)
1 month No further follow-up
Appropriateness of IVC filter retrieval is unclear
Patient lost to follow-up*
Referral to an hematologist
Attempts to contact patient by phone to follow-up with local physician
FIG. 33.1 Inferior vena cava (IVC) filter retrieval algorithm.23
in the office. Retrospective analyses have confirmed the safety and efficacy of both filter insertion17 and removal in the office-based setting, with an increased retrieval rate associated with access to an office endovascular center.24 Furthermore, the continuity of care, physicianpatient rapport, and presence of dedicated support staff associated with office-based centers make it an ideal environment for development of a culture dedicated to IVCF retrieval. All staff should be made aware of this effort and motivated to educate patients on their filter status. All patients who receive filter insertion in the office, report a history of filter placement, or have evidence of an IVCF on imaging should have their information placed in a registry that allows for continuous follow-up and evaluation of the necessity of the filter.
TOTALLY IMPLANTABLE VENOUS ACCESS DEVICES Overview TIVADs, commonly referred to as “ports,” provide reliable access for patients who require long-term,
intermittent intravenous therapy, typically in those with chronic hematologic disease and malignancy.28 While device selection and technique vary greatly between providers, the general principle of TIVAD placement is reliable central venous access through a subcutaneous port. Most modern ports are magnetic resonance imaging (MRI)-safe, able to endure thousands of repeat Huber needle punctures and can withstand high pressures and infusion volumes associated with intravenous contrast studies. The catheters attached to these ports may be double, single, or lumen, the latter allowing for simultaneous infusions, such as chemotherapy alongside total parenteral nutrition (TPN).29
Indications Ports are often necessary for those with chronic diseases, such as malignancy or hematologic disorders, who require intermittent infusion of venotoxic agents or exchange transfusions. The most common indications for TIVAD placement include solid and hematologic malignancies, and a long-term need for apheresis.
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In general, two options exist for long-term venous device-aided access: tunneled or subcutaneous catheters. Whereas a tunneled device is preferable when venous access is needed on a constant basis, TIVADs are better suited for intermittent access, such as for chemotherapy, TPN, or routine transfusions.28 Tunneled catheters are typically preferred for shortterm use, whereas TIVADs are more suitable for longterm access, such as in patients with chronic disease. The subcutaneous port aspect of the TIVAD design is the factor most associated with fewer complications, a lower infection rate, higher quality of life, and increased patient satisfaction, when compared with tunneled, nontunneled, and peripherally inserted central venous catheters.30,31
obtaining venous access via the femoral, subclavian, or internal jugular vein (IJV).38,39 In the office, highresolution DUS should be available for both diagnosis and image-guided intervention. US guidance allows for preprocedural identification of nonviable access sites, such as a thrombosed IJV, or a small caliber cephalic vein. Use of the routine US guidance reduces the incidence of iatrogenic PTX and prevents inadvertent arterial injury. Due to the lower incidence of hemopneumothorax, the authors prefer placement of TIVADs in the right IJV. This also eliminates the rare occurrence of “pinch off” syndrome with interaction and possible obstruction of the catheter due to compression at the costoclavicular junction with placement via the subclavian route.40e42
Technique
Follow-Up
We recommend routine administration of a prophylactic, preoperative antibiotic. Our preferred agent is cefazolin; however, for patients with allergy or sensitivity to beta lactam antibiotics, we utilize clindamycin or vancomycin. Initial venous access can be obtained percutaneously or via an open surgical approach. A recent metaanalysis showed a higher successful primary implantation rate with the Seldinger technique when compared with open venous cutdown; however, percutaneously placed subclavian catheters were more likely to experience complications. These complications, however, were not related to pneumothorax (PTX) or infection.32 Classically, a two-incision method has been the standard procedure for TIVAD placement33; however, a single-incision technique has also been described.34,35 Ultrasound-guided catheter placement into the internal jugular vein is preferred due to the ease of access and ability for direct visualization. Unless contraindicated due to prior surgery, wound, or history of ipsilateral device placement, some authors prefer insertion of the TIVAD catheter in the right subclavian or cephalic vein, as these options necessitate the shortest catheter length and least amount of angulation for proper positioning.36 Other options include branches of the thoracoacromial vein.37 The femoral vein is an alternative TIVAD site for patients with unsuitable upper extremity access, which can be due to central venous stenosis, thrombosis, inadequate vasculature, or superior vena cava syndrome. Regardless of insertion site, all office-based centers should have electrocautery available, as extensive axillary, pectoral, or femoral venous collaterals may cause bleeding during pocket creation. As with all percutaneous endovascular procedures, systematic reviews have demonstrated that ultrasound (US) guidance improves safety outcomes when
As with all intravascular devices and long-term access sites, frequent follow-up evaluation is paramount in order to maintain patency, prevent complications, and ensure removaldwhen indicated. We recommend evaluation with physical exam within 7 days of implantation, and every 3 months thereafter. New onset neck or upper extremity swelling should prompt a thorough DUS examination. If sonogram cannot identify a culprit lesion, a contrast port study may be indicated, especially since the tip of the catheterda common site of thrombusdis not able to be visualized due to its location at the caval-atrial junction.
Complications Pneumothorax Complications associated with TIVAD placement are rare. In many centers, routine postprocedural chest X-ray (CXR) is required after obtaining central venous access via the IJV and subclavian veins, in order to evaluate for iatrogenic PTX and proper catheter tip placement. However, some authors have suggested that this practice may be unnecessary due to a variety of reasons. First, the incidence of PTX is exceedingly low when utilizing US guidance to assist with TIVAD placement.43 Second, CXR has poor diagnostic capabilities in terms of both identifying postoperative PTX43 and catheter malposition.44 Third, postprocedure US can be used to assess for iatrogenic PTX and catheter malposition with similar or better efficacy when compared with CXR.45,46 Nevertheless, we still recommend a postinsertion chest radiograph following any type of central catheter placement. Some authors forgo formal radiographs in lieu of postinsertion fluoroscopic assessment; however, some infusion centers mandate confirmatory CXR prior to initial TIVAD access.
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Suspected postprocedure PTX is suggested by dyspnea, tachycardia, and decreased oxygen saturation and should be evaluated with prompt CXR or US and managed initially oxygen supplementation. The authors suggest having some type of pleural decompression device available in the office setting, such as a large gauge intravenous cannula, in the case of a tension PTX. All patients with suspected PTX should be sent to the nearest emergency department for further evaluation and monitoring.
The benefits of office-based TIVAD placement are multifaceted. Compared with implantation in the hospital setting, office-based placement results in fewer infections,51 decreased costs,52 and increased patient satisfaction. As healthcare expenditures continue to rise, providers should be cognizant of all options that reduce costs, especially for high-utilization patients, such as those with chronic disease who require TIVAD insertion or removal.
Infection
REFERENCES
As with the placement of any indwelling catheter, the risk of infection is of paramount concern. The strongest risk factors for TIVAD-associated infections include presence of a hematologic malignancy, frequent device utilization, young age, difficulty obtaining proper needle insertion, concomitant steroid use, and infusion of TPN through the port.47e49 Ports placed in the office have a lower incidence of infection and dehiscence when compared with those placed in the inpatient setting.50 Suspected port infection should be expeditiously evaluated, first by differentiating between local and bloodstream infection. Since local infections often occur due to extraluminal contamination, concomitant bloodstream infection is rare, and local signs are rarely seen with disseminated disease. Whereas local infection can be confirmed by tissue culture, bloodstream infection attributed to a contaminated TIVAD can be confirmed by positive, matching cultures withdrawn from both a native peripheral vein and the device itself. The management of TIVAD-related infection depends on location and severity. In some cases, local infections can be managed conservatively; however, in the majority of cases of catheter-associated bloodstream infection, the TIVAD should be explanted along with systemic antimicrobial therapy.47 In select scenarios, conservative management of systemic antimicrobial therapy with close observation and repeated cultures may be warranted.
Rationale for office-based placement and removal A large percentage of endovascular and vascular access procedures have migrated from the hospital to the outpatient and office setting,51 owing to reduced costs and increased preference by both patient and provider.52 As indications for port placement typically include chronic disease and cancer, TIVAD implantation is not emergent and can be scheduled as an elective, office-based procedure.
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patients with hematologic malignancies. J Vasc Interv Radiol. 2018;29(8):1148e1155. Wang TY, Lee KD, Chen PT, et al. Incidence and risk factors for central venous access port-related infection in Chinese cancer patients. J Formos Med Assoc. 2015;114(11): 1055e1060. Pandey N, Chittams JL, Trerotola SO. Outpatient placement of subcutaneous venous access ports reduces the rate of infection and dehiscence compared with inpatient placement. J Vasc Interv Radiol. 2013;24(6):849e854. Patel N, Hingorani A, Ascher E. Office-based surgery for vascular surgeons. Perspect Vasc Surg Endovasc Ther. 2008; 20(4):326e330. Feo CF, Ginesu GC, Bellini A, et al. Cost and morbidity analysis of chest port insertion in adults: outpatient clinic versus operating room placement. Ann Med Surg. 2017;21: 81e84.