- Email: [email protected]
Superior vena cava filters
Superior Vena Cava Filters Kenneth D. Murphy, MD
he incidence of upper-extremity venous thrombosis is increasing, largely in part to the expanded indications, frequency, and duration of central and peripheral venous line placement. Conservative estimates suggest upper-extremity venous thrombosis account for 4 to 5% of all cases of deep venous thrombosis (DVT).1,2 The most significant complications of upper-extremity DVT include pulmonary embolism (PE), postphlebotic syndrome, and loss of future access. The exact incidence of PE associated with upper-extremity DVT remains yet defined; however, Becker and coworkers suggested a 5 to 10% rate of PE associated with upper-extremity DVT.3 Other series suggest a higher rate of PE ranging from 11 to 36%, with fatal PEs reported.2,4-6 Percutaneous inferior vena cava (IVC) filter placement is a well-established method for preventing PE due to lower-extremity DVT. Recently, with the advent of FDA approved “optional” or retrievable IVC filters, the indications, techniques, and utilization of caval interruption are expanding and being redefined. Based on the established and evolving IVC experience, placement of a superior vena cava (SVC) filter is a potentially attractive option for prevention of PE from upper-extremity DVT. In 1985, Langham and coworkers reported placement of a Greenfield filter in the SVC of 11 dogs. The procedure was tolerated well, with follow-up at 3 months documenting caval patency.7 Cases of SVC filter placement in humans have been limited to relatively small series and case reports, but the experience is growing, and the potential for “optional” SVC filtration may further enhance this approach. The objective of this article is to discuss relevant issues associated with SVC filter placement including its history, proposed indications, reported techniques, published results, and the relevant issues.
T
small case series have been reported, reflecting a slow application and transition into the human population.
SVC Anatomy The SVC is derived from the right anterior cardinal vein. The mean length is approximately 7 cm and mean diameter is 2 cm. The SVC is devoid of valves. The superior margin is generally at the level of the first right costal cartilage, and the lower margin at the third right costal cartilage. The pericardial reflection/ insertion on the SVC is variable. In a study of 34 cadavers, Schuster et al found a mean intrapericardial SVC segment of 3.0 cm, in a range of 1.0 to 5.0 cm.8 They also noted the carina was always located at or above the pericardium as it transverses the SVC. Variants of the SVC are rare, with a duplicated SVC the most common (0.3%) and a left SVC very rare.
Indications The placement of a permanent or “optional” IVC filter device in the SVC constitutes deployment of a FDA-approved device in a nonapproved location. The procedure is considered investigational to date. The proposed indications for SVC filter are analogous to the IVC filter indications. Indications include the following: (1) upper-extremity DVT with contraindications to or failure of anticoagulation; (2) upper-extremity DVT with PE and contraindication to anticoagulation; (3) thrombus extension with an anticoagulation; (4) free floating clot that is at risk for eminent embolization. Contraindications include the following: (1) extensive SVC thrombus; (2) SVC diameter ⬎28 to 30 mm; (3) uncorrectable, significant coagulopathy; (4) venous pacemaker.
History In 1985, Langham described SVC filter placement in 11 dogs. Femoral Greenfield filters (Boston Scientific Corp., Watertown, MA) were deployed in the SVC.7 Thrombus harvested from a phenolized IVC was injected into the external jugular vein, and central venous pressure (CVP) was measured and SVC filter patency was assessed at 3 months. They reported no SVC perforation, no PE, a minimal rise in CVP, complete resolution of entrapped clot, and 100% filter patency.7 Based on this initial animal feasibility study, a limited number of case reports and
From the Upstate Medical University, State University of New York, Syracuse, NY. Address reprint requests to Kenneth D. Murphy, MD, Upstate Medical University, State University of New York, Department of Radiology, 750 East Adams Street, Syracuse, NY 13210. E-mail: [email protected] © 2004 Elsevier Inc. All rights reserved. 1089-2516/04/0702-0010$30.00/0 doi:10.1053/j.tvir.2004.02.007
Technique Placement of a SVC filter is technically more demanding than the IVC counterpart mainly based on anatomical constraints. First, the “landing zone” within the SVC is shorter than the IVC infrarenal segment. The SVC filter “landing zone” is the SVC segment defined by SVC-right atrial junction and the confluence of the left and right brachiocephalic veins (Fig 1). In addition, this segment of SVC is subjected to cardiac pulsations, further complicating the procedure. The procedure requires comprehensive and accurate central upper-extremity venography to define the anatomy and the presence/absence of thrombus. The diameter and length of the SVC should be determined with calibrated catheters or imaging software (Fig 2A, B). Any central venous lines should be removed or retracted back from the SVC before filter placement (Fig 3A, B). Femoral or jugular access is feasible; however, the greatest experience has been with femoral. If femoral access is chosen, a filter with polarity requires a jugular filter kit to be used to insure proper filter
Techniques in Vascular and Interventional Radiology, Vol 7, No 2 (June), 2004: pp 105-109
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rior to the pericardial insertion and azygous (Fig 4A, B). Filters used in the SVC include Greenfield (Medi-Tech/Boston, Watertown, MA), Simon nitinol filter (Bard, Salt Lake City, UT), Vena Tech Filter (B. Braun/Vena Tech, Evanston, IL), Gianturco– Roehm Bird’s Nest filter (Cook, Bloomington, IN), and Gu¨ nther Tulip filter (Cook). Deployment is otherwise analogous to IVC filter deployment. A complete central venogram and chest radiograph should be obtained as a baseline for position documentation (Fig 5).
Results
Fig 1. SVC filter “landing zone.”
orientation. Conversely, a femoral filter kit is required for a jugular approach. The choice of filter is operator’s preference. The recent FDA approval of “optional” filters and growing experience lends to a potential advantage for investigational SVC deployment. A filter with one level of “hook fixation” is favored as the risk of SVC perforation and potential cardiac tamponade is theoretically reduced. The filter should be deployed in a fashion such that the “hook fixation” level is supe-
The published literature for SVC filters consists of scattered case reports and relatively small series to date. In 2000, Ascher reported the largest series of 72 SVC filter placements.9 The indication for SVC filter was a contraindication to— or failure of—anticoagulation in the setting of upper-extremity DVT. In this series, all filters were all placed percutaneously (femoral 83%, jugular 17%) by vascular surgeons in the operating room. The technical success rate was 99%, with one complication involving filter malplacement into the innominate vein. There was no pre- or post-procedure pneumothorax, hemithorax, or arrhythmias reported. A large subset of this population (47%) died of unrelated causes during the same hospitalization. The appropriateness of SVC filter placement in such a critical population is debatable. Follow-up of the surviving 53% of patients ranged from 1 to 78 months (mean, 22 months), with no evidence of PE, SVC thrombosis, or perforation.9 In 1999, Spence et al reported short-term results for SVC filter placement in 41 patients with acute upper-extremity DVT and contraindications and/or unsuccessful anticoagulation.10
Fig 2. (A) SVC diameter assessment with calibrated catheter. (B) SVC diameter determination with imaging software.
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SUPERIOR VENA CAVA FILTERS
Fig 3. (A) Pre SVC filter placement chest with central line. (B) Central line retracted back for SVC filter deployment.
Follow-up consisted of chest radiographs and clinical analysis for PE or SVC thrombosis. At a median follow-up of 12 weeks there were no filter migration, dislodgment, or fracture. At a median follow-up of 15 weeks, there was no clinical evidence of PE.10 Other small series and case reports have reported a total of 11 successful SVC filter cases in the English literature.11-16 There is no reported experience of SVC filter “retrieval” to date.
guidewire without fluoroscopy.9 Filter entrapment of the J-tip guidewire during central venous line placement is a known complication that has been described for upper-extremity access in the setting of an IVC filter.17 Although the experience is small, it appears central lines can be placed safely if a straighttip guidewire is used, and placement is performed under fluoroscopy (Fig 6). In similar fashion, catheter repositioning or removal should be performed under fluoroscopy.
Central Lines
Conclusion
One concern regarding SVC filter placement is the effect on the central vein line placement and associated complications. Spence reported 23 patients who underwent placement of a SVC filter followed by a central line, without any complication.10 In Ascher’s series of 72 SVC filters, there was one filter dislodgment during subsequent central venous line placement.9 In this case, a venous catheter was placed using a J-tip
SVC filters are technically feasible, and preliminary literaturebased results document protection from upper-extremity-induced PE. As the role of central venous access continues to expand, the incidence of upper-extremity DVT will also increase. Since upper-extremity DVT can result in PE, the role of more aggressive upper-extremity DVT management appears appropriate.
KENNETH D. MURPHY
107
Fig 4. (A) Schematic and (B) fluoroscopic image demonstrating filter “hook fixation” superior to azygous and pericardial insertion. (Color version of figure is available online.)
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Fig 6. Central line placement with fluoroscopic guidance using straight guidewire after SVC filter placement.
Fig 5. Complete venogram after SVC filter placement.
References 1. Marinella MA, Kathula SK, Markert RJ: Spectrum of upper-extremity deep venous thrombosis in a community teaching hospital. Heart Lung 29:113-117, 2000 2. Prandoni P, Polistena P, Bernardi E, et al: Upper-extremity deep vein thrombosis: risks factors, diagnosis, and complications. Arch Intern Med 157:57-62, 1997 3. Becker DM, Philbrick JT, Walker FB IV: Axillary and subclavian venous thrombosis: prognosis and treatment. Arch Intern Med 151: 1934-1943, 1991 4. Heron E, Lozinguez O, Emmerich J, Laurian C, Fiessinger J: Longterm sequelae of spontaneous axillary-subclavian venous thrombosis. Ann Intern Med 131:510-513, 1999 5. Linblad B, Tengborn L, Bergqvist D: Deep vein thrombosis of the axillary-subclavian veins: epidemiologic date, effects of different types of treatment and late sequelae. Eur J Vasc Surg 2:161-165, 1988 6. Monreal M, Lafoz E, Ruiz J, Valls R, Alastrue A: Upper-extremity deep venous thrombosis and pulmonary embolism: a prospective study. Chest 99:280-283, 1991 7. Langham MR Jr, Etheridge JC, Crute SL, Greenfield LJ: Experimental superior vena caval placement of the Greenfield filter. J Vasc Surg 2:794-798, 1985 8. Schuster M, Nave H, Piepenbrock S, Pabst R, Panning B: The carina as a landmark in central venous catheter placement. Br J Anesth 85:192-194, 2000
KENNETH D. MURPHY
9. Ascher E, Hingorani A, Tsemekhin B, Yorkovich W, Gunduz Y: Lessons learned from a 6-year clinical experience with superior vena cava Greenfield filter. J Vasc Surg 32:881-887, 2000 10. Spence LD, Gironta MG, Malde HM, Mickolick CT, Geisinger MA, Dolmatch BL: Acute upper extremity deep venous thrombosis: safety and effectiveness of superior vena caval filters. Radiology 210:53-58, 1999 11. Ascher E, Gennaro M, Lorensen E, Pollina RM: Superior vena caval Greenfield Filters: indications, techniques, and results. J Vasc Surg 23:498-503, 1996 12. Hoffman MJ, Greenfield LJ: Central venous septic thrombosis managed by superior vena cava Greenfield filter and venous thrombectomy: a case report. J Vasc Surg 4:606-611, 1986 13. Pais SO, De Orchis DF, Mirvis SE: Superior vena caval placement of a Kimray-Greenfield filter. Radiology 165:385-386, 1987 14. Owen EW, Schoettle GP, Harrington OB: Placement of a Greenfield filter in the superior vena cava. Ann Thorac Surg 53:896-897, 1992 15. Lidagoster MI, Widmann WD, Chevinsky AH: Superior vena cava occlusion after filter insertion (letter). J Vasc Surg 20:158-159, 1994 16. Black MD, French GJ, Rasuli P, Bourchard AC: Upper extremity deep venous thrombosis; underdiagnosed and potentially lethal. Chest 103:1887-1890, 1993 17. Andrews RT, Geschwind JF, Savader SJ, Venbrux AC: Entrapment of J-tip guidewires by Venatech and stainless steel Greenfield vena cava filters during central venous catheter placement: percutaneous management in four patients. Cardiovasc Intervent Radiol 21:424428, 1998
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he incidence of upper-extremity venous thrombosis is increasing, largely in part to the expanded indications, frequency, and duration of central and peripheral venous line placement. Conservative estimates suggest upper-extremity venous thrombosis account for 4 to 5% of all cases of deep venous thrombosis (DVT).1,2 The most significant complications of upper-extremity DVT include pulmonary embolism (PE), postphlebotic syndrome, and loss of future access. The exact incidence of PE associated with upper-extremity DVT remains yet defined; however, Becker and coworkers suggested a 5 to 10% rate of PE associated with upper-extremity DVT.3 Other series suggest a higher rate of PE ranging from 11 to 36%, with fatal PEs reported.2,4-6 Percutaneous inferior vena cava (IVC) filter placement is a well-established method for preventing PE due to lower-extremity DVT. Recently, with the advent of FDA approved “optional” or retrievable IVC filters, the indications, techniques, and utilization of caval interruption are expanding and being redefined. Based on the established and evolving IVC experience, placement of a superior vena cava (SVC) filter is a potentially attractive option for prevention of PE from upper-extremity DVT. In 1985, Langham and coworkers reported placement of a Greenfield filter in the SVC of 11 dogs. The procedure was tolerated well, with follow-up at 3 months documenting caval patency.7 Cases of SVC filter placement in humans have been limited to relatively small series and case reports, but the experience is growing, and the potential for “optional” SVC filtration may further enhance this approach. The objective of this article is to discuss relevant issues associated with SVC filter placement including its history, proposed indications, reported techniques, published results, and the relevant issues.
T
small case series have been reported, reflecting a slow application and transition into the human population.
SVC Anatomy The SVC is derived from the right anterior cardinal vein. The mean length is approximately 7 cm and mean diameter is 2 cm. The SVC is devoid of valves. The superior margin is generally at the level of the first right costal cartilage, and the lower margin at the third right costal cartilage. The pericardial reflection/ insertion on the SVC is variable. In a study of 34 cadavers, Schuster et al found a mean intrapericardial SVC segment of 3.0 cm, in a range of 1.0 to 5.0 cm.8 They also noted the carina was always located at or above the pericardium as it transverses the SVC. Variants of the SVC are rare, with a duplicated SVC the most common (0.3%) and a left SVC very rare.
Indications The placement of a permanent or “optional” IVC filter device in the SVC constitutes deployment of a FDA-approved device in a nonapproved location. The procedure is considered investigational to date. The proposed indications for SVC filter are analogous to the IVC filter indications. Indications include the following: (1) upper-extremity DVT with contraindications to or failure of anticoagulation; (2) upper-extremity DVT with PE and contraindication to anticoagulation; (3) thrombus extension with an anticoagulation; (4) free floating clot that is at risk for eminent embolization. Contraindications include the following: (1) extensive SVC thrombus; (2) SVC diameter ⬎28 to 30 mm; (3) uncorrectable, significant coagulopathy; (4) venous pacemaker.
History In 1985, Langham described SVC filter placement in 11 dogs. Femoral Greenfield filters (Boston Scientific Corp., Watertown, MA) were deployed in the SVC.7 Thrombus harvested from a phenolized IVC was injected into the external jugular vein, and central venous pressure (CVP) was measured and SVC filter patency was assessed at 3 months. They reported no SVC perforation, no PE, a minimal rise in CVP, complete resolution of entrapped clot, and 100% filter patency.7 Based on this initial animal feasibility study, a limited number of case reports and
From the Upstate Medical University, State University of New York, Syracuse, NY. Address reprint requests to Kenneth D. Murphy, MD, Upstate Medical University, State University of New York, Department of Radiology, 750 East Adams Street, Syracuse, NY 13210. E-mail: [email protected] © 2004 Elsevier Inc. All rights reserved. 1089-2516/04/0702-0010$30.00/0 doi:10.1053/j.tvir.2004.02.007
Technique Placement of a SVC filter is technically more demanding than the IVC counterpart mainly based on anatomical constraints. First, the “landing zone” within the SVC is shorter than the IVC infrarenal segment. The SVC filter “landing zone” is the SVC segment defined by SVC-right atrial junction and the confluence of the left and right brachiocephalic veins (Fig 1). In addition, this segment of SVC is subjected to cardiac pulsations, further complicating the procedure. The procedure requires comprehensive and accurate central upper-extremity venography to define the anatomy and the presence/absence of thrombus. The diameter and length of the SVC should be determined with calibrated catheters or imaging software (Fig 2A, B). Any central venous lines should be removed or retracted back from the SVC before filter placement (Fig 3A, B). Femoral or jugular access is feasible; however, the greatest experience has been with femoral. If femoral access is chosen, a filter with polarity requires a jugular filter kit to be used to insure proper filter
Techniques in Vascular and Interventional Radiology, Vol 7, No 2 (June), 2004: pp 105-109
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rior to the pericardial insertion and azygous (Fig 4A, B). Filters used in the SVC include Greenfield (Medi-Tech/Boston, Watertown, MA), Simon nitinol filter (Bard, Salt Lake City, UT), Vena Tech Filter (B. Braun/Vena Tech, Evanston, IL), Gianturco– Roehm Bird’s Nest filter (Cook, Bloomington, IN), and Gu¨ nther Tulip filter (Cook). Deployment is otherwise analogous to IVC filter deployment. A complete central venogram and chest radiograph should be obtained as a baseline for position documentation (Fig 5).
Results
Fig 1. SVC filter “landing zone.”
orientation. Conversely, a femoral filter kit is required for a jugular approach. The choice of filter is operator’s preference. The recent FDA approval of “optional” filters and growing experience lends to a potential advantage for investigational SVC deployment. A filter with one level of “hook fixation” is favored as the risk of SVC perforation and potential cardiac tamponade is theoretically reduced. The filter should be deployed in a fashion such that the “hook fixation” level is supe-
The published literature for SVC filters consists of scattered case reports and relatively small series to date. In 2000, Ascher reported the largest series of 72 SVC filter placements.9 The indication for SVC filter was a contraindication to— or failure of—anticoagulation in the setting of upper-extremity DVT. In this series, all filters were all placed percutaneously (femoral 83%, jugular 17%) by vascular surgeons in the operating room. The technical success rate was 99%, with one complication involving filter malplacement into the innominate vein. There was no pre- or post-procedure pneumothorax, hemithorax, or arrhythmias reported. A large subset of this population (47%) died of unrelated causes during the same hospitalization. The appropriateness of SVC filter placement in such a critical population is debatable. Follow-up of the surviving 53% of patients ranged from 1 to 78 months (mean, 22 months), with no evidence of PE, SVC thrombosis, or perforation.9 In 1999, Spence et al reported short-term results for SVC filter placement in 41 patients with acute upper-extremity DVT and contraindications and/or unsuccessful anticoagulation.10
Fig 2. (A) SVC diameter assessment with calibrated catheter. (B) SVC diameter determination with imaging software.
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SUPERIOR VENA CAVA FILTERS
Fig 3. (A) Pre SVC filter placement chest with central line. (B) Central line retracted back for SVC filter deployment.
Follow-up consisted of chest radiographs and clinical analysis for PE or SVC thrombosis. At a median follow-up of 12 weeks there were no filter migration, dislodgment, or fracture. At a median follow-up of 15 weeks, there was no clinical evidence of PE.10 Other small series and case reports have reported a total of 11 successful SVC filter cases in the English literature.11-16 There is no reported experience of SVC filter “retrieval” to date.
guidewire without fluoroscopy.9 Filter entrapment of the J-tip guidewire during central venous line placement is a known complication that has been described for upper-extremity access in the setting of an IVC filter.17 Although the experience is small, it appears central lines can be placed safely if a straighttip guidewire is used, and placement is performed under fluoroscopy (Fig 6). In similar fashion, catheter repositioning or removal should be performed under fluoroscopy.
Central Lines
Conclusion
One concern regarding SVC filter placement is the effect on the central vein line placement and associated complications. Spence reported 23 patients who underwent placement of a SVC filter followed by a central line, without any complication.10 In Ascher’s series of 72 SVC filters, there was one filter dislodgment during subsequent central venous line placement.9 In this case, a venous catheter was placed using a J-tip
SVC filters are technically feasible, and preliminary literaturebased results document protection from upper-extremity-induced PE. As the role of central venous access continues to expand, the incidence of upper-extremity DVT will also increase. Since upper-extremity DVT can result in PE, the role of more aggressive upper-extremity DVT management appears appropriate.
KENNETH D. MURPHY
107
Fig 4. (A) Schematic and (B) fluoroscopic image demonstrating filter “hook fixation” superior to azygous and pericardial insertion. (Color version of figure is available online.)
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SUPERIOR VENA CAVA FILTERS
Fig 6. Central line placement with fluoroscopic guidance using straight guidewire after SVC filter placement.
Fig 5. Complete venogram after SVC filter placement.
References 1. Marinella MA, Kathula SK, Markert RJ: Spectrum of upper-extremity deep venous thrombosis in a community teaching hospital. Heart Lung 29:113-117, 2000 2. Prandoni P, Polistena P, Bernardi E, et al: Upper-extremity deep vein thrombosis: risks factors, diagnosis, and complications. Arch Intern Med 157:57-62, 1997 3. Becker DM, Philbrick JT, Walker FB IV: Axillary and subclavian venous thrombosis: prognosis and treatment. Arch Intern Med 151: 1934-1943, 1991 4. Heron E, Lozinguez O, Emmerich J, Laurian C, Fiessinger J: Longterm sequelae of spontaneous axillary-subclavian venous thrombosis. Ann Intern Med 131:510-513, 1999 5. Linblad B, Tengborn L, Bergqvist D: Deep vein thrombosis of the axillary-subclavian veins: epidemiologic date, effects of different types of treatment and late sequelae. Eur J Vasc Surg 2:161-165, 1988 6. Monreal M, Lafoz E, Ruiz J, Valls R, Alastrue A: Upper-extremity deep venous thrombosis and pulmonary embolism: a prospective study. Chest 99:280-283, 1991 7. Langham MR Jr, Etheridge JC, Crute SL, Greenfield LJ: Experimental superior vena caval placement of the Greenfield filter. J Vasc Surg 2:794-798, 1985 8. Schuster M, Nave H, Piepenbrock S, Pabst R, Panning B: The carina as a landmark in central venous catheter placement. Br J Anesth 85:192-194, 2000
KENNETH D. MURPHY
9. Ascher E, Hingorani A, Tsemekhin B, Yorkovich W, Gunduz Y: Lessons learned from a 6-year clinical experience with superior vena cava Greenfield filter. J Vasc Surg 32:881-887, 2000 10. Spence LD, Gironta MG, Malde HM, Mickolick CT, Geisinger MA, Dolmatch BL: Acute upper extremity deep venous thrombosis: safety and effectiveness of superior vena caval filters. Radiology 210:53-58, 1999 11. Ascher E, Gennaro M, Lorensen E, Pollina RM: Superior vena caval Greenfield Filters: indications, techniques, and results. J Vasc Surg 23:498-503, 1996 12. Hoffman MJ, Greenfield LJ: Central venous septic thrombosis managed by superior vena cava Greenfield filter and venous thrombectomy: a case report. J Vasc Surg 4:606-611, 1986 13. Pais SO, De Orchis DF, Mirvis SE: Superior vena caval placement of a Kimray-Greenfield filter. Radiology 165:385-386, 1987 14. Owen EW, Schoettle GP, Harrington OB: Placement of a Greenfield filter in the superior vena cava. Ann Thorac Surg 53:896-897, 1992 15. Lidagoster MI, Widmann WD, Chevinsky AH: Superior vena cava occlusion after filter insertion (letter). J Vasc Surg 20:158-159, 1994 16. Black MD, French GJ, Rasuli P, Bourchard AC: Upper extremity deep venous thrombosis; underdiagnosed and potentially lethal. Chest 103:1887-1890, 1993 17. Andrews RT, Geschwind JF, Savader SJ, Venbrux AC: Entrapment of J-tip guidewires by Venatech and stainless steel Greenfield vena cava filters during central venous catheter placement: percutaneous management in four patients. Cardiovasc Intervent Radiol 21:424428, 1998
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