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Use of a TrapEase Device as a Temporary Caval Filter
Brief Reports
Use of a TrapEase Device as a Temporary Caval Filter Charles Nutting, DO, and Douglas Coldwell, PhD, MD Inferior vena cava (IVC) thrombosis in younger patients presents a difficult management problem and is associated with a significant incidence of pulmonary embolism (PE). Treatment options include anticoagulation, mechanical thrombectomy, or thrombolytic therapy, often in combination with placement of a filter above the thrombus. The authors report the use of a permanent filter in a temporary fashion while performing thrombectomy and thrombolysis of an IVC thrombus. Index terms:
Embolism, pulmonary
•
Thrombosis, venous
•
Venae cavae, filters
J Vasc Interv Radiol 2001; 12:991–993 Abbreviations: IVC ⫽ inferior vena cava, PE ⫽ pulmonary embolism
WE report a case of a young man with a recent history of a near fatal pulmonary embolism secondary to a hypercoagulable state, who presented with renal vein thrombosis and near-occlusive thrombosis of the inferior vena cava (IVC). We describe the use of a temporary suprarenal IVC filter as a means of preventing further pulmonary embolism during thrombolysis and thrombectomy of the IVC thrombus.
ratio of 5.0. After discharge, the patient stopped taking warfarin and he presented to the Emergency Department 4 days later with severe right flank pain. Computed tomography (CT) and magnetic resonance (MR) imaging on readmission demonstrated a large nonocclusive IVC thrombus with right
renal vein occlusion (Fig 1). Because of the possible long- and short-term sequelae of IVC thrombosis, we elected to percutaneously treat the thrombus. In view of the high thrombotic load, embolic risk, and poor pulmonary reserve, a TrapEase filter (Cordis, Miami, FL) was deployed in a suprarenal location from the right internal jugular
CASE REPORT A 20-year-old patient presenting to our hospital had been recently hospitalized for a life-threatening pulmonary embolism for which he received intrapulmonary tissue plasminogen activator. Surgical thrombectomy was considered, but his symptoms gradually improved. He underwent anticoagulation with heparin until a therapeutic level of warfarin was reached and he was discharged from the hospital with an international normalized
From the Department of Radiology, Interventional Radiology Section, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona. Received February 22, 2001; revision requested March 20; revision received April 10; accepted April 13. Address correspondence to C.N., 2033 E. Vista Ave., Phoenix, AZ 85020; E-mail: [email protected] © SCVIR, 2001
Figure 1. Gradient echo MR image demonstrates free-floating IVC thrombus (arrow) and occlusion of the right renal vein.
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Use of a TrapEase Device as a Temporary Caval Filter
approach. A combination of catheterdirected thrombolysis and mechanical thrombectomy was then performed under the protection of a suprarenal IVC filter. The TrapEase delivery sheath in the right side of the neck was exchanged for a 6-F 10-cm sheath and used for continuous saline solution infusion. Mechanical thrombectomy was attempted with use of a 7-F Hydrolyser catheter (Cordis) through a 10-F sheath (Cook, Bloomington, IN) from a right femoral approach. Because after several passes of the catheter, poor cosmetic results were achieved, thrombolytic therapy was then initiated through a 5-F 10-cm infusion catheter (Angiodynamics, Queensbury, NY) via the right groin sheath. Tissue plasminogen activator was infused at a rate of 1 mg/h through the catheter and 300 U/h heparin was infused via the sidearm of the sheath. The patient was monitored overnight in the intensive care unit. He returned the next day for follow-up imaging. Twenty-two hours of thrombolytic therapy did not yield a significant decrease in the thrombus burden involving the IVC and right renal vein. A 6-F Hydrolyser catheter was then inserted through an 8-F double renal curve guiding catheter (Cordis) via the right groin sheath. The guiding catheter helped direct the Hydrolyser, which extended approximately 3 cm from the tip into the thrombus. There was improved cosmetic appearance of the IVC; however, the right renal vein thrombus was not significantly changed. The filter trapped embolized pieces of the thrombus (Fig 2). The Hydrolyzer was used to remove the trapped thrombus from within the filter. Because of the patient’s age, hypercoagulable state, and possible longterm complications of IVC filters, explantation was attempted. The preexisting right groin sheath was exchanged for a 45-cm 10-F Flex sheath (Arrow, Minneapolis, MN). A 5-F RIM catheter (Cook) was then used to engage the lower interstices of the TrapEase filter. A 145-cm 0.018-inch Glidewire (Boston Scientific/Medi-tech, Watertown, MA) was advanced through the catheter (Fig 3), snared with a 25-mm Goose Neck snare (Microvena, White Bear Lake, MN), and pulled back out of the groin sheath
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JVIR
Figure 2. Inferior vena cavogram demonstrates trapped pieces of thrombus (arrows) within the filter, which had embolized during IVC thrombolysis.
from which it came. The catheter was then removed, with both ends of the Glidewire controlled. A similar procedure was then performed from the right neck. The preexisting sheath was exchanged for a 14-F 50-cm sheath (Cook) and advanced into the IVC. A Mickelson catheter (Cook) was used to engage the upper interstices of the filter. A 0.018-inch 260-cm Glidewire was advanced, snared and pulled back out of the jugular sheath from which it was originally placed. Simultaneous tension was then applied to the wires in the neck and groin. The filter was pulled taut and it disengaged the wall of the IVC (Fig 4). The 10-F sheath was advanced from below and covered the filter to the level of the superior barbs.
Figure 3. A Glidewire was placed through the lower interstices of the filter with use of a RIM catheter.
The 14-F neck sheath was then coaxially advanced over the filter, superior barbs, and 10-F sheath (Fig 5). The filter and wires were then pulled through the 14-F neck sheath. An inferior vena cavogram was performed through the right groin sheath (Fig 6). There was no evidence of extravasation or intimal injury. The sheaths were removed and hemostasis was achieved. The patient underwent heparin infusion and was discharged 3 days later and given oral anticoagulants. No evidence of bleeding was present before discharge or during the next 90 days.
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Figure 6. Inferior vena cavogram demonstrates that the filter has been removed and there is no evidence of extravasation.
Figures 4, 5. (4) The TrapEase filter is stretched and disengages the wall of the IVC (arrow) by simultaneously pulling the looped Glidewires from the neck and groin (arrowheads). (5) The filter is covered by a 10-F sheath from below (arrow) to the level of the superior barbs. A 14-F sheath was then advanced coaxially from the neck to cover the filter and 10-F sheath (arrowhead).
DISCUSSION The risk of fatal pulmonary embolus during thrombolytic therapy of iliac or iliocaval thrombus is approximately 6%, but our patient’s risk was significantly higher because he had previously demonstrated that he was subject to pulmonary embolus forma-
tion as a result of his hypercoagulable state (1). Because of the patient’s poor pulmonary reserve and the high likelihood of pulmonary embolus, we elected to temporarily deploy a TrapEase IVC filter above the thrombus to protect against a pulmonary embolus during the treatment of this large thrombus burden. The potential of leaving this filter in place after thrombus removal was not attractive because of the lifespan of the patient and the added risk of thrombus formation from a foreign body in an already atrisk individual. It is important that the wires used to stretch the filter be made of nitinol. This extremely pliable material will not kink, unlike stainless steel, and its tensile strength is high enough that breakage of the wire is not a risk when the wires are pulled taut to collapse the filter. The symmetric shape of the TrapEase filter allows the barbs to disengage from the walls of the IVC without damage. Because the filter will spring back into shape and re-engage the vena cava, only a single stretching of the filter should be performed. The
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993
wires must be pulled taut from the cephalad and caudad directions with equal force while the filter is monitored fluoroscopically. The filter must not be moved while the recovery is ongoing because the anchoring barbs could tear the vena cava. The use of two sheaths, one 10-F, the other 14-F, allows the larger to be coaxially advanced over the smaller for protected filter removal. We are aware of ongoing efforts by Cordis and others to develop recoverable filters. The only filter currently available in the United States designed to act as a temporary or permanent filter is the Tulip filter (Cook). Although this device is not approved for temporary use in the United States, it is currently used for this purpose in Europe. This filter was not available at the time of our procedure. The risks of permanent filter placement include IVC thrombosis, recurrent pulmonary embolism, IVC perforation, and fracture and/or migration of the device (2). Because the life expectancy of our young patient was at least 20 years, the risk of developing any of these complications is prohibitive. Although no series of filter placements in young patients have been performed, consensus is that permanent filter placement in such patients should be avoided. A temporary filter could solve this problem in an at-risk young patient. Although similar procedures have been performed with misplaced IVC filters, this is an unusual case because the filter was placed with the intention of removing it after thrombolysis was finished (3,4). References 1. Grimm W, Schwieder G, Wagner T. Fatal pulmonary embolism in venous thrombosis of the leg and pelvis during lysis therapy. Dtsch Med Wochenschr 1990; 115:1183–1187. 2. Athanasoulis C, Kaufman J, Halpern E, Waltman A, Geller S, Fan C. Inferior vena caval filters: review of a 26-year single-center clinical experience. Radiology 2000; 216:54 – 66. 3. Hastings G, Chughtai S, Radack D, Santilli J. Repositioning the 12-F over-thewire Greenfield filter. J Vasc Interv Radiol 2000; 11:1207–1210. 4. Yegul N, Bonilla S, Goodwin S, Wong G, Vott S, Lai A. Retrieval of a Greenfield IVC filter displaced to the right brachiocephalic vein. Cardiovasc Intervent Radiol 2000; 23:403– 405.
Use of a TrapEase Device as a Temporary Caval Filter Charles Nutting, DO, and Douglas Coldwell, PhD, MD Inferior vena cava (IVC) thrombosis in younger patients presents a difficult management problem and is associated with a significant incidence of pulmonary embolism (PE). Treatment options include anticoagulation, mechanical thrombectomy, or thrombolytic therapy, often in combination with placement of a filter above the thrombus. The authors report the use of a permanent filter in a temporary fashion while performing thrombectomy and thrombolysis of an IVC thrombus. Index terms:
Embolism, pulmonary
•
Thrombosis, venous
•
Venae cavae, filters
J Vasc Interv Radiol 2001; 12:991–993 Abbreviations: IVC ⫽ inferior vena cava, PE ⫽ pulmonary embolism
WE report a case of a young man with a recent history of a near fatal pulmonary embolism secondary to a hypercoagulable state, who presented with renal vein thrombosis and near-occlusive thrombosis of the inferior vena cava (IVC). We describe the use of a temporary suprarenal IVC filter as a means of preventing further pulmonary embolism during thrombolysis and thrombectomy of the IVC thrombus.
ratio of 5.0. After discharge, the patient stopped taking warfarin and he presented to the Emergency Department 4 days later with severe right flank pain. Computed tomography (CT) and magnetic resonance (MR) imaging on readmission demonstrated a large nonocclusive IVC thrombus with right
renal vein occlusion (Fig 1). Because of the possible long- and short-term sequelae of IVC thrombosis, we elected to percutaneously treat the thrombus. In view of the high thrombotic load, embolic risk, and poor pulmonary reserve, a TrapEase filter (Cordis, Miami, FL) was deployed in a suprarenal location from the right internal jugular
CASE REPORT A 20-year-old patient presenting to our hospital had been recently hospitalized for a life-threatening pulmonary embolism for which he received intrapulmonary tissue plasminogen activator. Surgical thrombectomy was considered, but his symptoms gradually improved. He underwent anticoagulation with heparin until a therapeutic level of warfarin was reached and he was discharged from the hospital with an international normalized
From the Department of Radiology, Interventional Radiology Section, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona. Received February 22, 2001; revision requested March 20; revision received April 10; accepted April 13. Address correspondence to C.N., 2033 E. Vista Ave., Phoenix, AZ 85020; E-mail: [email protected] © SCVIR, 2001
Figure 1. Gradient echo MR image demonstrates free-floating IVC thrombus (arrow) and occlusion of the right renal vein.
991
992
•
Use of a TrapEase Device as a Temporary Caval Filter
approach. A combination of catheterdirected thrombolysis and mechanical thrombectomy was then performed under the protection of a suprarenal IVC filter. The TrapEase delivery sheath in the right side of the neck was exchanged for a 6-F 10-cm sheath and used for continuous saline solution infusion. Mechanical thrombectomy was attempted with use of a 7-F Hydrolyser catheter (Cordis) through a 10-F sheath (Cook, Bloomington, IN) from a right femoral approach. Because after several passes of the catheter, poor cosmetic results were achieved, thrombolytic therapy was then initiated through a 5-F 10-cm infusion catheter (Angiodynamics, Queensbury, NY) via the right groin sheath. Tissue plasminogen activator was infused at a rate of 1 mg/h through the catheter and 300 U/h heparin was infused via the sidearm of the sheath. The patient was monitored overnight in the intensive care unit. He returned the next day for follow-up imaging. Twenty-two hours of thrombolytic therapy did not yield a significant decrease in the thrombus burden involving the IVC and right renal vein. A 6-F Hydrolyser catheter was then inserted through an 8-F double renal curve guiding catheter (Cordis) via the right groin sheath. The guiding catheter helped direct the Hydrolyser, which extended approximately 3 cm from the tip into the thrombus. There was improved cosmetic appearance of the IVC; however, the right renal vein thrombus was not significantly changed. The filter trapped embolized pieces of the thrombus (Fig 2). The Hydrolyzer was used to remove the trapped thrombus from within the filter. Because of the patient’s age, hypercoagulable state, and possible longterm complications of IVC filters, explantation was attempted. The preexisting right groin sheath was exchanged for a 45-cm 10-F Flex sheath (Arrow, Minneapolis, MN). A 5-F RIM catheter (Cook) was then used to engage the lower interstices of the TrapEase filter. A 145-cm 0.018-inch Glidewire (Boston Scientific/Medi-tech, Watertown, MA) was advanced through the catheter (Fig 3), snared with a 25-mm Goose Neck snare (Microvena, White Bear Lake, MN), and pulled back out of the groin sheath
August 2001
JVIR
Figure 2. Inferior vena cavogram demonstrates trapped pieces of thrombus (arrows) within the filter, which had embolized during IVC thrombolysis.
from which it came. The catheter was then removed, with both ends of the Glidewire controlled. A similar procedure was then performed from the right neck. The preexisting sheath was exchanged for a 14-F 50-cm sheath (Cook) and advanced into the IVC. A Mickelson catheter (Cook) was used to engage the upper interstices of the filter. A 0.018-inch 260-cm Glidewire was advanced, snared and pulled back out of the jugular sheath from which it was originally placed. Simultaneous tension was then applied to the wires in the neck and groin. The filter was pulled taut and it disengaged the wall of the IVC (Fig 4). The 10-F sheath was advanced from below and covered the filter to the level of the superior barbs.
Figure 3. A Glidewire was placed through the lower interstices of the filter with use of a RIM catheter.
The 14-F neck sheath was then coaxially advanced over the filter, superior barbs, and 10-F sheath (Fig 5). The filter and wires were then pulled through the 14-F neck sheath. An inferior vena cavogram was performed through the right groin sheath (Fig 6). There was no evidence of extravasation or intimal injury. The sheaths were removed and hemostasis was achieved. The patient underwent heparin infusion and was discharged 3 days later and given oral anticoagulants. No evidence of bleeding was present before discharge or during the next 90 days.
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Nutting and Coldwell
Figure 6. Inferior vena cavogram demonstrates that the filter has been removed and there is no evidence of extravasation.
Figures 4, 5. (4) The TrapEase filter is stretched and disengages the wall of the IVC (arrow) by simultaneously pulling the looped Glidewires from the neck and groin (arrowheads). (5) The filter is covered by a 10-F sheath from below (arrow) to the level of the superior barbs. A 14-F sheath was then advanced coaxially from the neck to cover the filter and 10-F sheath (arrowhead).
DISCUSSION The risk of fatal pulmonary embolus during thrombolytic therapy of iliac or iliocaval thrombus is approximately 6%, but our patient’s risk was significantly higher because he had previously demonstrated that he was subject to pulmonary embolus forma-
tion as a result of his hypercoagulable state (1). Because of the patient’s poor pulmonary reserve and the high likelihood of pulmonary embolus, we elected to temporarily deploy a TrapEase IVC filter above the thrombus to protect against a pulmonary embolus during the treatment of this large thrombus burden. The potential of leaving this filter in place after thrombus removal was not attractive because of the lifespan of the patient and the added risk of thrombus formation from a foreign body in an already atrisk individual. It is important that the wires used to stretch the filter be made of nitinol. This extremely pliable material will not kink, unlike stainless steel, and its tensile strength is high enough that breakage of the wire is not a risk when the wires are pulled taut to collapse the filter. The symmetric shape of the TrapEase filter allows the barbs to disengage from the walls of the IVC without damage. Because the filter will spring back into shape and re-engage the vena cava, only a single stretching of the filter should be performed. The
•
993
wires must be pulled taut from the cephalad and caudad directions with equal force while the filter is monitored fluoroscopically. The filter must not be moved while the recovery is ongoing because the anchoring barbs could tear the vena cava. The use of two sheaths, one 10-F, the other 14-F, allows the larger to be coaxially advanced over the smaller for protected filter removal. We are aware of ongoing efforts by Cordis and others to develop recoverable filters. The only filter currently available in the United States designed to act as a temporary or permanent filter is the Tulip filter (Cook). Although this device is not approved for temporary use in the United States, it is currently used for this purpose in Europe. This filter was not available at the time of our procedure. The risks of permanent filter placement include IVC thrombosis, recurrent pulmonary embolism, IVC perforation, and fracture and/or migration of the device (2). Because the life expectancy of our young patient was at least 20 years, the risk of developing any of these complications is prohibitive. Although no series of filter placements in young patients have been performed, consensus is that permanent filter placement in such patients should be avoided. A temporary filter could solve this problem in an at-risk young patient. Although similar procedures have been performed with misplaced IVC filters, this is an unusual case because the filter was placed with the intention of removing it after thrombolysis was finished (3,4). References 1. Grimm W, Schwieder G, Wagner T. Fatal pulmonary embolism in venous thrombosis of the leg and pelvis during lysis therapy. Dtsch Med Wochenschr 1990; 115:1183–1187. 2. Athanasoulis C, Kaufman J, Halpern E, Waltman A, Geller S, Fan C. Inferior vena caval filters: review of a 26-year single-center clinical experience. Radiology 2000; 216:54 – 66. 3. Hastings G, Chughtai S, Radack D, Santilli J. Repositioning the 12-F over-thewire Greenfield filter. J Vasc Interv Radiol 2000; 11:1207–1210. 4. Yegul N, Bonilla S, Goodwin S, Wong G, Vott S, Lai A. Retrieval of a Greenfield IVC filter displaced to the right brachiocephalic vein. Cardiovasc Intervent Radiol 2000; 23:403– 405.