Inferior Vena Cava Filter Placement

Updated: Feb 24, 2017
  • Author: Sapna Puppala, MBBS, MRCS, MRCS(Edin), FRCS(Edin), FRCR, CBCCT, EBIR; Chief Editor: Justin A Siegal, MD  more...
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Overview

Background

Thromboembolic disease continues to be a cause of morbidity and mortality. [1, 2]  Placing a filter in the inferior vena cava (IVC) is an important way to prevent significant pulmonary embolism (PE) arising from a deep vein thrombosis (DVT). [3, 4]  This procedure is currently performed under radiologic guidance via femoral vein or jugular vein access. [3]

This article provides a step-by-step guide to jugular approach to insertion of retrievable Gunther Tulip or Celect IVC filters. For a comparison of retrievable and nonretrievable IVC filters, see Inferior Vena Cava Filters.

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Indications

An absolute indication for IVC filter placement is the presence of DVT or PE with any of the following conditions:

  • Contraindication for anticoagulation [5]
  • Recurrent PE in spite of anticoagulation
  • Anticoagulation-related complication

However, a meta-analysis of three randomized controlled studies by Jiang et al, which included 863 patients with DVT concluded that the addition of an IVC filter to anticoagulation, as compared with anticoagulation alone, did not reduce the incidence of recurrent PE in the short term (3 months). [6]

Relative indications include the following:

  • Free-floating thrombus in the IVC or ileofemoral segments
  • PE and limited cardiac reserve
  • Prophylaxis in patients with severe trauma, spinal cord injury, or paraplegia [7, 8]
  • Prophylaxis before surgery (in patients with DVT)
  • Poor compliance with anticoagulation
  • Protection during DVT thrombolysis
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Contraindications

An absolute contraindication for IVC placement is lack of access into the IVC.

Relative contraindications include the following:

  • Deranged coagulation
  • Total thrombosis of the IVC
  • Bacteremia, sepsis, or both
  • Caval diameter less than 15 mm

A consensus statement from the Neurocritical Care Society recommended against the routine use of IVC filters for primary prophylaxis of venous thromboembolism in adult patients with an external ventricular drain in place. [9]  

A guideline from the American College of Chest Physicians recommended against the use of IVC filters in patients with acute DVT or PE who are receiving anticoagulant therapy. [10]

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Technical Considerations

Anatomy

The internal jugular vein (IJV) lies anterior and lateral to the carotid artery. A low puncture increases the risk of pneumothorax, and a high puncture increases the risk of arterial puncture, in that the artery lies more directly posterior to the vein as it courses higher up in the neck. (See the video below.) The common femoral vein lies medial to the artery. Ultrasonography can be used to perform a vein puncture.

Transverse neck ultrasonography shows anatomic relation of internal jugular (IJ) vein and carotid artery. Note that vein is compressible.

Procedural planning

Filter types

IVC filters come in two different types, permanent (nonretrievable) and temporary (retrievable). [11]  (See Inferior Vena Cava Filters.)

Permanent filters cannot be removed or repositioned. Temporary filters (also called optional filters) can usually be retrieved or repositioned up to a certain point in time. With time, the filter becomes incorporated into the caval wall and may not be removable. The Cook Celect and Gunther Tulip filters are optional filters; they have retrieval kits that are used to snare the apical hooks and retrieve the filters. Removal within 30 days is typical, but successful filter removal more than 1 year after implantation has been reported. [12, 13, 14]

In 2014, the US Food and Drug Administration (FDA), out of concern that retrievable IVC filters placed for short-term PE risk are not always removed once the risk subsides, issued a safety communication on filter removal, which made the following recommendations [15] :

  • Implanting physicians and clinicians responsible for the ongoing care of patients with retrievable IVC filters should consider removing the filter as soon as protection from PE is no longer needed
  • All physicians involved in the treatment and follow-up of patients receiving IVC filters should consider the risks and benefits of filter removal for each patient; a patient should be referred for IVC filter removal when the risk-benefit profile favors removal and the procedure is feasible in light of the patient’s health status

Various studies have reported poor retrieval rates for retrievable IVC filters; work continues on methods of improving these rates. [16, 17]

Insertion methods

IVC filters come in various shapes and can be inserted via either a jugular or a femoral approach. The jugular approach is preferable if an iliofemoral thrombus is present. Some filters cannot be inserted from the left jugular vein because of the lack of flexibility of the delivery system. Most devices can be used if the IVC diameter is smaller than 3 cm (check manufacturer recommendations for a particular filter). If a patient has a megacava, a bird’s nest filter should be used (≤4 cm).

Two main methods of insertion are used, as follows:

  • Fluoroscopy-guided
  • Ultrasound-guided [18, 19]

A report of two cases by Winkler et al suggests that for morbidly obese patients, in whom fluoroscopic guidance is sometimes problematic, guidance with noncontrast CT may prove to be an acceptable alternative. [20]

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