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, 5] This procedure is currently performed under radiologic guidance via femoral vein or jugular vein access. [4] It can be safely performed in office-based laboratories for patients who are at low-to-moderate procedural risk. [6]
This article provides a step-by-step guide to the 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.
Indications
An absolute indication for IVC filter placement is the presence of DVT or PE with any of the following conditions:
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Contraindication for anticoagulation [7]
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Recurrent PE in spite of anticoagulation
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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 mo). [8]
Relative indications include the following:
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Free-floating thrombus in the IVC or ileofemoral segments
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PE and limited cardiac reserve
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Prophylaxis before surgery [11] (in patients with DVT)
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Poor compliance with anticoagulation
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Protection during DVT thrombolysis
The Society of Interventional Radiology (SIR) has published guidelines for the use of IVC filters in the treatment of patients with venous thromboembolism (VTE). [12]
Although data on the utility of prophylactic IVC filters specifically in patients with cancer are limited, a study by Balabhadra suggested that IVC filter placement is associated with an increased rate of PE-free survival in patients with cancer and DVT and bleeding risk factors. [13]
Contraindications
An absolute contraindication for IVC placement is lack of access to the IVC.
Relative contraindications include the following:
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Deranged coagulation
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Total thrombosis of the IVC
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Bacteremia, sepsis, or both
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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 VTE in adult patients with an external ventricular drain in place. [14]
A guideline from the American College of Chest Physicians (ACCP) recommended against the use of IVC filters in patients with acute DVT or PE who are receiving anticoagulant therapy. [15]
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 (US) can be used to perform a vein puncture.
Procedural planning
Filter types
IVC filters come in two different types, permanent (nonretrievable) and temporary (retrievable). [16] (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. [17, 18, 19]
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 [20] :
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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
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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. [21, 22] Better retrieval rates may be at achievable by attempting filter retrieval earlier and referring patients with prolonged dwell times to specialized centers with expertise in complex retrievals. [23]
IVC filter placement is associated with a significant risk of malpractice litigation. [24]
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:
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Fluoroscopy-guided
A report of two cases by Winkler et al suggested that for morbidly obese patients, in whom fluoroscopic guidance is sometimes problematic, guidance with noncontrast computed tomography (CT) may prove to be an acceptable alternative. [27]
Outcomes
A study of prophylactic IVC filter placement in bariatric surgery patients, who are at increased risk for VTE, found a 3% incidence of DVT and a 1% incidence of PE postoperatively; the PE was low-risk, and there were no cases of life-threatening PE. [28] The risk of filter-related complications was low, and the success rate of retrieval was high.
A study of prophylactic IVC filter placement in severely injured trauma patients found that placement was associated with higher rates of DVT and nonfatal PE, as well as increased length of stay in the intensive care unit (ICU). [29] Prophylactic filter placement was not associated with increased in-hospital mortality in these patients. In those patients who had concomitant critical head injuries, prophylactic IVC filter placement was associated with lower in-hospital mortality than VTE chemoprophylaxis.
A retrospective study (N = 13,221; 218 patients were excluded) using data from the Vascular Quality Initiative registry compared the outcomes of IJV access (n = 4789) and femoral vein access (n = 8214) in IVC filter placement. [30] Femoral access was associated with a significant increase in filter angulation (0.9% vs 0.34%), as well as increased access-site complications. There was no significant correlation between access site and retrieval rate.
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Transverse neck ultrasonography shows anatomic relation of internal jugular (IJ) vein and carotid artery. Note that vein is compressible.
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Ultrasound-guided puncture of right internal jugular (IJ) vein.
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Inferior vena cava (IVC) filter placement. IVC thrombus and suprarenal filter.
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Inferior vena cava (IVC) filter placement. Ultrasound-guided puncture of right internal jugular (IJ) vein.
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Inferior vena cava (IVC) filter placement. Cavogram after filter deployment.
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Inferior vena cava (IVC) filter placement. Cavogram after filter deployment.
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Inferior vena cava (IVC) filter placement. Shown is 7 French sheath with filter inside.
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Inferior vena cava (IVC) filter placement. Filter unsheathed but still hooked on.
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Inferior vena cava (IVC) filter placement. Filter fully released.
