Inferior Vena Cava Filter Placement

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.

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

• Contraindication for anticoagulation ^[7]
• 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 mo).[8]

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 ^{[9, 10]}
• Prophylaxis before surgery ^[11] (in patients with DVT)
• Poor compliance with anticoagulation
• 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]

An absolute contraindication for IVC placement is lack of access to 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 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]

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] :

• 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.[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:

• Fluoroscopy-guided
• US-guided ^{[25, 26]}

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]

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.

Equipment used in placing an inferior vena cava (IVC) filter includes the following:

• Ultrasound machine with linear-array probe
• Fluoroscopy
• Chlorhexidine or povidone-iodine solution for skin disinfection
• Heparinized saline (1000 IU heparin in 1000 mL of 0.9% saline)
• Basic angiography set
• Catheter (a catheter with radiopaque calibration markers can be helpful to measure caval diameter)
• Guide wire, 0.035 in.
• Filter kit (this article describes the insertion of a Cook Gunther Tulip or Celect potentially retrievable filter via jugular or femoral approaches)

Anesthesia

Local anesthesia with approximately 5 mL of 1% lidocaine may be administered via infiltration before venipuncture. (See Local Anesthetic Agents, Infiltrative Administration.) Procedural sedation is optional and may be considered, depending on the patient and on local practices.

Positioning

The patient should be supine. When using the jugular approach, some operators have the patient rotate his or her head in a contralateral direction.

Obtain informed consent. Ensure that no contrast allergy exists. Patients should have nothing by mouth for 4-6 hours prior to the procedure. Some operators administer antibiotic prophylaxis.

Clean the skin on the neck with chlorhexidine or povidone-iodine solution. Use the ultrasound device (with sterile cover) to choose a point on the skin above the vein (see the image below). Infiltrate 3-5 mL of local anesthesia. Make a small (≤ 1 cm) horizontal skin incision.

Inferior vena cava (IVC) filter placement. Ultrasound-guided puncture of right internal jugular (IJ) vein.

Using a micropuncture or 18-gauge puncture needle under ultrasonographic (US) guidance, puncture the anterior wall of the vein and enter the vein (see the video below). Aspirate venous blood to confirm correct positioning. Evaluate the path of the wire on fluoroscopy to ensure an appropriate venous course. If using a micropuncture kit, convert to 0.035-in. wire.

Advance the 0.035- or 0.038-in. guide wire into the inferior vena cava (IVC). Place the sheath (some operators advance the catheter without the sheath for diagnostic venography). Advance the catheter into the iliac vein.

Remove the wire, and confirm luminal location by injecting a small amount of contrast. Perform cavography, either with power injection through a pigtail-type catheter or with hand injection. Evaluate the venogram for the following purposes[31] :

• To ensure patency of the IVC
• To measure the size of the IVC
• To locate the renal veins
• To ensure that no left-side IVC is present

If venography results are acceptable, exchange the catheter for the introducer sheath included in the kit (7 French for jugular access, 8.5 French for femoral access; predilate if necessary). Advance the sheath to the region of planned deployment.

Remove the inner dilator, and introduce the filter premounted on its deployment catheter. (Repeat angiography or roadmapping if interval movement of the table or image intensifier is a concern). Do not push the filter out of the sheath, but advance it to the sheath's end. Align the filter and sheath at the planned position below the lowest renal vein.

Next, draw the sheath back to expose the filter; at this stage, the filter opens but is still hooked onto the deploying catheter (see the first image below). If the filter is improperly positioned or tilted, it can be resheathed. Once it is appropriately positioned, release the filter hook (see the second image below). Pay attention to the hook orientation at the time of deployment to facilitate future retrieval.

Inferior vena cava (IVC) filter placement. Filter unsheathed but still hooked on.

Inferior vena cava (IVC) filter placement. Filter fully released.

Perform completion cavography through the sheath or catheter (see the images below).

Inferior vena cava (IVC) filter placement. Cavogram after filter deployment.

Inferior vena cava (IVC) filter placement. Cavogram after filter deployment.

Procedural pearls

Different makes of filter require different deployment techniques. Always read the instructions on the filter kit.

If unable to advance the guide wire, use fluoroscopy to guide the wire insertion.

Review the extent of thrombus on US or computed tomography (CT) to minimize the chance of placing a catheter through a clot, which could lead to iatrogenic pulmonary embolism (PE).

Inflow of unopacified blood from the renal veins into opacified blood in the IVC reveals the position of the renal veins.

Once cavography has been performed (with identification of the lower renal vein), do not move the table or the intensifier.

If IVC thrombus is present, a suprarenal IVC filter may be considered (see the image below).[32]

Inferior vena cava (IVC) filter placement. IVC thrombus and suprarenal filter.

Most IVC filters are listed as compatible with magnetic resonance imaging (MRI) with a magnetic field of 3 Tesla or less; thus, insertion of an IVC filter does not preclude future MRI studies.

A study using data from the Vascular Quality Initiative registry (N = 14,784; median follow-up, 11 mo) found that 1.8% of patients who received an IVC filter developed immediate complications (venous injury requiring treatment, misplacement, angulation >20º, or insertion-site complications), whereas 3.1% developed delayed complications (migration, angulation >15º, fracture, caval or iliac thrombosis, filter thrombus, fragment embolization, or perforation).[33]

Complications related to jugular puncture include the following[34, 35] :

• Pneumothorax - When US is used to guide a jugular approach, the incidence of pneumothorax is very low
• Access-site thrombosis (incidence, 2%)
• Persistent bleeding from the insertion site - To combat this complication, apply compression, elevate the head of the bed, correct any coagulation abnormality, and use a local procoagulant
• PE (if passage was through a thrombosed vein)

Complications related to the filter include the following[34, 36] :

• IVC trauma
• Penetration of caval wall by filter legs (may rarely lead to retroperitoneal hematoma or bowel injury)
• Filter migration (incidence, < 1%; may be caused by trapped guide wires)
• Filter fracture (incidence, < 1%)
• Filter infection (incidence, < 1%)
• Thirty-day mortality (incidence, < 1%)
• Caval thrombosis (incidence, 5%)

Penetration of adjacent bowel[37] and bony structures[38] has been reported.