Placement of Inferior Vena Cava Filter
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] :
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To ensure patency of the IVC
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To measure the size of the IVC
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To locate the renal veins
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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.
Perform completion cavography through the sheath or catheter (see the images below).
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]
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.
Complications
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] :
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Pneumothorax - When US is used to guide a jugular approach, the incidence of pneumothorax is very low
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Access-site thrombosis (incidence, 2%)
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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
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PE (if passage was through a thrombosed vein)
Complications related to the filter include the following [34, 36] :
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IVC trauma
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Penetration of caval wall by filter legs (may rarely lead to retroperitoneal hematoma or bowel injury)
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Filter migration (incidence, < 1%; may be caused by trapped guide wires)
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Filter fracture (incidence, < 1%)
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Filter infection (incidence, < 1%)
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Thirty-day mortality (incidence, < 1%)
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Caval thrombosis (incidence, 5%)
Penetration of adjacent bowel [37] and bony structures [38] has been reported.
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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.
