IVC Filters:

Why, When and How?

Dr S Rostampour, DR N Patel, Dr B Pitrola, Dr E Kashef

Imperial College NHS Trust, London
LEARNING OBJECTIVES
• Learning objectives
• Revise the indications for insertion and removal
of IVC filters – When and Why?
• Share our local experience and guidelines on
who should receive IVC filters
• Discuss pre-removal imaging and procedure
planning
• Share tips and tricks from our own challenging
removal cases including the management of
complications arising from the procedure
 INDICATIONS FOR IVC FILTER INSERTION
1) Iliofemoral thromboembolic 2) Prophylaxis
disease with one of the following:
• CONTRAINDICATION FOR • High risk immobilised patient
ANTICOAGULATION • SEVERE TRAUMA
• COMPLICATION OF ANTICOAGULATION
• HEAD INJURY
• PULMONARY EMBOLISM Despite
ADEQUATE ANTICOAGULATION • Multiple long bone or pelvic fractures
• MASSIVE PE WITH FURTHER RISK OF PE
• FREE FLOATING IVC/ILIAC THROMBUS

Caplin DM, Nikolic B, Kalva SP, Ganguli S, Saad WE, Zuckerman DA: Quality improvement
guidelines for the performance of inferior vena cava filter placement for the prevention of
pulmonary embolism. J Vasc Interv Radiol 2011, 22(11):1499-1506.
GUIDELINES FOR INSERTION IN TRAUMA
▪ At Imperial we have developed our own guidelines for IVC filter insertion in the
trauma setting
• Indications: • Timing of Insertion:
• Patient unable to receive
anticoagulation due to bleeding risk • When patient is physiologically stable
• Injury which renders patient Or
immobile for prolonged period • Part of the One-Stop-Trauma-IR-Shop
• Severe head injury (GCS <8), spinal cord Single visit for:
injury, severe pelvic fractures, multiple long Angio +/- embolizations,
bone fractures
IVC Filter insertion
• Technical Considerations: Cystogram
Check Chest X-ray post CVC line and ET
• Neck immobilisation ( femoral tube insertion
approach) Long bone X-rays
• Pelvic fracture or groin haematoma
(consider jugular approach)
Image Optimization
Image assessment:
• CT- Measure IVC 28mm-30mm
• Check access: IJV vs CFV
• Check clot/thrombus burden
• Anatomical variation including Enlarged ovarian
vein

Intra-procedure:
• Good quality cava-gram from iliac veins to identify
renal vein origin
• Hyoscine Butylbromide (Buscopan) can be given to
reduce artefacts from bowel peristalsis (provided
no contraindication)

Site of implantation:
• close to renal vein without occluding it to reduce
filter thrombosis.
 PRE – REMOVAL WORK UP
IVC filter removal
• Should take place within 6 months of placement ideally to prevent long term
complications such as filter migration and IVC thrombosis
• Timing Important in trauma when patient has cervical immobilization
• Essential that the patient is followed up
• Patients requiring ongoing anticoagulation should receive bridging low molecular
weight heparin (LMWH) as appropriate -according to local guidelines
• During the procedure a retrograde venogram should be performed to ensure no
thrombus lies within the filter
• If thrombus is identified, the patient will receive 6 further weeks of
anticoagulation followed by a CT Venogram to ensure removal is safe

PATIENT SELECTION IS CRITICAL AS IVC FILTERS INSERTED IN PATIENTS WITH NO

RISK OF THROMBOEMBOLIC DISEASE ARE PROCOAGULANT
Removal Technique
Access:
• Check product recommendations
• Most filters are IJV access removal only
• Ensure patient can lie supine
• Check IJV access to ensure patency
Procedure:
• Good quality cava-gram with breath hold
• Retrieval kit
• Normally 9-11F Sheath access
• Snare
TM
kit ( e.g. Amplatz Gooseneck Snare TM, Merit En Snare
)
• On reserve:
• larger sheath, reverse curve SOS catheter (0,2 and 3) Removal of the Cordis Optease TM Filter from femoral approach. This filter type is no longer
mainstream in use. One of its main problems was that the filter had a tendency to tilt and
(Not dissimilar to fishing !) therefore insertion and removal via a femoral approach could be advantageous
 REMOVAL TIPS AND TRICKS
• Standard Technique: Retrieval Kit
with a snare via internal jugular
approach
• Tilting and endothelialisation of
the filter can make removal
difficult depending on length of
time in situ
Other techniques:
• Snare-Over-Loop technique
• Balloon-assisted
• Bronchial Forceps Retrieval
In the above sequence of images a fibrin cap had formed around the hook. Therefore the traditional snare could not retrieve the filter. A glide wire was
negotiated through the struts and the sheath cannulated and out of the sheath at the neck. The guidewire loop was fixed at the the sheath and the
If the filter cannot be removed after several sheath advanced over the filter. The filter was successfully removed. Acknowledgement: Dr R Thomas Imperial College

attempts the patient will need lifelong

anticoagulation
 MANAGEMENT OF COMPLICATIONS
Figure 1 Figure 2 Figure 3
Documented complications
include
• Filter migration (0.1%)
• Malposition ( 1-9%)
• IVC injury (0.4%)
• IVC occlusion (2-30%)
• Strut fracture (2-10%)
• Access site thrombosis (3-10%) Figure 1: Demonstrates a tilted filter with
clot in it Figure 2: An example of a mis-sited
Management of complication filter within an enlarged right gonadal vein
Figure 3: A tilted filter which has migrated
• IVC Injury – tamponade with north into the left renal vein
balloon inflation
• 10-12 mm to reduce flow and
tamponade
CONCLUSIONS
• IVC filters are a useful temporary therapy for patients with
thromboembolic disease and in thromboprophylaxis in the context of
trauma
• They are associated with multiple complications long term and therefore
judicious use with appropriate patient selection is key
• Good knowledge of your local guidelines is essential when inserting and
removing IVC filters
• There are multiple useful tips for removal filters when standard removal
system fails
• Recent publications have raised awareness of complications of IVC filters
• A lack of overall benefit/improved outcome for patients for historical
indication warrants review of local filter guidelines to ensure compliance
with current best medical practice
REFERENCES
• Caplin DM, Nikolic B, Kalva SP, Ganguli S, Saad WE, Zuckerman DA: Quality improvement
guidelines for the performance of inferior vena cava filter placement for the prevention of
pulmonary embolism. J Vasc Interv Radiol 2011, 22(11):1499-1506.
• Standard Operating Procedure: IVC Filter Insertion for Trauma Patients in Interventional
Radiology; Dr E Kashef, Dr A Shleback, Dr N Batrick, Mr S Hettieratchy. Imperial College NHS Trust