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Diagn Interv Radiol 2014; 20:341-344
© Turkish Society of Radiology 2014
Internal jugular and common femoral venous access for the
removal of a long-term embedded vena cava filter
Umer Salati, Pradeep Govender, William Torreggiani, Ronan Browne
INTERVENTIONAL RADIOLOGY
TECHNICAL NOTE
ABSTRACT
We describe an inferior vena cava lter retrieval technique
requiring triple venous access performed in a 35-year-old
male who was referred for lter removal 16 months after its
insertion. The lter showed a right-sided tilt with endothelial-
ization of the distal lter struts into the caval wall. Access was
required via both internal jugular veins to straighten the lter
using a snared-loop technique. Further 18 F right common
femoral vein access was required to snare and remove the
lter, which could not be completely collapsed distally due
to endothelialized tissue, precluding normal removal via the
jugular venous route.
Inferior vena cava (IVC) filters are often placed for the prevention of
venous thromboembolism in high-risk patients as well as those who
have contraindications to or have failed anticoagulation in the set-
ting of existing venous thromboembolism. In these situations, there is
proven efficacy in the short-term setting without similar results in the
longer term (1, 2). Optional retrievable IVC filters are now increasingly
being used in multiple trauma patients with a high risk of pulmonary
embolism (3). In these patients, filters are usually placed with the in-
tent of removal when the patients’ clinical condition permits and where
possible within the manufacturer’s recommended temporal guidelines.
At our institution, a tertiary trauma referral center, IVC filters are often
prescribed in this setting, with patients often requiring multiple sur-
geries and a protracted recovery period. We describe a difficult case of
filter retrieval performed 16 months after initial placement due to loss at
the clinical follow-up. This case required triple venous access, via both
internal jugular veins (IJVs) and right common femoral vein (CFV), em-
ploying both previously described techniques: the wire loop-and-snare
and cone-over-guidewire techniques (4).
Technique
A 35-year-old male patient had an optional retrievable IVC filter
(Günther-Tulip, William Cook Europe, Bjaeverskov, Denmark) inserted
preoperatively following extensive traumatic pelvic fractures. The pa-
tient had a protracted period of treatment and rehabilitation, and was
lost to the initial clinical follow-up. He presented for filter retrieval 16
months after its initial placement. Although this condition was outside
of the manufacturer’s normal temporal guidelines of 20 days, the proce-
dure was attempted considering the patient’s age and desire for retrieval.
After securing access into the right IJV using an aseptic technique and
under ultrasonography guidance, a 5 F multiendhole catheter (Omni-
flush, AngioDynamics, Hampshire, United Kingdom) was manipulated
in the IVC caudal to the filter over a 0.035-inch J guidewire. Inferior
vena cavography confirmed the intravascular location of the filter with
the filter apex tilted to the right and the absence of significant throm-
bus (Fig. 1). Using a Günther Tulip vena cava filter retrieval set (William
Cook, Europe) via the right IJV access, unsuccessful attempts were made
to snare the filter because it was tilted and likely endothelialized with
the IVC vessel wall. Therefore, attempts were made to displace the tilted
filter apex from the IVC wall using a 5 F Rösch interior mesenteric (RIM)
catheter (AngioDynamics) and 0.035-inch hydrophilic guidewire (Ter-
umo UK, Surrey, United Kingdom) in combination with the retrieval
snare from the Günther Tulip vena cava filter retrieval set using a wire
From the Department of Radiology (U.S. umersalati@gmail.
com), Tallaght Hospital, Dublin, Ireland.
Received 19 August 2013; revision requested 23 September 2013; revision
received 23 October 2013; accepted 28 October 2013.
Published online 7 February 2014.
DOI 10.5152/dir.2014.13362
341
342 • July–August 2014 • Diagnostic and Interventional Radiology Salati et al.
loop-and-snare single access technique
(Sling technique). Unfortunately, the
filter apex could not be displaced.
The orientation of the tilted filter
apex suggested greater advantage in
displacing it using additional access
via the left IJV. After securing access in
the left IJV with a 6 F×5.5 cm introduc-
er sheath (Avanti+Sheath Introducer,
Cordis Europe, Waterloo, Belgium), a 5
F RIM catheter and 0.035-inch hydro-
philic guidewire (Terumo UK) combi-
nation via the left IJV access and the
Günther Tulip retrieval snare from the
right IJV were successful in displacing
the tilted filter apex from the IVC wall
using a wire loop-and-snare technique
(Sling technique) (Fig. 2). However,
after snaring the filter apex, attempts
to sheath the filter through the 11 F
retrieval sheath failed due to the in-
ability to collapse the distal filter struts
completely. Repeat vena cavography
revealed significant tenting of the caval
walls suggesting endothelialization of
the filter struts, which were successfully
released with repeated intermittent cau-
dal traction with the retrieval sheath.
The filter, despite now lying freely
within the caval lumen, remained in-
completely collapsed and could not be
sheathed. An attempt to remove the
partially collapsed filter via the right IJV
was not undertaken due to the poten-
tial for vascular trauma. An attempt to
further collapse the filter struts using a
25 mm eV3 Amplatz GooseNeck snare
(eV3 Europe, Paris, France) to assist in
completely sheathing the filter was un-
successful and, unfortunately, the snare
became entangled on the struts.
Therefore, access into the right CFV
was secured with an 18 F vascular
sheath (William Cook Europe) to at-
tempt retrieval of the filter and entan-
gled snares via the CFV. Another 25
mm GooseNeck Snare was then used
to snare the distal filter struts via this
access and guide the filter into the 18
F sheath (Fig. 3). The IVC filter, includ-
ing the entangled Günther Tulip re-
trieval snare in the filter apex and the
Amplatz GooseNeck snare on the filter
struts, were pulled into the 18 F sheath.
The completely retrieved filter and en-
tangled snares that were released from
their respective IJV access were pulled
in the 18 F sheath up to the right CFV,
and the sheath containing the filter
Figure 1. Anteroposterior uoroscopic image with corresponding schematic diagram
showing an inferior vena cava lter with a right-sided tilt (arrowheads) and contrast injection,
conrming an intravascular position.
Figure 2. Fluoroscopic image with corresponding schematic diagram showing a partially
collapsed and sheathed lter (arrowheads) with distal struts exposed. Note the vascular sheath
in the right internal jugular vein (asterisks), 5 F Rösch interior mesenteric catheter, and Amplatz
gooseneck snare placed via the left internal jugular vein (arrows).
Techniques for the removal of vena caval filters • 343
was partially removed from the right
CFV. The 18 F sheath was clamped at
the right common femoral vein der-
matotomy to ensure hemostasis, and
the proximal end containing the filter
was cut to reveal the partially collapsed
filter and snare wires. The latter step
was performed to allow direct visual-
ization and ensure good control of the
snares because they were removed with
the 18 F sheath (Fig. 4). Further vena
cavography revealed no evidence of
caval injury. The patient displayed no
immediate post procedure complica-
tions and had an uneventful recovery.
Discussion
Several publications have described
nonstandard filter retrieval techniques,
including the wire loop-and-snare and
cone-over-guidewire techniques (4, 5).
Modifications of both these techniques
were employed in our case. The long
period of the filter indwelling time
(468 days) resulted in considerable en-
dothelialization of both the filter apex
and struts such that, after they were
freed from the caval wall, they pre-
vented complete distal filter collapse
due to excessive endothelial tissue on
the struts (Fig. 4), thereby precluding
safe removal of the filter via the initial
right IJV access. Additionally, caudal
access was required via the right CFV,
allowing the snaring of the partially
collapsed filter struts and guidance
into a large-caliber vascular sheath.
The latter condition was particularly
important because the Günther Tulip
retrieval snare was entangled in the
endothelial tissue in the filter apex via
the right IJV access, and the Amplatz
GooseNeck snare was entangled in the
endothelial tissue in the filter struts
via the left IJV access. Additional cau-
dal venous access via the CFV should
be considered whenever a freed but
non-collapsible IVC filter needs to be
removed. We acknowledge that single
IJV access should be sufficient in most
cases; however, the filter apex could
not be displaced in our case but was
successfully removed using dual IJV ac-
cess given the orientation of the tilted
filter apex.
In conclusion, we believe that our
described approach may be beneficial
Figure 3. Fluoroscopic image with corresponding schematic diagram demonstrating an 18 F
vascular sheath and gooseneck snare (arrows) via the right common femoral vein ensnaring
the lter (arrowheads). The lter lies partially collapsed within the vascular sheath inserted via
the right internal jugular vein (asterisks).
Figure 4. The removed lter via the right common femoral vein shows signicant endothelial
tissue on the lter struts that prevented complete distal collapse and removal via the internal
jugular veins.
344 • July–August 2014 • Diagnostic and Interventional Radiology Salati et al.
for long indwelling filters where en-
dothelialized tissue on the filter struts
prevents complete distal filter collapse,
precluding safe jugular removal. Many
previous reports have demonstrated
successful Günther Tulip filter retriev-
al outside the recommended temporal
guidelines (6, 7), with one case of fil-
ter retrieval up to 3006 days postinser-
tion (8), although the rate of success-
ful retrieval decreases with increased
indwelling time (6), and nonstandard
techniques may be required.
Conflict of interest disclosure
The authors declared no conflicts of interest.
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