TECHNIQUES OF I.V.C FILTER DEPLOYMENT & PITFALLS :TECHNIQUES OF I.V.C FILTER DEPLOYMENT & PITFALLS Mr.Mohamed Omar El-Farok M.Scm FRCS


Topics to be covered: :Topics to be covered: Techniques of IVC filter placement . Difficulties in venous access Difficulties in size of IVC Difficulties in tortuous iliac vein Difficulties in upside down deployment Difficulties in Misalignment Difficulties in deployment mechanism 2 Mr.Mohamed Omar El-Farok M.Sc, FRCS


Technique of IVC filter placement: :Technique of IVC filter placement: Pre-operative workup Venous access puncture Pass GW to IVC then IVC filter sheath Check venogram Filter deployment Completiong venogram Followup-plan Mr.Mohamed Omar El-Farok M.Sc, FRCS 3


Difficulties in venous access :Difficulties in venous access Always do venous duplex scan to both femoral veins and internal jugular veins Some filters can be deployed through femoral , jugular and cephalic route One can use occluded vein as an access for IVC filter placement if you have to First use femoral pulse as a landmark and then bone landmark if failed then duplex guided if all failed 4 Mr.Mohamed Omar El-Farok M.Sc, FRCS


Steps in Ultrasound Guided Venous Puncture (Access) :Steps in Ultrasound Guided Venous Puncture (Access) Examine planned access vein with ultrasound If one cannot work through thrombosed/occluded vein, consider another access site Prep and drape site of access vein Localize skin entry point over vein access point Anesthetize skin and make incision large for tools to pass through and blunt dissect soft tissues tract Enter vein with access needle under ultrasound Can use syringe with suction to look for blood flashback to confirm vein entry It may be helpful to use a Valsalva maneuver to distend the vein Pass guidewire via needle into vein Troubleshoot as needed 5 Mr.Mohamed Omar El-Farok M.Sc, FRCS


Duplex guided vein puncture: :Duplex guided vein puncture: 6 Mr.Mohamed Omar El-Farok M.Sc, FRCS


Troubleshooting Guidewire Difficulties :Troubleshooting Guidewire Difficulties If the guidewire does not pass easily : Double wall puncture (bevel beyond back wall). Ultrasound may show this. Pull wire back into needle. Pull needle back into lumen. Readvance guidewire Single puncture of front wall. Ultrasound may show this (bevel indenting front wall) Advance needle until it penetrate into lumen and advance guidewire Bevel partially in lumen. This can give blood return. Advance needle marginally and try readvancing guidewire 7 Mr.Mohamed Omar El-Farok M.Sc, FRCS


Resistance after advancing guidewire a short distance :Resistance after advancing guidewire a short distance Guidewire in side branch (Fluoroscopy reveals unexpected course of guidewire) Pull back guidewire and redirect under fluoroscopy Guidewire against unexpected stenosis/occlusion (Fluoroscopy shows guide looping back on itself/deflected into unexpected course) Advance sheath or catheter over wire and perform venogram to define anatomy/pathology 8 Mr.Mohamed Omar El-Farok M.Sc, FRCS


Some IVC filters permanent :Some IVC filters permanent 9 Mr.Mohamed Omar El-Farok M.Sc, FRCS


Some IVC filters temporary :Some IVC filters temporary 10 Mr.Mohamed Omar El-Farok M.Sc, FRCS


Preoperative Workup and Planning :Preoperative Workup and Planning Review the clinical data to determine which group of filters to use (see the later section on filters) and examine the patient to determine what access site is available for use. It is good to match the access site to the filter required. Any available imaging should be reviewed, such as an abdominal CT scan, to get some information relating to possible variant IVC anatomy. In a morbidly obese patient, where the fluoroscopy table weight limit is exceeded, plan to use IVUS guidance for placement. 11 Mr.Mohamed Omar El-Farok M.Sc, FRCS


Different Scenarios of IVC placement :Different Scenarios of IVC placement If thrombus in IVC What to do ? Suprarenal filter (if no room in infrarenal IVC), or infrarenal filter above the clot 12 Mr.Mohamed Omar El-Farok M.Sc, FRCS


Duplicate IVC what to do ? :Duplicate IVC what to do ? 1. One infrarenal filter in each IVC, or   2. Suprarenal filter. 13 Mr.Mohamed Omar El-Farok M.Sc, FRCS


Accessory IVC (small IVC forming venous ring from level of iliac veins to renal veins) :Accessory IVC (small IVC forming venous ring from level of iliac veins to renal veins) 1. Place filter in main IVC and embolize the accessory IVC with coils. 14 Mr.Mohamed Omar El-Farok M.Sc, FRCS


Circumaortic left renal vein (forming venous ring from normal renal vein via hilum into inferior aspect of infrarenal IVC) :Circumaortic left renal vein (forming venous ring from normal renal vein via hilum into inferior aspect of infrarenal IVC) 1. If room permits place filter below IVC opening of circumaortic vein, or   2. Suprarenal filter. 15 Mr.Mohamed Omar El-Farok M.Sc, FRCS


Retro aortic renal vein (single left renal vein that empties lower in IVC) :Retro aortic renal vein (single left renal vein that empties lower in IVC) 1. Infrarenal IVC filter below vein orifice if there is room, or   2. Filter in each iliac vein. 16 Mr.Mohamed Omar El-Farok M.Sc, FRCS


Mega-Cava (IVC diameter >28 mm) :Mega-Cava (IVC diameter >28 mm) 1. Place a bird's nest filter in infrarenal IVC, or   2. One filter in each common iliac vein. 17 Mr.Mohamed Omar El-Farok M.Sc, FRCS


Pregnant woman :Pregnant woman 1. Suprarenal filter 18 Mr.Mohamed Omar El-Farok M.Sc, FRCS


SVC filter needed (points to keep in mind) :SVC filter needed (points to keep in mind) Keep apex of filter out of RA Position legs of filter above azygos if possible Avoid bird's nest filter (components will prolapse into RA) 19 Mr.Mohamed Omar El-Farok M.Sc, FRCS


Occluded filter what to do? :Occluded filter what to do? Filter occlusion (no intervention in asymptomatic patient) 20 Mr.Mohamed Omar El-Farok M.Sc, FRCS


Symptomatic IVC filter thrombosis :Symptomatic IVC filter thrombosis Pharmacologic thrombolysis/anticoagulation Mechanical thrombolysis (especially if AC contraindicated) to restore flow Suprarenal IVC filter 21 Mr.Mohamed Omar El-Farok M.Sc, FRCS


Filter migration inferiorly into iliac veins :Filter migration inferiorly into iliac veins Place second filter above in IVC 22 Mr.Mohamed Omar El-Farok M.Sc, FRCS


Filter migration superiorly into RA/PA :Filter migration superiorly into RA/PA If possible attempt percutaneous filter retrieval/repositioning or Consult cardiac surgery for removal 23 Mr.Mohamed Omar El-Farok M.Sc, FRCS


Filter failure :Filter failure Place second filter below 1st if there is room, or Suprarenal IVC filter, or SVC filter (if upper extremity source) 24 Mr.Mohamed Omar El-Farok M.Sc, FRCS


Thank You :Thank You 25 Mr.Mohamed Omar El-Farok M.Sc, FRCS