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IVC Filter : 

IVC Filter Mr. Mohamed Omar El-Farok, M.Sc F.R.C.S. Consultant Vascular Surgeon

Topics to be covered : 

Topics to be covered History Introduction PE diagnosis Indications Complications Devices Which is the best one ? Insertion techniques

History : 

History John Hunter Ligated femoral vein 1784 . Bottini IVC ligation 1893. IVC suture , Stappling were developed 1930 . Mobin-Uddin umbrella was developed 1951 .

History : 

History The earlier caval filters in the mid-1960 were associated with a high caval occlusion rate. Greenfield filter introduced in the early 1970s showed >95% caval patency at 18 months The first stainless steel GF filter was large bore(29.5Fr) requiring surgical venectomy

Introduction : 

Introduction Pulmonary Embolism is a major cause of hospital morbidity and mortality. 75-90 % of PE arise in the lower limbs or pelvis. Before anticoagulation therapy IVC ligation or clipping was performed to interrupt the flow of emboli to the lungs. It has a 10-15% mortality and serious morbidity. Therapy changed dramatically in 1960s anticoagulation therapy for DVT

Pulmonary Embolism : 

Pulmonary Embolism Is a common dissease . Is a lethal dissease . Is a preventable dissease .

How common is PE ? : 

How common is PE ? Five million cases of venous thrombosis each year in USA 10% of these will have a PE 10% will die Correct diagnosis is made in only 10-30% of cases Up to 60% of autopsies will show some evidence of past PE

How common is PE ? : 

How common is PE ? PE is a major cause of death in the United States, with as many as 650,000 cases/yr 50,000 to 200,000 fatalities annually. •>400,000 diagnoses of PE are missed in the United States annually. •Most deaths from PE are due to failure to diagnose rather than failure to treat adequately. •Two thirds of patients die within 1 hour of symptom onset; this is the golden hour.

Where does PE come from ? : 

Where does PE come from ? 90-95% of pulmonary emboli originate in the deep venous system of the lower extremities Other rare locations include Uterine and prostatic veins Upper extremities Renal veins Right side of the heart

How to diagnose PE ? : 

How to diagnose PE ? You have to be PE minded .

Risk Factors : 

Risk Factors Inherited Factor V leiden Prothrombin gene mutation Low protein C, protein S, antithrombin III Family history of VTE Acquired Age Smoking Obesity immobility Malignancy APL Ab syndrome [venous and arterial] Hyperhomocysteinemia (can be acquired) [venous and arterial] OCPs or hormone replacement Atherosclerosis Trauma, surgery, hospitalization Infection Long haul air travel Electronic leads, indwelling catheters

Diagnosis Symptoms and Signs : 

Diagnosis Symptoms and Signs Symptoms Dyspnea Chest pain (pleuritic) Apprehension Cough Hemoptysis Syncope Palpitations Wheezing Leg pain Leg swelling Signs Tachycardia Tachypnea hypoxemia Accentuated S2 Fever Diaphoresis Signs of DVT Cardiac murmur Jugular venous distention Cyanosis Hypotension

Diagnosis Laboratory Evaluation : 

Diagnosis Laboratory Evaluation D-dimer Non specific measure of fibrinolysis Measured by ELISA High sensitivity (positive in presence of dz) High negative predictive value (dz is absent when test is negative) in the outpatient setting Useful in outpatient setting/emergency room, not an inpatient test for ruling out PE

Diagnosis Chest XR : 

Diagnosis Chest XR CXR Most often normal May show collapse, consolidation, small pleural effusion, elevated diaphragm. Uncommon findings include Westermark’s sign Dilation of vessels proximal to embolism Hampton’s hump Pleural based opacities with convex medial margins

Diagnosis VQ Scan : 

Diagnosis VQ Scan Perfusion Ventilation Mismatch

Diagnosis V/Q scans : 

Diagnosis V/Q scans Old standard Currently reserved for Renal impairment IV contrast allergies Pregnancy Chronic PE (controversial)

Diagnosis CT scan – New Standard : 

Diagnosis CT scan – New Standard Data suggests CT is as accurate as invasive angiography (gold standard) Negative predictive value of 99% Quiroz et al, JAMA 2005

Diagnosis Spiral CT/ Multislice : 

Diagnosis Spiral CT/ Multislice Ascending Aorta Lt Pulmonary Artery Main Pulmonary Artery Rt Pulmonary Artery Descending Aorta Thrombus

Pulmonary Angiogram : 

Pulmonary Angiogram

Diagnosis MRI MR Angiogram : 

Diagnosis MRI MR Angiogram Very good to visualize the blood flow. Almost similar to invasive angiogram

Indications of IVC filter placement : 

Indications of IVC filter placement DVT Contraindication to anticoagulation Large, poorly-adherent or free-floating thrombus Propagation of thrombus or unresolving thrombus on anticoagulation Pulmonary embolus Prophylaxis post multiple trauma Noncompliance with anticoagulation medication and follow-up Elderly, organ transplant’s Pts.

Contraindication to anticoagulation : 

Contraindication to anticoagulation Bleeding diathesis Active bleeding Allergy to warfarin or heparin Significant bleeding risks Chronic liver disease Coagulopathy Varices Factor deficiency Metastatic cancer CNS injury, edema, hemorrhage, neoplasm Major thoracoabdominal trauma Hx of bleeding problem on anticoagulation

Absolute Indications : 

Absolute Indications DVT ,PE in a patient with contraindication to anticoagulation . Recurrent DVT, PE despite adequate anticoagulation . Complication of anticoagulation . After pulmonary embolectomy . Failure of another form of caval interruption with recurrent PE .

Relative Indication : 

Relative Indication A large free floating ilio-femoral thrombus . Propagation of ilio-femoral DVT despite adequate anticoagulation . Chronic PE in patient with cor pulmonale or pulmonary hypertension . More than 50 % occlusion of pulmonary vascular bed . Recurrent septic embolism . Multiple trauma patients Malignancy

Trauma : 

Trauma Trauma Pts. At increased risk of DVT (20-90%) and PE (1-2%)and with the ease and safety of filter placement, the indications for IVC filter have been extended One study showed 7% incidence of venous thromboebolism in a group of high risk trauma Pts.receiving either SC heparin or venous compression stockings One study showed a drop in PE incidence from 1% to 0.25 % with a liberalized use of the IVC filter Prophylactic IVC filter insertion has proven to be safe and efficacious in the trauma population.

DVT Incidence in Trauma Patients : 

DVT Incidence in Trauma Patients No. of Patients withStudy Year patients Age Study DVT # (%) Sevitt and Gallaher 1961 125 15-75 Autopsy 81 (65) Freeark et al 1967 124 -- Venogram 44 (35) Silver et al 1975 100 11-70 Venogram 18 (18) Willen et al 1982 38 25-79 Venogram 8 (21) Myllynen et al 1985 37 17-76 Venogram 18 (48) Shackford 1988 177 -- Venogram 12 (78) Kudsk 1989 38 19-78 Venogram 24 (78)

Injury Groups at Risk for PE : 

Injury Groups at Risk for PE No. of Patients withPE Study Type of Injury Patients # (%) Sevitt and Gallaher Lower extremity 302 66 22 fracture Williams, S&G Pelvic fracture 90 17 19 Silver, S&G Spine fracture 557 33 6 Brach, Naso, S&G Burns 163 10 6 Loon, S&G Head injury 182 7 4 O’Malley Major trauma 1316 30 2.3 Shackford Major trauma 177 4 2.25 Rogers Major trauma 2525 25 1

Recommendations : 

Recommendations From the evidence-based recommendations of the Seventh American College of Chest Physicians (ACCP) Consensus Conference on Antithrombotic Therapy Buller, HR, Agnelli, G, Hull, RD, et al. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126:401s

Recommendations : 

Recommendations Therapy of acute deep vein thrombosis or pulmonary embolism should be initiated with IV heparin …

Recommendations : 

Recommendations Heparin therapy should be continued for at least five days. Oral anticoagulation should be overlapped with heparin therapy for four to five days. Heparin and warfarin therapy can be initiated simultaneously, with heparin therapy discontinued on day five or six if the INR has been therapeutic for two consecutive days. Longer periods of initial heparin therapy may be considered in the case of massive pulmonary embolism or iliofemoral thrombosis.

Recommendations : 

Recommendations LMW heparin may be used in place of unfractionated heparin. Dosing requirements are individualized for each product.

Recommendations Duration of therapy : 

Recommendations Duration of therapy First thromboembolic event in the context of a reversible risk factor -- treated for three to six months Idiopathic first thromboembolic event -- AT LEAST full six months of treatment -- further therapy at discretion of clinician Recurrent venous thrombosis or a continuing risk factor -- treated indefinitely.

Recommendations : 

Recommendations IVC filter placement is recommended when -- anticoagulation is contraindicated -- recurrent thromboembolism despite adequate anticoagulation -- chronic recurrent embolism with pulmonary hypertension -- high-risk of recurrent embolization -- conjunction with the performance of pulmonary embolectomy or endarterectomy

Treatment IVC filter : 

Treatment IVC filter With filter 5% risk of recurrent pulmonary embolus, especially after 6 mos. complication of leg swelling can occur. anticoagulation is continued if possible.

Diagnostic algorithm : 

Diagnostic algorithm Outpatient/ED Inpatient D-dimer normal Elevated No PE Chest CT 3rd gen scanner Ist gen scanner No PE PE No PE PE Ultrasound of leg veins DVT No DVT PAgram if continued clinical suspicion

Procedure-related complications : 

Procedure-related complications in a recent review of over 1700 filter insertions over 26 yrs, major complications occurred during placement in 0.3 % of pts. Placement errors and filter migration are the most alarming Asymptomatic, but fatal arrhythmias and pericardial tamponade have occurred. Filters have been misplaced in the iliac, ascending lumbar, renal and hepatic veins; these positions will compromise filter function If a filter fails to open correctly, its filtering capabilities will be compromised air embolism and arteriovenous fistula

Long-term complications : 

Long-term complications Recurrent PE 2.6-3.8 % Recurrent DVT 6-32 % IVC thrombosis 3.6-11.2 % Insertion site thrombosis 23-36 % Post phlebitic syndrome 13-41 %

Complications : 

Complications Structural failure is uncommon, usually asymptomatic but carries the risk of migration of filter fragments and recurrent of PE. Greenfield filter was found to be susceptible to tilting post placement which may reduce the clot-capturing capabilities. IVC wall penetration is rarely symptomatic. Perforation of small bowel, aorta, erosion of lumbar vertebra

Permanent Devices : 

Permanent Devices Greenfield filter Bird Nest filter LGM Vena-cava filter Simon Nitinol filter TrapEase filter

Temporary Devices : 

Temporary Devices Günther temporary IVC filter Anthéor temporary filter LGT temporary filter Prolyser temporary filter

Which is the best filter in my view : 

Which is the best filter in my view One that can be inserted by the three routes The smallest profile 6 F One with double protection With central alignment device Very biocompatible MRI compatible

Insertion Technique : 

Insertion Technique Bedside insertion of an IVC filter with IVUS guidance is feasible and may be an effective alternative in the ICU Pts Just with duplex guided insertion at bedside Chicago, IL 2001 J Vasc surg.

Shapes of IVC filters : 

Shapes of IVC filters Cone shaped Bird’s Nest Coils Double barrel With or without hooks 70% filled with clot only 50% cross diameter reduction . 80% filled with clot to have pressure difference.

Access : 

Access Femoral Jugular Cephalic

One kit for all access sites : 

One kit for all access sites

Filter Placement : 

Filter Placement Infrarenal Suprarenal Superior Vena Caval filter

Technical Considerations : 

Technical Considerations Venous access under local anesthesia . Passing a guide wire and venography to IVC (less than 30mm , patent ) Inf-rarenal positioning The right way (femoral – Jugular ) Filter deployment . Check venography .

Problems : 

Problems Mal-alignment . Filter Migration . Filter occlusion . Filter perforation . Infection . Incomplete opening . Upside down configuration

Why nitinol for filters : 

Why nitinol for filters

Trapease profile : 

Trapease profile

Slide 52: 

We must have contraversy No great advance has ever been made in science, politics, or religion, without controversy. - Lyman Beecher (1775–1863) American Historian

Slide 53: 

Thank you

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