Which technical considerations impact the approach to inferior vena cava (IVC) filter placement?

Updated: Oct 31, 2020
  • Author: Gary P Siskin, MD; Chief Editor: Kyung J Cho, MD, FACR, FSIR  more...
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Answer

Answer

Desired quality of IVC filters

Inferior vena cava (IVC) filters are designed for their physical properties, clot-trapping effectiveness, ability to preserve flow in the IVC, and ease of placement. Of the currently available filters, each type has some but not all of the following properties or capabilities:

  • The filter should be able to trap most, if not all, thrombi to prevent new or recurrent pulmonary emboli (PE)

  • The filter should be nonthrombogenic and should maintain caval patency

  • The filter should be made of a biocompatible material that is durable and noncorrosive

  • The filter's shape and structural integrity should be maintainable for a long time

  • The filter's delivery system should have a low profile and allow easy placement

  • Clot trapping should be reasonably effective even if the filter deployment is suboptimal

  • The filter should not migrate after deployment

  • No perforation of the IVC should occur

  • The filter should be nonferromagnetic to allow magnetic resonance imaging (MRI) to be performed after its placement

  • The filter may be retrievable

Technical considerations of filter placement

Mobin-Uddin umbrella and 24F Kimray-Greenfield filters were originally designed for placement through a surgical venotomy. All of the other currently available filters can be placed percutaneously.

According to manufacturer recommendations, certain filters cannot or should not be placed by using certain approaches. When filter design allows placement through the jugular or femoral veins, the filter is specially packaged to ensure that it is deployed in the correct orientation.

Most filter placement procedures are performed in the angiographic suite with fluoroscopic guidance. In recent years, IVC filters have been placed successfully at the bedside in trauma patients in critical condition. [1] The procedures may be performed under guidance with a C-arm portable radiographic unit or with an intravascular ultrasonographic (US) scanner.

Most filters are placed in the infrarenal IVC. On the basis of the knowledge gained from caval ligation, some investigators advocate placement of the apex of any filter specifically within the inflow from the lowest renal vein to minimize the dead space between the filter and the renal veins. Suprarenal filter placement, when necessary, has been proven to be safe. Placement of a suprarenal IVC filter may be indicated in the following situations:

  • Renal vein thrombosis

  • IVC thrombosis extending above the level of the renal veins

  • Thrombus in the infrarenal IVC that does not leave enough room for the filter between the thrombus and renal veins

  • Recurrent PE despite infrarenal filter placement (in which upper extremity or superior vena cava [SVC] thrombosis should be excluded)

  • PE after ovarian vein thrombosis

  • Pregnancy

Regarding SVC filter placement, upper-extremity deep vein thrombosis (DVT) accounts for fewer than 5% of cases of venous thrombosis. The incidence has increased since the 1960s because of the more common use of indwelling catheters. Central venous catheters are responsible for 17-47% of reported upper-extremity DVTs. PE develops in as many as 12% of patients with upper-extremity venous thrombosis. Treatment options include rest and elevation of the affected arm, anticoagulation therapy, and thrombolysis. Filters have been deployed in the SVC and can effectively prevent symptomatic or fatal PE.

Placement of an SVC filter requires use of a modified technique. To maintain the correct orientation of the filter, a filter designed for jugular access is placed via a femoral approach, whereas the filter designed for femoral access is placed via a jugular approach.

It is more technically demanding to perform percutaneous insertion of an SVC filter than placement of an IVC filter, because the SVC is shorter and has a relatively smaller area for safe filter deployment. However, in reported series, no evidence of filter migration, dislodgement, or fracture was observed.


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