ultrasound placement of vena cava filters thomas naslund vanderbilt university medical center
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Ultrasound Placement of Vena Cava Filters
Thomas Naslund
Vanderbilt University Medical Center
CONFLICT OF INTERESTS
WL Gore Consultant
Boston Scientific Consultant
LeMaitre VascularScientific Advisory Board
Greenfield Filter• Introduced 35 years ago• Excellent safety and efficacy• Integral component of venous thromboembolism (VTE)• Initially performed in OR with cutdown• Routinely performed percutaneously - angio suites• Bedside placement with ultrasound
Filters for Ultrasound Placement
• Greenfield, Cook Tulip, Simon Nitinol – well suited to ultrasound placement
• Greenfield visualized well out of sheath
• Tulip best visualized while in sheath
Indications for FilterAbsolute Indications VTE with contraindication to anticoagulation
VTE with complication of anticoagulation
Recurrent VTE despite adequate anticoagulation
Concurrent with pulmonary embolectomy
Failure of alternate form of vena caval interruption
Relative Indications Free-floating iliofemoral thrombus (>5cm) in high-risk patient
Propagating iliofemoral thrombus despite adequate anticoagulation
Septic pulmonary emboli
Pulmonary hypertension/cor pulmonale with chronic VTE
VTE in high risk patient
VTE prophylaxis in multiple trauma or malignancy
Ultrasound Placement
• Initiated in 1995
• Adaptable to bedside placement
• Surface or IVUS can be utilized
• Eliminates patient transport
• Reduced institutional cost
• Efficient use of physician time
Technique Filter Placement with Surface Ultrasound
• Preliminary duplex of femoral vein & IVC– Identify thrombus, diameter, landmarks
• Establish femoral access/identify wire in IVC
• Routine sheath placement/visualization
• Position filter tip at right renal vein (remove wire) and deploy
• Completion KUB
Technique Filter Placement with Surface Ultrasound
• Preliminary duplex of femoral vein & IVC– Identify thrombus, diameter, landmarks
Technique IVUSDual Access
• Duplex femoral veins-optional• Dual femoral access (preferred bilateral)• Visualize sheath and iliac vein confluence• Advance to atrium• “Pull back” visualization/IVC diameter• Position filter tip at renal vein• Pull IVUS back and deploy• Advance IVUS to evaluate filter• Completion KUB
Technique IVUSsingle access
• Interrogate atrium to iliacs (using filter sheath)
• Mark location of renal vein on catheter (tie)
• Translate mark onto the filter delivery catheter
• Insert to mark to deploy blind
• Advance IVUS to check deployment
• Completion KUB
Series of Ultrasound Guided Filter Placement
Author Year nModalit
y LocationPuncture
TechniqueTechnical Success
Misplacement
Overall Complication Rate
Corriere1 2005 382 DUS Bedside Single Puncture 97% 5% 2%
Rosenthal2 2004 94 IVUS Bedside Double Puncture 97% 3% 6%
Garrett3 2004 28 IVUS BedsideSingle/Double
Puncture93% 8% 15%
Gamblin4 2003 36 IVUS OR Single Puncture 94% 0% 0%
Wellons5 2003 45 IVUSIR
Suite/Bedside
Double Puncture 94% 3% 6%
Conners6 2002 284 DUS Bedside Single Puncture 98% 2% 4%
Ashley7 2001 21 IVUS OR Single Puncture 100% 0% 0%
Ebaugh8 2001 26 IVUS Bedside Single Puncture 92% 4% 12%
Bonn9 1999 30 IVUS IR SuiteSingle/Double
Puncture100% 0% 0%
Sato10 1999 53 DUS Bedside Single Puncture 98% 0% 2%
Benjamin11 1999 25 DUS Bedside Single Puncture 100% 4% 4%
Neuzil12 1998 29 DUS Bedside Single Puncture 100% 4% 8%
Neuzil13 1997 49 DUS Bedside Single Puncture 89% − 8%
DUS, duplex ultrasound. IVUS, intravascular ultrasound. OR, operating room. IR, interventional radiology.
Safety ConsiderationsAvoiding Patient Transport
• Invasive monitoring lines
• Pressors
• Ventilators
• Drains
• Transportation complications risk up to 15.5%
Misplacement
• Most common 0-8%
• Iliac vein or suprarenal IVC
• Often attributed to poor visualization or U/S misinterpretation
• Suprarenal placement is satisfactory
• Iliac requires fluoroscopic filter repositioning
Insertion Site Thrombosis
• Occurs in up to 16.7% of patients
• Double venous puncture technique increases exposure to risk
• Incidence is related to surveillance of access site
• With routine surveillance, IST may occur in up to one third of patients
Financial ConsiderationsCost Reduction
• Avoid patient transport
• No interventional suite
• Over $2000 cost reduction per patient (2002)
Comparison of Techniques
Advantages Disadvantages
Contrast Venography
Accurate deployment, detection of venous anomalies
Transportation of critically-ill patients, radiation exposure, radiocontrast exposure, cost
DUS Portable, non-invasive, no contrast or radiation exposure, cost-effective
Imaging limited by body habitus, bowel gas, abdominal wounds, anasarca, immobilization, learning curve
IVUS Portable, no contrast or radiation exposure, cost-effective, unlimited by gas, edema, or body habitus
Invasive, catheter expense, learning curve, need for bilateral femoral venous access*, complexity
*unless single puncture technique usedDUS, duplex ultrasonography. IVUS, intravascular ultrasound.