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Online ISSN 1827-1766
Pieri S. 1, Agresti P. 1, Pancione L. 2, Laganà D. 3, Carrafiello G. 3
1 Vascular and Interventional Radiology Az. Osp. “S.Camillo-Forlanini” Rome, Italy
2 Maria Vittoria Hospital Department of Radiology ASL 3 – Turin, Italy
3 Institute of Radiology, University Insubria, Varese, Italy
Aim. The role of vena cava filters has been profoundly transformed over the last decades. The “optional” vena cava filter with long permanence, which may be removed in the event of termination of the indications for which the implant was advised, is the novelty that overcomes the limits of temporary and permanent filters. The aim of this paper is to report the observations and the problems connected with the retrieval of this surgical aid, based on a relatively large case history.
Methods. In the period 1999-2005, 276 long-permanence vena cava filters were implanted. The various indications for the positioning of a vena cava filter were the failure or contraindications for anticoagulant therapy, haemorrhagic complications during anticoagulant therapy, the presence of a massive embolism with residual thrombosis, the presence of a floating thrombus, the presence of a severe cardiopulmonary deficit in the presence of a repeated pulmonary embolism, preoperative prophylaxis and in polytraumatised patients. Retrieval of the filter was attempted in 78 patients. Preceded by a CT scan of the abdomen, the retrieval procedure was carried out using a transjugular approach. Once the legs of the retrieval system had gripped the head of the vena cava filter, the sheath of the retrieval system was slid over the gripper-filter assembly, directly observing with fluoroscopy the gradual and complete capture of all the most peripheral components of the filter inside the sheath. Only at this point was it possible to extract the surgical aid completely via the jugular vein.
Results. The filters were explanted using the jugular approach; this was attempted in 78 patients (28.2%), with very high percentages of technical success: 93% (range 90-96%). In the 6 cases of failure, the angle of the filter was the main reason for not succeeding. Among the 72 procedures completed, some difficulties were found in 18 (25%); in most of the cases (10 patients – 12.8%) this was due to a difficulty in covering the gripper-filter assembly with the retrieval sheath, after the initial capture. The reason for this was the non alignment of the filter with the retrieval catheter. In 6 other cases (7.7%), the excessive angle of the filter required the use of other devices in order to facilitate better positioning in axis with the retrieval system. In 4 cases (2.5%) the difficulty was due to the excessive embeddedness of the filter in the walls of the vena cava. The mean period in situ was 171.3 days (range 8 – 469).
Conclusion. The “optional” vena cava filter with long permanence, which may be removed in the event of termination of the indications for which the implant was advised, is a useful surgical aid for combating the migration of the thrombus and its potentially lethal consequences, in cases of deep vein thrombosis in which anticoagulant therapy is not feasible. Despite problems connected with a physiological learning curve, in our experience their retrieval proved feasible in the majority of cases (93%), without complications, directly using the extraction kit or, occasionally, with the aid of other devices. The knowledge of the various technical aspects and of the solutions applied during the retrieval of this surgical aid is of particular importance, in view of the increasing use of this type of filter in current clinical practice.