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Retrievable vena cava filter placement during treatment for deep venous thrombosis

T Yamagami, MD, PhD, T Kato, MD, S Iida, MD, O Tanaka, MD and T Nishimura, MD, PhD

Various kinds of temporary vena cava filters are currently commercially available [1–3]. Prophylaxis of pulmonary embolism occurring during thrombolytic and anticoagulation therapies for lower extremity deep venous thrombosis is among the proposed indications for the use of temporary vena cava filters [2, 4]. However, problems have been reported with use of such filters that were mainly related to their structure, in that part of the device projects from the insertion site [1, 5, 6].

On the contrary, no such problems have arisen in the use of the retrievable vena cava filter, which was developed more recently. Nevertheless, there are few reports of its use to avoid the complication of pulmonary embolism during therapy for deep venous thrombosis in the lower extremity. In the present study, the feasibility and safety of a retrievable vena cava filter and its efficacy in preventing pulmonary embolism during treatment of deep venous thrombosis of the lower extremity were evaluated.

Subjects and methods

Between April 1998 and December 2001, 10 procedures for placement of a Gunther tulip retrievable vena cava filter (GTF) (William Cook Europe, Bjaeverskov, Denmark) during treatment for stenosis or obstruction of the lower extremity due to deep venous thrombosis were performed at our institution in six consecutive patients (four women, two men; age range, 18–87 years; mean age 60.8 years) (Table 1). The period from the appearance of symptoms until the patients’ presentation, filter placement and initiation of any therapy for deep venous thrombosis was between 7 days and approximately 2 months.

In all cases, existence of stenosis or obstruction of the lower extremity due to deep venous thrombosis was confirmed by intravenous venography. Before GTF placement, pulmonary perfusion scintigraphy and/or pulmonary arteriography were performed. One case was found to have pulmonary embolism in addition to deep venous thrombosis at the time of GTF placement (patient 4), but the remaining 5 were without this complication.

The GTF was introduced through the right internal jugular vein and was positioned at the infrarenal inferior vena cava in all 10 procedures after a vena cavogram determined the position of filter placement. The GTF was placed through a 10-French sheath introducer according to the manufacturer’s instructions. Retrieval of the GTF was performed using the Gunther tulip vena cava filter retrieval set supplied by the manufacturer (William Cook Europe). Details of techniques to place or retrieve the GTF are described elsewhere [7, 8]. In principle, following the recommendation of the manufacturer [9], when the period of implantation was longer than approximately 10 days, the GTF was retrieved and another inserted near but not at the same site as the former GTF. In all cases, immediately after GTF placement, various combinations of therapies for deep venous thrombosis of the lower extremity were initiated.

Investigated parameters

We retrospectively investigated the following: rate of success of GTF placement; rate of success in preventing the worsening or development of pulmonary embolism by GTF placement; treatments including interventional radiological procedures performed for deep venous thrombosis; state of deep venous thrombosis after such therapies; and management of the GTF thereafter.

Table 1. Characteristics of six patients with deep venous thrombosis of the lower extremity and management of Gunther retrievable vena cava filter

Results

GTF placement was successfully performed in all 10 procedures for 6 patients in the planned position. In the patient having pulmonary embolism at the time of GTF placement (patient 4), pulmonary embolism resolved after systemic thrombolytic and anticoagulation therapy. Pulmonary embolism did not occur in any of the five patients who did not have pulmonary embolism before GTF placement.

As treatment for deep venous thrombosis, systemic thrombolytic therapy (120 000–240 000 IU day21 urokinase (Uronase, Mochida, Tokyo, Japan)) and anticoagulation therapy (10 000–20 000 IU day21 heparin (Heparin, Aventis Pharma Japan, Tokyo, Japan)) were administered intravenously for 4–24 days, followed by conventional therapy, i.e. anticoagulation with orally administered warfarin (Warfarin, Eizai, Tokyo, Japan). Additionally, in four patients (patients 1–3 and 6) catheterdirected thrombolysis (Figures 1 and 2) with 120 000– 240 000 IU of urokinase was administered via a commercially available multiside-hole catheter (Cragg-McNamara Valved Infusion Catheter; Micro Therapeutics, Irvine, CA). The tip of the catheter was positioned in the thrombus. In these same four patients, percutaneous transluminal angioplasty for the narrowed part was also performed. In two cases (patients 1 and 2), the approach was via the femoral vein and in two (patients 3 and 6) via the jugular vein. In two cases, a self-expandable metallic stent (Easywall stent, Boston Scientific, Watertown, MA) was placed at the narrowed lesion (patients 1 and 2) (Figure 2). In patient 2, mechanical thrombectomy using a commercially available thrombectomy device (Hydrolyser, Cordis, Miami, FL) was performed. During all of these interventional radiology procedures, GTF remained in place at the infrarenal inferior vena cava.

In three cases (patients 1, 3 and 6), deep venous thrombosis in the lower extremities completely disappeared after therapy of 8 days’, 23 days’ and 20 days’ duration, respectively. Then, the GTF was retrieved and reinsertion was not required. However, in the remaining three cases the deep venous thrombosis remained in spite of various therapies (patients 2, 4 and 5). In these patients, the last GTF inserted during therapy was left in the vena cava without retrieval to play a role thereafter as a permanent inferior vena cava filter (Figure 2).

Overall, as shown in Table 1, of the 10 GTFs inserted, 7 among 4 patients were retrieved without complications. Duration of a GTF positioned in the vena cava was from 3 days to 13 days (mean, 8.7 days).

In summary, no complication occurred in any patient either at the time of insertion or retrieval or during the period in which the GTF remained in the vena cava.

Fig. 1.
An 18-year-old woman (patient 3). (a) Venography of the right lower extremity showed stenosis (arrow) due to venous thrombus existing from the right common femoral to the proximal superficial femoral vein. (b) Gunther tulip retrievable vena cava filter was implanted via the right jugular vein (arrow). The filter was placed with its tip at the infrarenal level.
(c) After filter placement, catheter-directed thrombolysis using 120 000 IU urokinase was performed via the catheter inserted from the right jugular vein. (d) Venography performed 23 days after the first treatment showed patency of the right common femoral to the proximal superficial femoral vein. Then, the Gunther tulip retrievable vena cava filter was retrieved. Before this, the filter had been replaced once. Note that treatments for deep venous thrombosis using interventional radiological techniques performed during the 23 days consisted of catheter-directed thrombolysis and percutaneous transluminal angioplasty.

Discussion

Deep venous thrombosis in the lower extremities is a common but elusive illness that can result in suffering and death if not recognized and treated effectively [10–12]. Death can occur when venous thrombi break off and form pulmonary emboli, which can pass to and obstruct the pulmonary arteries. Traditionally, therapy has consisted of systemic anticoagulation using heparin administered intravenously and/or systemic infusion of thrombolytic agents followed by warfarin sodium given by mouth [13, 14]. Because results in some cases have been disappointing, recently, additional aggressive therapy employing various techniques of interventional radiology such as catheterdirected thrombolysis [15, 16], percutaneous transluminal angioplasty, mechanical thrombectomy and self-expandable metallic stent placement [17] have been used and reported to be useful. Which of the therapies is the best choice remains controversial.

To prevent pulmonary embolism during treatment the use of a temporary vena cava filter has found widespread acceptance, particularly in Europe [1, 2, 18]. Terry et al [18] summarized their experience with implantation of temporary vena cava filters in 132 patients with deep venous thrombosis who were receiving thrombolytic therapy. They observed a clot that was lysed by thrombolytic therapy in the filter in 41 (31%) of the 132 patients. Specifically, such observation was made in 21 of 63 cases with partially occlusive deep venous thrombosis and in 20 of 69 with occlusive deep venous thrombosis. No pulmonary embolism occurred among the 132 patients. This suggests that the filter prevented pulmonary embolism during thrombolytic treatment in at least 41 of these patients, if not all 132 patients.

Some reports have described complications related to the insertion of temporary vena cava filters. Some were serious and included infection from the part of the device protruding from the insertion site [1], air embolism through a defective sheath [1], worsening of proximal thrombosis along the attached catheter [5], and migration of the filter into the pulmonary artery [6]. Moreover, many temporary filters necessitate replacement by permanent filters [1], because the maximal implantation period for the device is reached before therapy for deep venous thrombus can be successfully completed. All of these are largely related to the structure of temporary vena cava filters, in that part of the device, such as an attached catheter, sheath, or guide-wire, projects from the insertion site [1, 5, 6].

Considering these problems with the temporary vena cava filter, a retrievable temporary filter that could be implanted without an attached catheter or guide-wire and also could be used as a permanent filter without replacement would offer potential advantages. The GTF used in the present study was relatively recently developed as one such retrievable vena cava filter. The ease and safety of insertion of the GTF is well known [7–9, 19, 20], with some of these reports citing its use as a non-permanent filter [7, 8, 19, 20]. Millward et al [19] reported that attempts at retrieval were successful in 98% of 53 GTFs. In this report [19], the maximum period of implantation before successful retrieval was 25 days, although the manufacturer recommended a period of no longer than 10 days.

In the present study, all attempts at insertion (10/10) and retrieval (7/7) of the GTF were successfully accomplished without complications. In three cases in which the lower extremity deep venous thrombus remained in spite of various treatments, the GTF could be used as a permanent filter by simply leaving it in the inferior vena cava. From the viewpoint of preventing pulmonary embolism, our results were successful in all cases. The majority of indications for GTF as shown in previous reports were limited to avoiding worsening of the pulmonary embolism or the appearance of new embolism in patients with proved pulmonary embolism or deep venous thrombosis when anticoagulation therapy is contraindicated for various reasons such as recent or planned surgery, active bleeding or in pregnancy [7, 8, 19, 20]. However, our results suggest a useful role for the GTF in preventing the occurrence of pulmonary embolism during thrombolytic and anticoagulation therapy for lower extremity deep venous thrombosis, including procedures of interventional radiology. Studies with a larger number of subjects are needed before drawing any definite conclusions regarding the utility of this filter during various therapies for deep venous thrombosis.

Fig. 2.
A 62-year-old woman (patient 2). (a) Venography of the left lower extremity showed a long segmental obstruction from the common iliac vein to the femoral vein. The right iliac veins fill via extensive collateral veins. (b) After the Gunther tulip retrievable vena cava filter was implanted at the inferior vena cava with an approach from the right jugular vein (arrowhead), catheter-directed thrombolysis using 120 000 IU urokinase was performed via the catheter inserted from the left femoral vein. Multiple side holes of the catheter tip were positioned in the segment of the thrombus (arrows).
(c) Venography obtained immediately after procedures with interventional radiology, including catheter-directed thrombolysis, percutaneous transluminal angioplasty and self-expandable metallic stent placement, showed good venous blood flow of the left lower extremity. (d) Venography of the left lower extremity performed 14 days after the first treatment with an interventional technique showed re-obstruction of the treated region. In spite of further treatments such as systemic thrombolytic and anticoagulation therapy, post-stent percutaneous transluminal angioplasty, and mechanical thrombectomy performed thereafter, this obstruction was not relieved. The Gunther tulip retrievable vena cava filter was left as a permanent filter. Note that the implanted self-expandable metallic stent is shown (arrow).

 

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Autor: T Yamagami, MD, PhD, T Kato, MD, S Iida, MD, O Tanaka, MD and T Nishimura, MD, PhD

Fuente: The British Journal of Radiology, 76 (2003), 712–718 E 2003 The British Institute of Radiology

Ultima actualizacion: 20 DE FEBRERO DE 2008

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