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 Table of Contents  
LETTER TO EDITOR
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 49-50

Inferior vena cava filter retrieval with rigid endobronchial forceps resulting in redeployment in the superior vena cava


Department of Radiology, Division of Interventional Radiology, University of Alabama at Birmingham, Birmingham, AL, USA

Date of Submission28-Sep-2019
Date of Acceptance13-Nov-2019
Date of Web Publication12-Dec-2019

Correspondence Address:
Andrew John Gunn
Department of Radiology, Division of Interventional Radiology, University of Alabama at Birmingham, 619 19th St S, NHB 623, Birmingham 35249, AL
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AJIR.AJIR_23_19

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How to cite this article:
Cazano E, Gunn AJ. Inferior vena cava filter retrieval with rigid endobronchial forceps resulting in redeployment in the superior vena cava. Arab J Intervent Radiol 2020;4:49-50

How to cite this URL:
Cazano E, Gunn AJ. Inferior vena cava filter retrieval with rigid endobronchial forceps resulting in redeployment in the superior vena cava. Arab J Intervent Radiol [serial online] 2020 [cited 2020 Jul 14];4:49-50. Available from: http://www.arabjir.com/text.asp?2020/4/1/49/272814



A patient presented to our practice for inferior vena cava filter (IVCF) retrieval approximately 9 months after placement of a Bard Denali ® (Tempe, AZ, USA) filter because the patient was able to resume oral anticoagulant therapy. The IVCF was properly placed in an infrarenal location without complication. Although endobronchial forceps (#4162; Lymol Medical, Woburn, MA, USA) is not a standard first-line approach, we practice at a teaching institution and thus proceeded with forceps-assisted retrieval for educational purposes.[1],[2] The filter was grasped at what was thought to be the neck and over-sheathed with an 18F sheath (Performer™; Cook Medical) [Figure 1]. It is not typical practice at our institution to use fluoroscopy to visualize the filter once it is over-sheathed and above the diaphragm. As the filter was being removed through the sheath, the filter snapped and only a single tine was removed. Fluoroscopy demonstrated that the filter was no longer within the sheath but had redeployed in the superior vena cava (SVC) [Figure 2]. A laceration was noted along the vascular sheath [Figure 3]. Subsequently, a wire was reintroduced through the sheath and into the inferior vena cava (IVC). A new sheath (Performer™) was placed with its tip above the filter. We attempted to grasp the hook of the filter using a 20-mm Amplatz Goose Neck snare (Medtronic; Minneapolis, MN, USA); however, the hook of the filter was tilted into the left brachiocephalic vein, abutting its superior wall. To reposition the hook back in line with the vascular sheath, we employed the wire-loop snare technique,[3] which tilted the filter back in line with the vascular sheath but did not allow us to over-sheath the filter. Thus, the rigid endobronchial forceps was reinserted through the sheath, adjacent to the wire loop snare, and used to grasp the hook of the filter [Figure 4]. The filter was then removed through the sheath in its entirety. Venography of the IVC and SVC [Figure 5] demonstrated no evidence of immediate complication, and spot radiographs did not show residual filter fragments. The patient tolerated the procedure well and was discharged home the same day.
Figure 1: (a) The filter being grasped by the endobronchial forceps before being over-sheathed. (b) The endobronchial forceps were not securely on the filter apex at the time of retrieval

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Figure 2: A radiograph demonstrating the filter deployed in the superior vena cava, adjacent to a guidewire and the vascular sheath

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Figure 3: (a) A photograph of the laceration in the vascular sheath (black arrows). (b) A photograph demonstrating the length of the laceration (white arrows) against a ruler

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Figure 4: (a) The endobronchial forceps grasping the filter in the superior vena cava. (b) A photograph of the intact filter after removal

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Figure 5: (a) A digital subtraction venogram of the inferior vena cava showing no evidence of stenosis, thrombosis, or extravasation. (b) A digital subtraction venogram of the superior vena cava showing no evidence of stenosis, thrombosis, or extravasation

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Endobronchial forceps are a safe device, typically best for IVC filters with long dwell times, substantial tilt, or with a wall-embedded tip.[3],[4],[5] We suspect the forceps grabbed the base of the neck instead of hook, which caused the grasp to be unstable, allowing the hook to tear through the sheath. The laceration then allowed the filter to become redeployed in the SVC. The key to successfully retrieve the filter was to maintain vascular access and assess the location of the filter. Steps to prevent this uncommon event to occur include: confirming that the endobronchial forceps grasped the hook/apex of the filter in two planes, using a sheath within a sheath to prevent against laceration or damage to the sheath, and direct visualization under fluoroscopy as the filter is being removed through the sheath. This case emphasizes that special attention to detail is needed to minimize this rare complication.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zhou D, Spain J, Moon E, Mclennan G, Sands MJ, Wang W. Retrospective review of 120 celect inferior vena cava filter retrievals: experience at a single institution. J Vasc Interv Radiol 2012;23:1557-63.  Back to cited text no. 1
    
2.
Al-Hakim R, Kee ST, Olinger K, Lee EW, Moriarty JM, McWilliams JP. Inferior vena cava filter retrieval: effectiveness and complications of routine and advanced techniques. J Vasc Interv Radiol 2014;25:933-9.  Back to cited text no. 2
    
3.
Desai KR, Pandhi MB, Seedial SM, Errea MF, Salem R, Ryu RK, et al. Retrievable IVC filters: Comprehensive review of device-related complications and advanced retrieval techniques. Radiographics 2017;37:1236-45.  Back to cited text no. 3
    
4.
Tavri S, Patel IJ, Kavali P, Irani Z, Ganguli S, Walker TG. Endobronchial forceps-assisted complex retrieval of inferior vena cava filters. J Vasc Surg Venous Lymphat Disord 2019;7:413-9.  Back to cited text no. 4
    
5.
Stavropoulos SW, Ge BH, Mondschein JI, Shlansky-Goldberg RD, Sudheendra D, Trerotola SO. Retrieval of tip-embedded inferior vena cava filters by using the endobronchial forceps technique: Experience at a single institution. Radiology 2015;275:900-7.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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