Ultrasound Placement of Vena Cava Filters

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Ultrasound Placement of Vena Cava Filters

• Thomas Naslund
• Vanderbilt University Medical Center

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CONFLICT OF INTERESTS

• WL Gore Consultant
• Boston Scientific Consultant
• LeMaitre Vascular Scientific Advisory Board

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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

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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

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Indications for Filter
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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

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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

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Technique Filter Placement with Surface
Ultrasound

• Preliminary duplex of femoral vein IVC
• Identify thrombus, diameter, landmarks

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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

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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

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Series of Ultrasound Guided Filter Placement
DUS, duplex ultrasound. IVUS, intravascular
ultrasound. OR, operating room. IR,
interventional radiology.
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Safety ConsiderationsAvoiding Patient Transport

• Invasive monitoring lines
• Pressors
• Ventilators
• Drains
• Transportation complications risk up to 15.5

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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

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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

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Financial ConsiderationsCost Reduction

• Avoid patient transport
• No interventional suite
• Over 2000 cost reduction per patient (2002)

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Comparison of Techniques
unless single puncture technique used DUS,
duplex ultrasonography. IVUS, intravascular
ultrasound.
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