Günther Tulip inferior vena cava filter retrieval using a bidirectional loop-snare technique

Abstract

Inferior vena cava (IVC) filters are an effective means to prevent pulmonary embolism in the setting of a contraindication to anticoagulation. Their ease of placement and retrieval makes them a frequently used tool in interventional radiology. When conventional methods of retrieval fail, the operator must use creative means to extract the filter. Failure of retrieval is associated with a longer dwell time, more transverse tilt, and the presence of an embedded hook (1-4). A variety of advanced techniques have been reported in the literature when conventional methods fail. A rare cause of conventional failure is straightening of the filter hook when excessive axial force is applied. In this case report we encountered this complication along with adhered filter leg anchors likely secondary to fibrin scar formation. This report describes a novel technique for IVC filter retrieval through the use of a bidirectional loop-snare. TechniqueThis case report was approved by our institutional review board. A 52-year-old woman with a history of ulcerative colitis and end-stage liver disease secondary to primary sclerosing cholangitis presented to our institution with decompensated liver disease after a failed hepatic transplant. A computed tomography (CT) scan demonstrated thrombosis of the right ovarian vein with extension into the infrarenal IVC. Interventional radiology was consulted for IVC filter placement due to ongoing surgical needs. A Günther Tulip filter (Cook Medical) was placed using conventional methods. A subsequent abdominal CT demonstrated adequate placement of the IVC filter in the suprarenal IVC, with the apex centered in the vein (Fig. 1).The patient presented for filter removal 224 days after installation. A preprocedural CT was not performed. However, it was noted that the patient had a diagnostic CT of the abdomen and pelvis for unrelated reasons four months prior to retrieval, which demonstrated an unchanged position without invasion. Internal jugular venous access was obtained using conventional techniques and inferior vena cavography confirmed adequate placement of the filter. While the filter apex appeared to be centered within the IVC, pre-retrieval vena cavography demonstrated several of the filter legs to extend beyond the contrast, indicating wall implantation versus fibrin scar formation around the anchors (Fig. 2). A Günther Tulip filter retrieval kit (Cook Medical) was used to engage the filter hook. The sheath was advanced under significant force over the filter but the leg anchors would not dislodge from the IVC wall (Fig. 3). No buckling was observed while advancing the sheath over the filter, therefore a stiffer sheath was not thought to be of benefit. The IVC collapsed intermittently with each advancement of the sheath. During the initial attempt at removal the snare straightened the filter hook, so that it could no longer be engaged through standard means. As an alternative, a reverse curve SOS catheter (AngioDynamics) was used to direct a ABSTRACTMany advanced techniques have been rep...

Bidirectional Sling Technique with Biopsy Forceps for Inferior Vena Cava Filter Retrieval

“…The possible advantages of the bidirectional sling technique are strengthening of traction/ countertraction force and prevention of potential complications like caval wall dissection and intussusception. 9) Ross et al 10) reported the same concept using the bidirectional approach and emphasized the advantage of making a loop snare from both sides by maximizing axial stability. They also stressed second loop snare was able to strip the leg anchors from the caval wall.…”

“…Moreover, we believe this could provide more chance of retrieval success by increasing traction/countertraction force by pulling IVCF from both sides. Also, Ross et al 10) described this technique as a last resort because the presence of multiple wires and points of attachment creates an environment that risks entanglement of wires. However, we would like to propose that this technique is easily added in the middle of a procedure any time when we feel more powerful traction force is needed.…”

Bidirectional Pull-Back Technique for Retrieval of Strut-Embedded Cylinder-Shaped Filters in Inferior Vena Cava

“…Several unconventional techniques, such as loop-snare technique and use of endobronchial forceps, have been described [5,6]. However, most of these advanced techniques are designed for cone-shaped tilted or tip-embedded filters.…”

“…The desire to retrieve filters has led to the development and use of various advanced retrieval techniques to increase the retrieval success rate. Several unconventional techniques, such as loop-snare technique and use of endobronchial forceps, have been described [ 5 , 6 ]. However, most of these advanced techniques are designed for cone-shaped tilted or tip-embedded filters.…”