Management of Fractured Inferior Vena Cava Filters: Outcomes by Fragment Location

Abstract

Purpose To inform the management of fractured inferior vena cava filters on the basis of results from a tertiary referral center specializing in complex filter retrieval. Materials and Methods This study had institutional review board approval and was HIPAA compliant. Retrospective analysis of all patients with fractured filters and/or filter fragments evaluated for removal in a complex filter removal program was performed. Removal was attempted when fragments were intravascular or immediately extravascular by using primarily endobronchial forceps for caval fragments and snares for cardiac and pulmonary fragments. Data collected included success rate and complications of filter and fragment removal, symptoms relating to the filter or fragment, techniques used for removal, and follow-up of retained fragments. Results Sixty-five patients (12 men, 53 women) of a total of 222 patients referred for complex retrieval had fractured filters. Of these patients, two had undergone filter removal elsewhere and had retained fragments. All 63 filters were removed successfully with forceps (n = 61), a cone (n = 1), or a snare (n = 1). There were 116 separate filter fragments; removal was attempted for 78 fragments. Removal was successful for 63 (81%) of 78 fragments and varied by location. All extravascular fragments except one were retained. In all, 63 (54%) of 116 fragments were removed percutaneously, rendering 34 (54%) of 63 patients fragment free. Five minor (7.7% [five of 65]) and four major (6.2% [four of 65]) complications occurred. Conclusion Intravascular filter fragments can be removed safely with success rates that vary according to location. Because extravascular fragments are not readily accessible for removal, many patients are not rendered fragment free. RSNA, 2017 Online supplemental material is available for this article.

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“…To leave the bullet and observe or to remove the bullet invasively is not an easy decision, and discussion should occur between the patient and treatment team. Embolization of intracardiac bullets into the distal pulmonary artery branches is unlikely to have a significant impact based on available literature on fractured IVC filter fragments leading to benign pulmonary artery embolization [ 14 ].…”

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“…In a study by Trerotola and Stavropoulos, 90% (43 of 48) of filters were retrieved from the IVC, 50% (three of six) from the heart, and 71% (17 of 24) from the pulmonary arteries. Because of extravascular fragment location and/or retrieval failure, only 50% of the patients were recognized to be fragment free [8].…”

Young Woman With Chest and Back Pain

“…2 Fractured fragments can embolize to the heart and lungs, and also extravascularly, causing bleeding, cardiac tamponade, arrhythmia, and other serious complications. 1,3,4 When characteristic foreign bodies are observed on imaging, bedside ultrasonography can quickly establish the presence of cardiac perforation and pericardial effusion. CT may be necessary for precise localization of fragments.…”

“…Removal by interventional radiology is becoming the most successful method of retrieving intravascular filter fragments, 1,4 however, extravascular embolization occurs frequently, and such fragments are often not retrievable. 4…”