Suprarenal Greenfield Filter Placement to Prevent Pulmonary Embolus in Patients with Vena Caval Tumor Thrombi

Abstract

The presence of tumor thrombus secondary to inferior vena caval extension from renal carcinoma carries the threat of pulmonary tumor embolus. In theory, safe prophylaxis could be accomplished by placement of a Greenfield filter in the suprarenal vena cava, which has been accomplished without complication. We treated 6 patients with renal call carcinoma and extensive tumor thrombus of the vena cava with suprarenal filter placement as an adjunct to thrombectomy and nephrectomy. Clinically all 6 patients have done well. However, the over-all rate of vena caval thrombosis or occlusion associated with infrarenal filter placement is 3 to 5%. To investigate the potential risk to renal function if a vena caval occlusion occurred above a solitary kidney shortly after unilateral nephrectomy, we performed suprarenal inferior vena caval ligations after unilateral nephrectomy in 10 dogs. A total of 6 dogs suffered persistent loss of renal function and 3 of these 6 died of uremia. Of 4 dogs who underwent suprarenal inferior vena caval ligation only 1 (25%) had persistent compromise of renal function. A total of 2 dogs underwent unilateral nephrectomy only without compromise of normal renal function. We conclude that the risk of total vena caval occlusion after suprarenal Greenfield filter placement is small. However, should it occur in the setting of recent nephrectomy there is potential for significant renal morbidity. In selected patients this risk may be offset by the potential benefits that the filter offers in terms of protection against tumor and/or bland pulmonary embolus. Further clinical experience will be needed to strengthen and clarify the indications and benefits of preoperative or intraoperative filter placement as reported.

The Mid-Term Efficacy and Safety of a Permanent Nitinol IVC Filter (TrapEase)

“…The design of the TrapEase filter would appear to be such that the chance of tilting and asymmetric placement are minimized because of the long side struts being directly connected to the proximal and distal baskets. This may reduce the possibility of individual side struts attaching asymmetrically to the vessel walls during filter release.. Improper placement of the filter has been reported to occur in the heart (17), renal vein (3), spermatic vein, iliac vein (18), lumbar vein (19), and suprarenal caval vein (20). All filters were implanted in the IVC in this study.…”

Surgical Treatment of Inferior Vena Cava Tumor Thrombus in Patients with Renal Cell Carcinoma

“…Intraoperative deployment of a filter may protect the propagation of bland thrombi in patients with distal thrombi as well as tumor thrombi (27). In contrast, the overall rate of vena caval thrombosis or occlusion and renal dysfunction associated with infrarenal filter placement was 3-5%, suggesting that filter placement may increase significant overall morbidity in the setting of recent nephrectomy (24). Moreover, incorporation of the tumor in the filter may increase the difficulty of complete resection (27).…”

Accidental dislocation of an intracaval temporary filter into the heart in a case of renal cell carcinoma extending into the vena cava

“…Two types of intracaval filters, permanent and temporary, are available for clinical use. In cases of RCC extending into the vena cava, placement of permanent filters is reported to be effective for prevention of major pulmonary artery thrombosis 4,5 . However, subsequent obstruction of the vena cava might lead to deterioration of renal function 5 .…”

“…The frequency of fatal pulmonary thrombus during an operation is reported to be 1.2–4% 1–3 . To prevent perioperative fatal events by pulmonary emboli, placement of an intracaval filter has been tried with favorable outcomes 4–6 . In a case of RCC with an infrahepatic tumor thrombus, we introduced a temporary intracaval filter, which accidentally migrated into the right ventricle.…”