Inferior Vena Cava Filter Placement

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Thromboembolic disease continues to be a cause of morbidity and mortality. ^{[1, 2]}  Placing a filter in the inferior vena cava (IVC) is an important way to prevent significant pulmonary embolism (PE) arising from a deep vein thrombosis (DVT). ^{[3, 4]}  This procedure is currently performed under radiologic guidance via femoral vein or jugular vein access. ^[3]

This article provides a step-by-step guide to jugular approach to insertion of retrievable Gunther Tulip or Celect IVC filters. For a comparison of retrievable and nonretrievable IVC filters, see Inferior Vena Cava Filters.

An absolute indication for IVC filter placement is the presence of DVT or PE with any of the following conditions:

However, a meta-analysis of three randomized controlled studies by Jiang et al, which included 863 patients with DVT concluded that the addition of an IVC filter to anticoagulation, as compared with anticoagulation alone, did not reduce the incidence of recurrent PE in the short term (3 months). ^[6]

Relative indications include the following:

An absolute contraindication for IVC placement is lack of access into the IVC.

Relative contraindications include the following:

A consensus statement from the Neurocritical Care Society recommended against the routine use of IVC filters for primary prophylaxis of venous thromboembolism in adult patients with an external ventricular drain in place. ^[9]  

A guideline from the American College of Chest Physicians recommended against the use of IVC filters in patients with acute DVT or PE who are receiving anticoagulant therapy. ^[10]

The internal jugular vein (IJV) lies anterior and lateral to the carotid artery. A low puncture increases the risk of pneumothorax, and a high puncture increases the risk of arterial puncture, in that the artery lies more directly posterior to the vein as it courses higher up in the neck. (See the video below.) The common femoral vein lies medial to the artery. Ultrasonography can be used to perform a vein puncture.

Filter types

IVC filters come in two different types, permanent (nonretrievable) and temporary (retrievable). ^[11]  (See Inferior Vena Cava Filters.)

Permanent filters cannot be removed or repositioned. Temporary filters (also called optional filters) can usually be retrieved or repositioned up to a certain point in time. With time, the filter becomes incorporated into the caval wall and may not be removable. The Cook Celect and Gunther Tulip filters are optional filters; they have retrieval kits that are used to snare the apical hooks and retrieve the filters. Removal within 30 days is typical, but successful filter removal more than 1 year after implantation has been reported. ^{[12, 13, 14]}

In 2014, the US Food and Drug Administration (FDA), out of concern that retrievable IVC filters placed for short-term PE risk are not always removed once the risk subsides, issued a safety communication on filter removal, which made the following recommendations ^[15] :

Various studies have reported poor retrieval rates for retrievable IVC filters; work continues on methods of improving these rates. ^{[16, 17]}

Insertion methods

IVC filters come in various shapes and can be inserted via either a jugular or a femoral approach. The jugular approach is preferable if an iliofemoral thrombus is present. Some filters cannot be inserted from the left jugular vein because of the lack of flexibility of the delivery system. Most devices can be used if the IVC diameter is smaller than 3 cm (check manufacturer recommendations for a particular filter). If a patient has a megacava, a bird’s nest filter should be used (≤4 cm).

Two main methods of insertion are used, as follows:

A report of two cases by Winkler et al suggests that for morbidly obese patients, in whom fluoroscopic guidance is sometimes problematic, guidance with noncontrast CT may prove to be an acceptable alternative. ^[20]

Kessel D, Robertson I. Interventional Radiology: A Survival Guide. 2nd ed. Philadelphia: Elsevier; 2005.

Crowther MA. Inferior vena cava filters in the management of venous thromboembolism. Am J Med. 2007 Oct. 120(10 Suppl 2):S13-7. [Medline].

Amankwah KS, Seymour K, Costanza M, Berger J, Gahtan V. Transabdominal duplex ultrasonography for bedside inferior vena cava filter placement: examples, technique, and review. Vasc Endovascular Surg. 2009 Aug-Sep. 43(4):379-84. [Medline].

Duffett L, Carrier M. Inferior vena cava filters. J Thromb Haemost. 2017 Jan. 15 (1):3-12. [Medline].

Van Ha TG, Chien AS, Funaki BS, et al. Use of retrievable compared to permanent inferior vena cava filters: a single-institution experience. Cardiovasc Intervent Radiol. 2008 Mar-Apr. 31(2):308-15. [Medline].

Jiang J, Jiao Y, Zhang X. The short-term efficacy of vena cava filters for the prevention of pulmonary embolism in patients with venous thromboembolism receiving anticoagulation: Meta-analysis of randomized controlled trials. Phlebology. 2016 Dec 2. [Medline].

Giannoudis PV, Pountos I, Pape HC, et al. Safety and efficacy of vena cava filters in trauma patients. Injury. 2007 Jan. 38(1):7-18. [Medline].

Farray D, Carman TL, Fernandez BB Jr. The treatment and prevention of deep vein thrombosis in the preoperative management of patients who have neurologic diseases. Neurol Clin. 2004 May. 22(2):423-39. [Medline].

Fried HI, Nathan BR, Rowe AS, Zabramski JM, Andaluz N, Bhimraj A, et al. The Insertion and Management of External Ventricular Drains: An Evidence-Based Consensus Statement : A Statement for Healthcare Professionals from the Neurocritical Care Society. Neurocrit Care. 2016 Feb. 24 (1):61-81. [Medline].

[Guideline] Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016 Feb. 149 (2):315-52. [Medline]. [Full Text].

Kinney TB. Update on inferior vena cava filters. J Vasc Interv Radiol. 2003 Apr. 14(4):425-40. [Medline].

Smouse HB, Rosenthal D, Thuong VH, Knox MF, Dixon RG, Voorhees WD 3rd, et al. Long-term retrieval success rate profile for the Gunther Tulip vena cava filter. J Vasc Interv Radiol. 2009 Jul. 20(7):871-7; quiz 878. [Medline].

Dixon A, Stavropoulos SW. Improving retrieval rates for retrievable inferior vena cava filters. Expert Rev Med Devices. 2013 Jan. 10(1):135-41. [Medline].

Dinglasan LA, Oh JC, Schmitt JE, et al. Complicated inferior vena cava filter retrievals: associated factors identified at preretrieval CT. Radiology. 2013 Jan. 266(1):347-54. [Medline].

Removing retrievable inferior vena cava filters: FDA safety communication. US Food and Drug Administration. Available at http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm396377.htm. May 6, 2014; Accessed: February 10, 2017.

Simon TE, Walker PF, Daab LJ, White JM, White PW. A quality improvement project to improve inferior vena cava filter retrieval. J Vasc Surg Venous Lymphat Disord. 2017 Jan. 5 (1):42-46. [Medline].

Makary MS, Shah SH, Warhadpande S, Vargas IG, Sarbinoff J, Dowell JD. Design-of-Experiments Approach to Improving Inferior Vena Cava Filter Retrieval Rates. J Am Coll Radiol. 2017 Jan. 14 (1):72-77. [Medline].

Chiou AC. Intravascular ultrasound-guided bedside placement of inferior vena cava filters. Semin Vasc Surg. 2006 Sep. 19(3):150-4. [Medline].

Gunn AJ, Iqbal SI, Kalva SP, et al. Intravascular ultrasound-guided inferior vena cava filter placement using a single-puncture technique in 99 patients. Vasc Endovascular Surg. 2013 Feb. 47(2):97-101. [Medline].

Winkler MA, Majmudar PM, Landwehr KP, Hobbs SB, Saha SP. Use of noncontrast computed tomography of the inferior vena cava for real-time imaging guidance for the placement of inferior vena cava filters. Int J Angiol. 2015 Mar. 24(1):71-4. [Medline]. [Full Text].

Matthews BD, Joels CS, LeQuire MH. Inferior vena cava filter placement: preinsertion inferior vena cava imaging. Am Surg. 2003 Aug. 69(8):649-53. [Medline].

Marine L, Mertens R, Kramer Sch A, et al. [Suprarenal inferior vena cava filters. Retrospective review of 30 cases]. Rev Med Chil. 2008 Dec. 136(12):1535-41. [Medline].

Joels CS, Sing RF, Heniford BT. Complications of inferior vena cava filters. Am Surg. 2003 Aug. 69(8):654-9. [Medline].

Assifi MM, Bagameri G, Dimuzio PJ, Eisenberg JA. Management of infected caval filter with simultaneous aortic pseudoaneurysm and retroperitoneal perforation: a case report and literature review. Vascular. 2012 Aug. 20(4):225-8. [Medline].

Wang SL, Siddiqui A, Rosenthal E. Long-term complications of inferior vena cava filters. J Vasc Surg Venous Lymphat Disord. 2017 Jan. 5 (1):33-41. [Medline].

Sapna Puppala, MBBS, MRCS, MRCS(Edin), FRCS(Edin), FRCR, CBCCT, EBIR Consultant Cardiovascular Radiologist and Endovascular Specialist, Leeds Teaching Hospital, NHS Trust, UK

Sapna Puppala, MBBS, MRCS, MRCS(Edin), FRCS(Edin), FRCR, CBCCT, EBIR is a member of the following medical societies: Royal College of Radiologists, Cardiovascular and Interventional Radiological Society of Europe

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Justin A Siegal, MD Radiologist, Department of Radiology, Virginia Mason Medical Center

Disclosure: Nothing to disclose.

Thanks to all my patients for allowing me to photograph them and use their images.

Thanks to Dr S Agarwal and Dr V Acharya for proofreading.

Inferior Vena Cava Filter Placement

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