Presentation on theme: "Ultrasound Placement of Vena Cava Filters"— Presentation transcript:
1Ultrasound Placement of Vena Cava Filters Thomas NaslundVanderbilt University Medical Center
2CONFLICT OF INTERESTS WL Gore Consultant Boston Scientific Consultant LeMaitre Vascular Scientific Advisory Board
3Greenfield Filter Introduced 35 years ago Excellent safety and efficacyIntegral component of venous thromboembolism (VTE)Initially performed in OR with cutdownRoutinely performed percutaneously - angio suitesBedside placement with ultrasound
4Filters for Ultrasound Placement Greenfield, Cook Tulip, Simon Nitinol – well suited to ultrasound placementGreenfield visualized well out of sheathTulip best visualized while in sheath
5Indications for Filter Absolute IndicationsVTE with contraindication to anticoagulationVTE with complication of anticoagulationRecurrent VTE despite adequate anticoagulationConcurrent with pulmonary embolectomyFailure of alternate form of vena caval interruptionRelative IndicationsFree-floating iliofemoral thrombus (>5cm) in high-risk patientPropagating iliofemoral thrombus despite adequate anticoagulationSeptic pulmonary emboliPulmonary hypertension/cor pulmonale with chronic VTEVTE in high risk patientVTE prophylaxis in multiple trauma or malignancy
6Ultrasound Placement Initiated in 1995 Adaptable to bedside placement Surface or IVUS can be utilizedEliminates patient transportReduced institutional costEfficient use of physician time
7Technique Filter Placement with Surface Ultrasound Preliminary duplex of femoral vein & IVCIdentify thrombus, diameter, landmarksEstablish femoral access/identify wire in IVCRoutine sheath placement/visualizationPosition filter tip at right renal vein (remove wire) and deployCompletion KUB
8Technique Filter Placement with Surface Ultrasound Preliminary duplex of femoral vein & IVCIdentify thrombus, diameter, landmarks
13Technique IVUS Dual Access Duplex femoral veins-optionalDual femoral access (preferred bilateral)Visualize sheath and iliac vein confluenceAdvance to atrium“Pull back” visualization/IVC diameterPosition filter tip at renal veinPull IVUS back and deployAdvance IVUS to evaluate filterCompletion KUB
16Technique IVUS single access Interrogate atrium to iliacs (using filter sheath)Mark location of renal vein on catheter (tie)Translate mark onto the filter delivery catheterInsert to mark to deploy blindAdvance IVUS to check deploymentCompletion KUB
17Overall Complication Rate Series of Ultrasound Guided Filter PlacementAuthorYearnModalityLocationPuncture TechniqueTechnical SuccessMisplacementOverall Complication RateCorriere12005382DUSBedsideSingle Puncture97%5%2%Rosenthal2200494IVUSDouble Puncture3%6%Garrett328Single/Double Puncture93%8%15%Gamblin4200336OR94%0%Wellons545IR Suite/BedsideConners6200228498%4%Ashley7200121100%Ebaugh82692%12%Bonn9199930IR SuiteSato1053Benjamin1125Neuzil12199829Neuzil1319974989%−DUS, duplex ultrasound. IVUS, intravascular ultrasound. OR, operating room. IR, interventional radiology.
18Safety Considerations Avoiding Patient Transport Invasive monitoring linesPressorsVentilatorsDrainsTransportation complications risk up to 15.5%
19Misplacement Most common 0-8% Iliac vein or suprarenal IVC Often attributed to poor visualization or U/S misinterpretationSuprarenal placement is satisfactoryIliac requires fluoroscopic filter repositioning
20Insertion Site Thrombosis Occurs in up to 16.7% of patientsDouble venous puncture technique increases exposure to riskIncidence is related to surveillance of access siteWith routine surveillance, IST may occur in up to one third of patients
22Comparison of Techniques AdvantagesDisadvantagesContrast VenographyAccurate deployment, detection of venous anomaliesTransportation of critically-ill patients, radiation exposure, radiocontrast exposure, costDUSPortable, non-invasive, no contrast or radiation exposure, cost-effectiveImaging limited by body habitus, bowel gas, abdominal wounds, anasarca, immobilization, learning curveIVUSPortable, no contrast or radiation exposure, cost-effective, unlimited by gas, edema, or body habitusInvasive, catheter expense, learning curve, need for bilateral femoral venous access*, complexity*unless single puncture technique usedDUS, duplex ultrasonography. IVUS, intravascular ultrasound.