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Ultrasound Placement of Vena Cava Filters Thomas Naslund Vanderbilt University Medical Center.

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Presentation on theme: "Ultrasound Placement of Vena Cava Filters Thomas Naslund Vanderbilt University Medical Center."— Presentation transcript:

1 Ultrasound Placement of Vena Cava Filters Thomas Naslund Vanderbilt University Medical Center

2 CONFLICT OF INTERESTS WL Gore Consultant Boston ScientificConsultant LeMaitre VascularScientific Advisory Board

3 Greenfield Filter Introduced 35 years ago Excellent safety and efficacy Integral component of venous thromboembolism (VTE) Initially performed in OR with cutdown Routinely performed percutaneously - angio suites Bedside placement with ultrasound

4 Filters for Ultrasound Placement Greenfield, Cook Tulip, Simon Nitinol – well suited to ultrasound placement Greenfield visualized well out of sheath Tulip best visualized while in sheath

5 Indications for Filter Absolute IndicationsVTE with contraindication to anticoagulation VTE with complication of anticoagulation Recurrent VTE despite adequate anticoagulation Concurrent with pulmonary embolectomy Failure of alternate form of vena caval interruption Relative IndicationsFree-floating iliofemoral thrombus (>5cm) in high-risk patient Propagating iliofemoral thrombus despite adequate anticoagulation Septic pulmonary emboli Pulmonary hypertension/cor pulmonale with chronic VTE VTE in high risk patient VTE prophylaxis in multiple trauma or malignancy

6 Ultrasound Placement Initiated in 1995 Adaptable to bedside placement Surface or IVUS can be utilized Eliminates patient transport Reduced institutional cost Efficient use of physician time

7 Technique Filter Placement with Surface Ultrasound Preliminary duplex of femoral vein & IVC –Identify thrombus, diameter, landmarks Establish femoral access/identify wire in IVC Routine sheath placement/visualization Position filter tip at right renal vein (remove wire) and deploy Completion KUB

8 Technique Filter Placement with Surface Ultrasound Preliminary duplex of femoral vein & IVC –Identify thrombus, diameter, landmarks

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13 Technique IVUS Dual Access Duplex femoral veins-optional Dual femoral access (preferred bilateral) Visualize sheath and iliac vein confluence Advance to atrium “Pull back” visualization/IVC diameter Position filter tip at renal vein Pull IVUS back and deploy Advance IVUS to evaluate filter Completion KUB

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16 Technique IVUS single access Interrogate atrium to iliacs (using filter sheath) Mark location of renal vein on catheter (tie) Translate mark onto the filter delivery catheter Insert to mark to deploy blind Advance IVUS to check deployment Completion KUB

17 Series of Ultrasound Guided Filter Placement AuthorYearn Modalit yLocation Puncture Technique Technical Success Misplacemen t Overall Complication Rate Corriere DUSBedsideSingle Puncture97%5%2% Rosenthal IVUSBedsideDouble Puncture97%3%6% Garrett IVUSBedside Single/Double Puncture 93%8%15% Gamblin IVUSORSingle Puncture94%0% Wellons IVUS IR Suite/Bedsid e Double Puncture94%3%6% Conners DUSBedsideSingle Puncture98%2%4% Ashley IVUSORSingle Puncture100%0% Ebaugh IVUSBedsideSingle Puncture92%4%12% Bonn IVUSIR Suite Single/Double Puncture 100%0% Sato DUSBedsideSingle Puncture98%0%2% Benjamin DUSBedsideSingle Puncture100%4% Neuzil DUSBedsideSingle Puncture100%4%8% Neuzil DUSBedsideSingle Puncture89%−8% DUS, duplex ultrasound. IVUS, intravascular ultrasound. OR, operating room. IR, interventional radiology.

18 Safety Considerations Avoiding Patient Transport Invasive monitoring lines Pressors Ventilators Drains Transportation complications risk up to 15.5%

19 Misplacement Most common 0-8% Iliac vein or suprarenal IVC Often attributed to poor visualization or U/S misinterpretation Suprarenal placement is satisfactory Iliac requires fluoroscopic filter repositioning

20 Insertion Site Thrombosis Occurs in up to 16.7% of patients Double venous puncture technique increases exposure to risk Incidence is related to surveillance of access site With routine surveillance, IST may occur in up to one third of patients

21 Financial Considerations Cost Reduction Avoid patient transport No interventional suite Over $2000 cost reduction per patient (2002)

22 Comparison of Techniques AdvantagesDisadvantages Contrast Venography Accurate deployment, detection of venous anomalies Transportation of critically-ill patients, radiation exposure, radiocontrast exposure, cost DUSPortable, non-invasive, no contrast or radiation exposure, cost-effective Imaging limited by body habitus, bowel gas, abdominal wounds, anasarca, immobilization, learning curve IVUSPortable, no contrast or radiation exposure, cost- effective, unlimited by gas, edema, or body habitus Invasive, catheter expense, learning curve, need for bilateral femoral venous access*, complexity *unless single puncture technique used DUS, duplex ultrasonography. IVUS, intravascular ultrasound.

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