Vena Cava Filter Occlusion and Venous Thromboembolism Risk in Persistently Anticoagulated Patients: A Prospective, Observational Cohort Study
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Aim To explore the correlation between thrombosis and density change of gores.Methods Using physic methods in new blood samples,the natural thrombus is taken and used the blood boltsof differentages(gores,flowing out of our bodies in different intervals) is used to calculate the changes of density parameters in the gores.Results During the process of thrombosis,the density of thrombus was increasing obviously along with the gore forming time.That made it positive relationship that density of the clot complied with the prolonging thrombus ageing.It reflected that all the state changes during thrombosis had distinct changes of physical parameters.Conclusion The results showed that thrombus density has the characteristics of the changing with the gore aging.This may also provide reliable evidence that the changes of thrombus structures and densities may improve the effect of intravascular ultrasonic thrombosis ablation and may be beneficial of clinic use.
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The Günther-Tulip inferior vena cava filter (Cook Medical Inc, Bloomington, Ind) was one of the first inferior vena cava (IVC) filters to be approved by the U.S. Food and Drug Administration for retrieval. Clinical experience has documented that these IVC filters may be safely removed after 12 weeks of implantation. Recent reports have shown that the longer the indwelling time, the higher the retrieval failure rate. We present a case of a successful retrieval of a Günther-Tulip IVC filter 3334 days after implantation. Removal of the Günther-Tulip IVC filter is technically feasible, even after a prolonged indwelling time. The Günther-Tulip inferior vena cava filter (Cook Medical Inc, Bloomington, Ind) was one of the first inferior vena cava (IVC) filters to be approved by the U.S. Food and Drug Administration for retrieval. Clinical experience has documented that these IVC filters may be safely removed after 12 weeks of implantation. Recent reports have shown that the longer the indwelling time, the higher the retrieval failure rate. We present a case of a successful retrieval of a Günther-Tulip IVC filter 3334 days after implantation. Removal of the Günther-Tulip IVC filter is technically feasible, even after a prolonged indwelling time. The Günther-Tulip inferior vena cava (IVC) filter (Cook Medical Inc, Bloomington, Ind) was one of the first IVC filters to be approved by the U.S. Food and Drug Administration for retrieval.1Hoppe H. Nutting C.W. Smouse H.R. Vesely T.M. Pohl C. Bettmann M.A. et al.Gunther Tulip filter retrievability multicenter study including CT follow-up: final report.J Vasc Interv Radiol. 2006; 17: 1017-1023Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar Initial clinical experience reported that these filters could be successfully removed after a mean of 8.6 days after implantation, with a maximal implantation time of 13 days.2Millward S.F. Bhargava A. Aquino Jr., J. Peterson R.A. Veinot J.P. Bormanis J. et al.Gunther Tulip filter: preliminary clinical experience with retrieval.J Vasc Interv Radiol. 2000; 11: 75-82Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar Subsequent clinical experience showed that these filters could be retrieved successfully >12 weeks after implantation3Oh J.C. Trerotola S.O. Dagli M. Shlansky-Goldberg R.D. Soulen M.C. Itkin M. et al.Removal of retrievable inferior vena cava filters with computed tomography findings indicating tenting or penetration of the inferior vena cava wall.J Vasc Interv Radiol. 2011; 22: 70-74Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar, 4Kuo W.T. Cupp J.S. Louie J.D. Kothary N. Hofmann L.V. Sze D.Y. et al.Complex retrieval of embedded IVC filters: alternative techniques and histologic tissue analysis.Cardiovasc Intervent Radiol. 2012; 35: 588-597Crossref PubMed Scopus (57) Google Scholar; however, retrieval difficulty increases with IVC filter dwell time.5Uberoi R. Tapping C.R. Chalmers N. Allgar V. British Society of Interventional Radiology (BSIR) Inferior Vena Cava (IVC) Filter Registry.Cardiovasc Intervent Radiol. 2013; 36: 1548-1561Crossref PubMed Scopus (75) Google Scholar Recent publications have documented the association of complications with retrievable IVC filters, including deep vein thrombosis, filter fracture, filter migration, and perforation of the IVC wall, potentially damaging or penetrating surrounding structures.6McLoney E.D. Krishnasamy V.P. Castle J.C. Yang X. Guy G. Complications of Celect, Gunther Tulip, and Greenfield inferior vena cava filters on CT follow-up: a single-institution experience.J Vasc Interv Radiol. 2013; 24: 1723-1729Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar It is now advisable to remove retrievable IVC filters as soon as filtration is no longer necessary.5Uberoi R. Tapping C.R. Chalmers N. Allgar V. British Society of Interventional Radiology (BSIR) Inferior Vena Cava (IVC) Filter Registry.Cardiovasc Intervent Radiol. 2013; 36: 1548-1561Crossref PubMed Scopus (75) Google Scholar, 6McLoney E.D. Krishnasamy V.P. Castle J.C. Yang X. Guy G. Complications of Celect, Gunther Tulip, and Greenfield inferior vena cava filters on CT follow-up: a single-institution experience.J Vasc Interv Radiol. 2013; 24: 1723-1729Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar We present a case of a successful retrieval of a Günther-Tulip IVC filter 3334 days after implantation. The key aspect of this case is the safe removal of a Günther-Tulip IVC filter after an indwelling time beyond the manufacturer's recommendations.7Kuo W.T. Robertson S.W. Odegaard J.I. Hofmann L.V. Complex retrieval of fractured, embedded, and penetrating inferior vena cava filters: a prospective study with histologic and electron microscopic analysis.J Vasc Interv Radiol. 2013; 24 (quiz: 631): 622-630 e1Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 8Kuo W.T. Odegaard J.I. Rosenberg J.K. Hofmann L.V. Excimer laser-assisted removal of embedded inferior vena cava filters: a single-center prospective study.Circ Cardiovasc Interv. 2013; 6: 560-566Crossref PubMed Scopus (49) Google Scholar The patient consented to the publication of her case. The patient was a 53-year-old woman with history of psychiatric problems, alcohol abuse, and non-compliance with medical advice. She was admitted on December 12, 2004, with alcohol intoxication and right hip pain. An abdominal computed tomography scan disclosed an IVC thrombus. Given her history, it was decided to place an IVC filter. A Günther-Tulip IVC filter was placed on December 17, 2004. The patient was again admitted in 2006 with alcohol intoxication. No IVC filter removal attempts were conducted because it was thought that the window for safe removal had been exceeded. The patient returned in February 2014 complaining of diffuse, nonspecific abdominal pain and hematuria. Her initial workup included a computed tomography scan that confirmed the presence of an infrarenal IVC filter tilted anteriorly, with its tip embedded in the wall of the IVC and two filter prongs perforating beyond the wall of the IVC. One prong appeared to be penetrating into the duodenum and the other was close to the right proximal ureter. The case was discussed in the multidisciplinary endovascular conference and the consensus was to offer Günther-Tulip IVC filter removal. The urology service was consulted before the procedure, and a retrograde right-sided ureteral catheter was placed in case of ureter laceration during retrieval attempts. Occlusion balloons and stent grafts were available in the operating room in case of IVC injury during attempted removal. The patient was admitted on February 17, 2014. Given her history, it was agreed to perform the IVC filter removal under general anesthesia. Access was obtained under real-time ultrasound guidance within the right internal jugular and the right common femoral veins. A 16F, 45-cm sheath (Cook Inc) was placed in the right internal jugular vein and a 10F sheath (Terumo, Tokyo, Japan) was placed within the right common femoral vein. An initial venogram confirmed the presence of IVC filter limbs protruding outside the caval wall. Attempts to grasp the filter cone with a 25-mm Amplatz snare (ev-3, Minneapolis, Minn) and a 50-cm biopsy forceps (#505020, Pilling, Altena, Germany) were unsuccessful. A SOS select angiographic catheter (Angiodynamics, Queensbury, NY) and a stiff glidewire (Terumo) were then used to manipulate the cone of the filter and dislodge it off the wall of the IVC. Once it was evident that maneuvers to dislodge the IVC filter cone had been successful, the leading end of the stiff glidewire was captured with a snare from the femoral venous access, creating a through-and-through access (Fig 1). The 50-cm biopsy forceps was then used to capture the cone of the IVC filter and pull it into the 16F jugular vein sheath. This maneuver was performed with minimal effort. Once the cone of the IVC filter was within the 16F sheath, it was difficult to remove the IVC filter in its entirety. A 10-mm Amplatz snare was then used to snare the hook of the cone of the filter to pull the filter further within the sheath. The IVC filter still could not be removed, and the IVC filter prongs were thought to be embedded or somehow attached to the wall of the IVC. The next maneuver attempted was to “push” the IVC filter into the 16F sheath using the femoral venous access. A 6-mm angioplasty balloon was advanced from the right common femoral venous access and partially inflated within the lower aspect of the IVC filter (Fig 2). Then, in a coordinated fashion, a combination of pushing from the femoral venous end and pulling from the jugular venous end finally dislodged the IVC filter so it could be completely captured within the 16F sheath. The IVC filter was successfully removed, and a postremoval cavagram showed an intact IVC (Fig 3). The fluoroscopy time was 35 minutes, and the calculated radiation exposure dose was 1018 mGy. The patient was discharged in stable condition on February 19, 2014.Fig 3Digital subtraction venogram immediately after filter removal shows a patent and intact inferior vena cava (IVC). No perforation or extravasation is identified.View Large Image Figure ViewerDownload (PPT) To the best of our knowledge, this is the first report of a successful Günther-Tulip IVC filter removal >9 years after implantation. This patient's symptoms were thought to be related to the filter, and this was the main indication to pursue filter removal.4Kuo W.T. Cupp J.S. Louie J.D. Kothary N. Hofmann L.V. Sze D.Y. et al.Complex retrieval of embedded IVC filters: alternative techniques and histologic tissue analysis.Cardiovasc Intervent Radiol. 2012; 35: 588-597Crossref PubMed Scopus (57) Google Scholar, 7Kuo W.T. Robertson S.W. Odegaard J.I. Hofmann L.V. Complex retrieval of fractured, embedded, and penetrating inferior vena cava filters: a prospective study with histologic and electron microscopic analysis.J Vasc Interv Radiol. 2013; 24 (quiz: 631): 622-630 e1Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar The patient had adverse factors that could complicate removal attempts, including a prolonged indwelling time, filter tilting with cone embedded within the wall of the IVC, and IVC perforation by filter prongs.5Uberoi R. Tapping C.R. Chalmers N. Allgar V. British Society of Interventional Radiology (BSIR) Inferior Vena Cava (IVC) Filter Registry.Cardiovasc Intervent Radiol. 2013; 36: 1548-1561Crossref PubMed Scopus (75) Google Scholar The European registry reported a mean dwell time for Günther-Tulip IVC filters at 39.5 days, with a maximal dwell time of 101 days before retrieval.5Uberoi R. Tapping C.R. Chalmers N. Allgar V. British Society of Interventional Radiology (BSIR) Inferior Vena Cava (IVC) Filter Registry.Cardiovasc Intervent Radiol. 2013; 36: 1548-1561Crossref PubMed Scopus (75) Google Scholar Findings of this registry indicated that retrieval success diminished with duration of implantation.5Uberoi R. Tapping C.R. Chalmers N. Allgar V. British Society of Interventional Radiology (BSIR) Inferior Vena Cava (IVC) Filter Registry.Cardiovasc Intervent Radiol. 2013; 36: 1548-1561Crossref PubMed Scopus (75) Google Scholar The failure rate for Günther-Tulip filters was 25% for this registry.5Uberoi R. Tapping C.R. Chalmers N. Allgar V. British Society of Interventional Radiology (BSIR) Inferior Vena Cava (IVC) Filter Registry.Cardiovasc Intervent Radiol. 2013; 36: 1548-1561Crossref PubMed Scopus (75) Google Scholar Kuo et al7Kuo W.T. Robertson S.W. Odegaard J.I. Hofmann L.V. Complex retrieval of fractured, embedded, and penetrating inferior vena cava filters: a prospective study with histologic and electron microscopic analysis.J Vasc Interv Radiol. 2013; 24 (quiz: 631): 622-630 e1Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar were successful in all attempted cases of complex IVC filter removal. The mean implantation time in their report was 815 days, and the removed filter with the longest dwell time before retrieval was 2599 days, which amounts to a little over than 7 years. In their series, however, no Günther-Tulip filters were retrieved.7Kuo W.T. Robertson S.W. Odegaard J.I. Hofmann L.V. Complex retrieval of fractured, embedded, and penetrating inferior vena cava filters: a prospective study with histologic and electron microscopic analysis.J Vasc Interv Radiol. 2013; 24 (quiz: 631): 622-630 e1Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar The present case is interesting because, as described by other authors, as many as 20% to 40% of filters cannot be removed because the filters become embedded along the vessel wall.7Kuo W.T. Robertson S.W. Odegaard J.I. Hofmann L.V. Complex retrieval of fractured, embedded, and penetrating inferior vena cava filters: a prospective study with histologic and electron microscopic analysis.J Vasc Interv Radiol. 2013; 24 (quiz: 631): 622-630 e1Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar A considerable amount of endovascular experience is required to remove these filters.7Kuo W.T. Robertson S.W. Odegaard J.I. Hofmann L.V. Complex retrieval of fractured, embedded, and penetrating inferior vena cava filters: a prospective study with histologic and electron microscopic analysis.J Vasc Interv Radiol. 2013; 24 (quiz: 631): 622-630 e1Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar The key to the present case was careful planning.9Dinglasan L.A. Oh J.C. Schmitt J.E. Trerotola S.O. Shlansky-Goldberg R.D. Stavropoulos S.W. Complicated inferior vena cava filter retrievals: associated factors identified at preretrieval CT.Radiology. 2013; 266: 347-354Crossref PubMed Scopus (68) Google Scholar The most interesting aspect about this case is the safe and technically successful IVC filter retrieval after an indwelling time way beyond manufacturer's recommendations. The case illustrates the safe removal of a Günther-Tulip IVC filter after 3334 days of implantation. Evaluation of the imaging studies and careful procedure planning were essential factors in the successful filter retrieval.7Kuo W.T. Robertson S.W. Odegaard J.I. Hofmann L.V. Complex retrieval of fractured, embedded, and penetrating inferior vena cava filters: a prospective study with histologic and electron microscopic analysis.J Vasc Interv Radiol. 2013; 24 (quiz: 631): 622-630 e1Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 9Dinglasan L.A. Oh J.C. Schmitt J.E. Trerotola S.O. Shlansky-Goldberg R.D. Stavropoulos S.W. Complicated inferior vena cava filter retrievals: associated factors identified at preretrieval CT.Radiology. 2013; 266: 347-354Crossref PubMed Scopus (68) Google Scholar, 10Yan Y. Galfione M. William Stavropoulos S. Trerotola S.O. Forceps retrieval of a tip-embedded superior vena cava filter.J Vasc Interv Radiol. 2013; 24: 592-595Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar
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Objective To explore the feasibility and success rate of establishing inferior vena cava thrombus model by the operation in which the spiral copper wire was placed into the inferior vena cava of rabbits. Methods Thirty rabbits were randomly divided into thrombus group( n = 25) and control group( n = 5). The inferior vena cava of rabbits in thrombus group was exposed through operation,then the self-made spiral copper wire was punctured into the inferior vena cava. The self-made U-shaped copper wire clip was placed around the area of proximal parte of inferior vena cava. Then the clip was frapped and the 2mm gap was kept. After stopped bleeding,the abdominal muscle,peritoneum and skin were sewn up. The rabbits in control group were sham operated,however,the spiral copper wire was not placed in inferior vena cava. All the rabbits were executed and dissected 1 day after the operation. The thrombosis condition of rabbits in thrombus group was observed,the success rate of establishing the models with inferior vena cava thrombus was calculated. The inferior vena cava blood flow status in rabbits of control group was observed. Moreover the paraffin slices of thrombus were stained by Hematoxylin-eosin( HE) to check the pathological characteristic of thrombus in thrombus group. Results The inferior vena cava vessel wall of rabbits in thrombus group was complete in which thrombosis in inferior vena cava could be found in 23 rabbits,and the thrombus included white or red thrombus which adhered to the spiral copper wire,with the success rate was being 92%( 23 /25). However thrombosis in inferior vena cava could not be found in 5 rabbits of control group. The pathological examination showed that the thrombus in thrombus group was fresh mixed thrombus. Conclusion The success rate of establishing inferior vena cava thrombus model by the method is higher,and the pathological characteristics of thrombus are consistent with those of deep vein thrombus,which can be used in experimental study for vein thrombus.
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Objective
To explore the clinical efficacy of Da Vinci robotic surgical system assisted Inferior Vena Cava filter retrieval.
Methods
The retrospective descriptive study was conducted.The clinical data of the first patient in asia who underwent Da Vinci robotic surgical system assisted inferior vena cava filter retrieval in the department of vascular surgery of Southwest Hospital of Army Military Medical University in Jul. 2019 were collected. The patient underwent retrievable inferior vena cava filter implantation two months ago, and failed to removal of inferior vena cava filters by endovascular measures and underwent inferior vena cava filter retrieval assisted by Da Vinci robotic surgical system. Observation indicators: intra-and post-operative situations; follow-up and patients’ survival. Follow-up using outpatient examination to detect the patients’ postoperative survival and swelling reduction of affected extremity up to Aug.2019.
Results
Intra- and post-operative situations: patient underwent inferior vena cava filter retrieval using Da Vinci robotic surgical system successfully. Operation time was 326 minutes and estimated blood loss was 100 ml. After removal of inferior vena cava filter, the incision of inferior vena cava was anastomosed well without bleeding or stenosis. No intraoperative complications occurred. Duration of hospital stay after surgery was 3 days.Follow-up and patients’ survival: patient was followed up for 1 month.The patient had a good survive without any complications.
Conclusions
The Da Vinci robotic surgical system is safe and feasible in inferior vena cava filter retrieval.
Key words:
Da Vinci robotic surgical system; Inferior vena cava; Inferior vena cava filter; Minimally invasive surgery
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Objective To establish a model of deep venous thrombosis(DVT)in rats for dynamic study of antithrombotics or thrombolysis on thrombosis.Methods SD rats(n=60)were randomly divided into thrombosis model group(n=36),control group(n=18)and sham operation group(n=6).An improved method was used to make the inferior caval vein ligated in SD rats of thrombosis model group.After operation,rats in thrombosis model group and control group were divided into 6 period groups.The changes of thrombus and internal surface of vessels in each period were observed in thrombosis model group and were compared with those in other two groups,respectively.Results Stable venous thrombus were observed in all inferior caval vein in thrombosis model group,and the proximal part of venous thrombus was unobstructed and consistent with the pathological change of venous thrombosis during acute stage in human body.Conclusion The DVT model in rats was successfully established,which maybe helpful for dynamic study of the effect of antithrombotics or thrombolysis on thrombosis.
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275 cases of venous thrombosis were compared, and a conspicuous difference between clinical and phlebographic findings was discovered. The size alone of the thrombus has no relation to the symptoms it produces. 7 factors are presented to explain this lack of correlation: 1) Thrombosis in the rigid crural fascia causes more marked clinical symptoms than in other locations. 2) The larger the venous area to which the thrombus attaches itself, the more serious the symptoms. 3) In cases of deep venous thrombosis, if the superficial veins have dilated to aid collateral flow, venous congestion, an early indication of thrombosis, will be absent. 4) Ambulant patients have more pronounced symptoms than bed patients. 5) The faster a thrombus grows, the more marked are the symptoms of thrombosis. 6) Thrombosis can often be 1st diagnosed when the thrombus blocks the blood flow between the deep and the superficial veins. 7) Severe symptoms can arise if an earlier a symptomatic thrombus suddenly blocks the femoral canal.
Collateral circulation
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One hundred and thirty legs of 67 patients were examined 5-10 years after the patient had suffered a phlebographically proved deep-vein thrombosis. Forty-seven of the limbs were normal at the time of the phlebogram, 83 contained thrombus. There was little correlation between the phlebographic severity of the thrombus and the late symptoms and signs: 32% of the legs with no thrombosis had symptoms, while 33% of the legs which had suffered severe thrombosis had no symptoms. Postphlebitic symptoms were more common in legs with aging thrombus at the time of phlebography, but upper limit of the thrombus, the age of the patient, and preexisting symptoms did not affect the incidence of late sequelae. The development of a "postphlebitic leg" does not depend solely on the extent of the initial thrombosis and can apparently develop in the absence of thrombosis.
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