Transbrachial Caval Filter Removal: A Simple Alternative
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LETTER TO THE EDITOR
Transbrachial Caval Filter Removal: A Simple Alternative Wasim Hakim1,2 • Ali Alsafi2 • Richard Trent1 • Richard Dowling1 Alexander Rhodes1
•
Received: 17 May 2020 / Accepted: 6 July 2020 Ó Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2020
To the Editor, We report a simple method of retrieving inferior vena cava filters from a brachial approach, in two patients. The first, a 39-year-old male polytrauma victim who had pulmonary emboli, significant head injuries as well as fractures of the cervical spine and pelvis. Subsequent to a prolonged hospital admission, removal of his ALN caval filter (ALN implants chirurgicaux, Ghisonaccia, France) from the traditional jugular approach was made difficult by the need to maintain in situ cervical spine stabilisation. The second patient, a 71-year-old lady with a known leg deep vein thrombosis (DVT), was having a lobectomy for lung cancer. Removal of the Celect Platinum filter (Cook Medical, IN, USA) was hindered by the postoperative neck subcutaneous emphysema that obscured sonographic views of the jugular veins. Using ultrasound and fluoroscopy guidance, a 9F sheath (80 cm Flexor Introducer; Cook Medical, IN, USA) was inserted from the brachial vein to just above the level of the filter. (Fig. 1) Following venography, (Fig. 2) the filter hook was snared (Amplatz goose-neck snare 120 cm 9 25 mm; eV3/Covidien, MN, USA) and the struts were collapsed by advancing the sheath. (Fig. 3) The whole system was then withdrawn without complication.
& Wasim Hakim [email protected] 1
Department of Radiology, The Royal Melbourne Hospital, Grattan Street, Melbourne, VIC 3050, Australia
2
Imaging Department, Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
In both cases, IVC filter removal could have been delayed. However, poor follow-up is associated with low filter retrieval rates [1]. Furthermore, prolonged implantation carries a higher risk of retrieval failure as the device may tilt, embed, endothelialise and fracture [2]. This in turn may lead to a high rate of delayed device complications, such as iliocaval filter-related DVTs, migration, caval perforation and injury to adjacent structures (bowel, kidney, pancreas and aorta) [2], as well as the need for complex removal techniques [2, 3]. Some caval filters are licensed for brachial insertion, but not removal—for example, the ALN (ALN implants chirurgicaux, Ghisonaccia, France), Optease (Cordis/Cardinal Health, CA, USA) or Option Elite (Argon Medical Devices, TX, USA) filters. Most retrieval sets on the market utilise an 11F long sheath. We observe that most brachial, or indeed basilic, veins are larger than 4 mm in diameter and so would accommodate an 11F sheath [4]. However, upon consulting with company representatives, we learnt that a 9F sheath was unofficially the minimum diameter required. Also, crucially, a sheath longer than the 60 cm ones in the proprietar
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