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Introduction - Disclosures and Breakdown of Talk | Essentials of IVC Filters
Introduction - Disclosures and Breakdown of Talk | Essentials of IVC Filters
2017AVIRbloodchapterclotDVTessentialsfellowshipfilterfiltersfiltrationfull videogloballegslungsoncologypreventprogramradiationradiologyremovesymptomstalkthromboembolic
History of IVC Placement and Vena Caval Interruption | Essentials of IVC Filters
History of IVC Placement and Vena Caval Interruption | Essentials of IVC Filters
2017AVIRbloodchapterclipsclotclotscompletelyconicalcuttingembolismfilterfiltersflowfull videogreenfieldinterruptionlaparotomythrombosedthrombosistransvenous
Terminology and Various IVC Filters | Essentials of IVC Filters
Terminology and Various IVC Filters | Essentials of IVC Filters
2017AVIRcathetercavachapterconicalfilterfiltersfull videooptionalpermanentpracticingstenttemporaryvenous
IVC Filters Accepted and Controversial Indications | Essentials of IVC Filters
IVC Filters Accepted and Controversial Indications | Essentials of IVC Filters
2017acceptedanticoagulationAVIRbleedingbloodcenterschapterclotDVTembolismfilterfiltersfull videoindicationindicationspatientprophylactictherapeutic
PREPIC Study | Essentials of IVC Filters
PREPIC Study | Essentials of IVC Filters
2017AVIRbloodcenterschapterclotclotsDVTdvtsfilterfiltersfull videolegsmortalitypatientsrandomizestudysymptomatic
4 Studies of  Retrievable VCF in Trauma Patients | Essentials of IVC Filters
4 Studies of Retrievable VCF in Trauma Patients | Essentials of IVC Filters
2017AVIRbloodcenterschaptercontroversialfilterfull videopatientpatientsprophylactictrauma
Why Remove IVC Filters - Examples | Essentials of IVC Filters
Why Remove IVC Filters - Examples | Essentials of IVC Filters
2017AVIRchaptercomplicationsdeployedDVTextravascularfilterfiltersfull videoheartpatientpericardialtamponadeulcerationvein
Filter Penetration | Essentials of IVC Filters
Filter Penetration | Essentials of IVC Filters
2017arteriesasymptomaticAVIRchapterfilterfiltersfull videopatientstentingthrombosis
Need for Life Long Anticoagulation  | Essentials of IVC Filters
Need for Life Long Anticoagulation | Essentials of IVC Filters
2017anticoagulationAVIRbloodcenterscentricchaptercognizantcomplicationsfilterfiltersfull videogooglepatientpatientsrisk
When to Remove IVC Filters and Risk Benefit | Essentials of IVC Filters
When to Remove IVC Filters and Risk Benefit | Essentials of IVC Filters
2017analysisanticoagulationAVIRchapterextendersfilterfiltersfull videomediastinumpatientremove
Removal of Standard IVC Filters - Trapped Thrombus and Retrieval Technique | Essentials of IVC Filters
Removal of Standard IVC Filters - Trapped Thrombus and Retrieval Technique | Essentials of IVC Filters
2017anticoagulationAVIRchapterclotcomplexconeconicalfilterfiltersfull videoharderhookjugularoptionalpatientpermanentprocedureremoveremovedremovingretrievalscarsedationsheathsheathingsnaresorttulipvenogramwall
Removal of Challenging or Complex IVC Filters - Advanced Retrieval Techniques | Essentials of IVC Filters
Removal of Challenging or Complex IVC Filters - Advanced Retrieval Techniques | Essentials of IVC Filters
2017advancedapexAVIRballoonbarbscalledcatheterchaptercomplexcurvecurveddissectembeddedentirefibersfibrousfilterfiltersforcepsfrenchfull videoglidehookinsightjugularleveragepermanentpullremoveremovedscarsheetsheetssnaresnaringsortstepstechniquetechniquestexttiltedtissuewire
Thrombosed 2 Year Old Filter Laser Sheath | 65 | Male | Essentials of IVC Filters
Thrombosed 2 Year Old Filter Laser Sheath | 65 | Male | Essentials of IVC Filters
2017advancedangioplastyatherectomyAVIRcircumferentialcoaxialfiberfilterfilterslaserphotoretrievalsscarsheaththrombosedtissueuncommonvenous
Permanent IVC Filter Removals and Managing Complications | Essentials of IVC Filters
Permanent IVC Filter Removals and Managing Complications | Essentials of IVC Filters
2017anticasymptomaticAVIRchapterchasechronicallycliniccollapsedcomplexcomplicationcomplicationsembeddedfilterfiltersflowfull videolaserocclusionpatientpatientspermanentpseudoaneurysmpullingreferralsremovalremoveretrievalsimonstanfordstenttechniquethrombosis
Conclusion and Questions | Essentials of IVC Filters
Conclusion and Questions | Essentials of IVC Filters
2017AVIRcentricchaptercollaboratecollaborativefilterfiltersfull videonicheoptionalpatientremoveretrievalsspecialtiessurgeon
Transcript

so dr. marks lesney completed his medical training in Boston University and he completed his radiology residency and his fellowship at Duke University in Durham that's where I had the pleasure of meeting him for the first time and he is currently working with Charlotte

radiology and he serves as the assistant professor of radiology he told me he didn't have any official titles down there this would tell me otherwise the graduate fellowship program director and was the he was at Johns Hopkins

previously as well so so currently director of radiology and radiation oncology outreach program for the cancer treatment initiative and he also aims to practice radiation oncology and I are in China through education and global

collaboration so today dr. Leslie is going to talk to us about the essentials of IVC filters and I'd like to turn it over to dr. Leslie this is actually his first time speaking for a vir so please give him a warm welcome

thank you very much the pleasure just quick plug to all the sort of confusion about the radiation oncology so I part of a group called a rat aid used to work with their a great outreach program for global development for radiation

technology in the developing world if you ever want to volunteer and it look into it rad 8 it's a great organization today I will be speaking about the essentials of IVC filters over the next 45 minutes I'm going to give you a

whirlwind tour of IVC filters which I'm sure all of you've encountered quite a bit and I progress my slide using this little contraption is that true sweet no relevant disclosures the one thing I'll mention is I will not be discussing all

IVC filters that it's not because I'm prejudiced even though I am against some filters it's just most thing this interest of time and you'll hopefully determine my prejudice against them filters so what am I going to talk about

I'm going to talk about the history of IVC filtration I'm going to talk why we should place IVC filters in the first place why and when to remove IVC filters how to remove sort of a standard IVC filter and then we'll talk about how to

remove more challenging complex IVC filters which obviously I get a lot of help from my nice staff that I work with every day and then unfortunately we have talked about how to manage complications which sometimes arise from IVC filter

removals and IVC filter placements so why would cost about this at all well annuall suffer from bt which is veno thromboembolic disease Venus from about disease which

is either DVT blood call on the legs or blood clot going to the lungs and depending on your perspective and what you've seen IVC filters can either be a lifesaver that they prevent some massive life-threatening or life-ending PE or

they can be a complete disaster where they can cause from boces of the IVC and terrible symptoms terrible symptoms in the legs so the whole purpose of ibc filtration is basically to prevent a blood clot or minimize the risk of a

blood clot going from the legs to the lungs that is a whole point so over the

past 300 years this has been thought about in different ways early in the 17 they used to ligate just cut the femoral vein and that obviously would prevent

blood clots from the legs to the lungs except for the fact that the patient would have terrible leg swelling and sometimes blood clots would get there anyway then they moved to the IVC and they would actually cut the IVC to

prevent the highway from being present and allowing blood clot going to the lungs this of course resulted in significant morbidity obviously there was thrombosis recurrent embolism nonetheless there were a couple

different approaches for this and instead of just like gating it they said well what have we just interrupted either through a partial interruption or a complete interruption and there were different clips and sort of devices for

this this required a laparotomy so the patient was cut from stem to stern and access to cave obviously a very morbid procedure there was nearly Universal IVC thrombosis so all these patients are both driving see and all the deleterious

consequences that followed clips were then used again instead of cutting the cave itself just clipping it same thing and then finally in 1967 the mobis the moba newton umbrella came out and this was the first transvenous so did not

require a laparotomy cable interruption and basically with this little disc that's out in the IVC and it was a cyst so the hope was that have blood clots reach this it would stop but you still have blood flow travelling flow through

it well that didn't really work either that was also nearly completely IVC thrombosis but again we didn't at least have to cut the patient and so things were starting to get a little bit more sophisticated and then the here's an

example the moba newton and then of course here's an example dimova nude and completely thrombosed and then dr. Greenfield was really a game changer and in fact to this day people refer to as Greenfield filters even when we're not

placing Greenfield filters and it's because of dr. Greenfield and he said we'll hang on a second instead of just cutting off the IVC completely or putting in a sieve that basically cuts off completely he thought about the the

real lytic sort of the dynamics of the IVC and said well we can create this or a conical filter that even if there were blood clot in it it would still allow blood flow around the filter and that's exactly what

happened so a conical filter unit conical filter even if you thrombosed seventy percent of it the physics tells you that you can still flow around it and through it so that you only are at cutting about fifty percent of the ibc

off and this was a huge change we saw very few relatively speaking thrombosis and it actually did a good job since

that time we've further evolved into different IVC filters and we break them up into sort of three big categories

permanent filters temporary filters and optional River filters and almost all the ones we talk about nowadays are permanent and optional so when we talk about filters that we place everyday people sometimes call them temporary

those aren't temporary the only true temporary filter on the market right now is called an angel catheter which is basically a filter attached to a central venous catheter it's temporary it has to be removed you have to take it out

everything else is optional you have the option of removing it but you also have the option of keeping it in place forever and there's so-called convertible filters it's a filter that once you're done with it you go in and

actually converts into a stent and so there's no blockage of the cava so it is technically a permanent implant but the filtration is temporary or optional and I will remind you that all optional filters are fda-approved to stay in for

life and that is a very important discussion we have with our patients that these filters are approved to stain for life's and I will talk about there's reasons we don't want it to stay in for life so clearly for those of you been

practicing for a while there are many different types of filters they come in all shapes sizes some look strange especially the tennis racket in the left hand corner which is no longer on the market some are unit conical and the

unit conical basically looks like an umbrella the by conical looks like two umbrellas next to each other and that would be on the left hand side there I think I have a thing so we place all these IVC filters

question is why what's the day what are the data that allow us to place filters and fields are too good about ourselves well they're certainly guidelines and consensus statements at expert opinion but unfortunately in the IVC filter

world there's not a ton of hard data why we places and why we don't and so sort

of the accepted indications of why we play filters are two things and these are the two main ones the patient needs blood centers but can't get blood

thinners so a patient has these blood centers for whatever reason but they've got a head bleed or their platelets or 12 or whatever reason they can't get blood centers that is an accepted indication for RBC filtration or

anticoagulation failure they were on blood centers their clock progress despite blood flynner thinners so we need something else and that also is a little bit controversial now that said there are ton of less accepted

indications where one society says we this is appropriate other Society says it's not and that includes everything from a Widowmaker and what I mean by that is a patient with a massive pulmonary embolism they can get blood

thinners but we sort of need an extra level protection it is a belt buckle and suspenders sort of idea that even though they're on blood blood centers one more blood clot will kill them and so we've put in that filter for that extra

protection some patients have DVT with high risk of bleeding so they're not bleeding now but we're worried about it so we've come to filtered and so we break this up into therapeutic versus prophylactic indications privacy filters

and that's important so a prophylactic indication is the patient does not have a blood clot but we are concerned that they may get a blood clot and we can't give blood thinners and so we put in a filter or therapeutic indication the

patient has a blood clot now and they can't cut blood centers and so we put in the filter and as we'll talk about the prophylactic indications for IVC filters are a lot weaker than the therapeutic ones and actually fortunately we've seen

a decline in prophylactic filter placements because the data is just not there

so most of our data most about to lecture about this hang our hats on the pratik study the perfect study was a

very large 400 patients study it was randomized so it was a good quality study and they took patients with big blood clots in their legs and randomize them to either either receive a filter or no filter all right now the problem

is all of them got blood centers which is sort of not our practice right so all of them so already you can tell this study has limitations but it's what we have and what they found is within about two weeks there were a lot less Pease in

a patients with filters that sort of makes sense they had a filter in but then they went back in eight years and they said okay did the filters actually save lives and what they found was overall the filter group had left

symptomatic Pease but they had more symptomatic DVTs and so the thought was well did the filter cause or promote blood clots in the legs and importantly there was no difference in mortality so for those of us who say oh we put an IVC

filter make sure the patient doesn't die from a PE well it's hard for us to say that because there's no difference in mortality and there are some people said well not only that but filters seem to have more blood clots in the legs so in

fact are we doing patients harm by putting filters in because we're promoting DVT and then the counter-argument that is no we're trait those DVTs would have been Pease but the filter caught it thank God it's a

miracle so it depends on your perspective you look at a blood clot in the filter and you say the filter did its job or you look at a blood clot in the filter and you say stupid filter it caused the blood clot it's a it's open

to interpretation unfortunately the data is limited that's true also in trauma

patients which would be a prophylactic indication for IVC filter so trauma patients there in mobile they're going to be immobile for a while they have a

very bad pro-inflammatory state they're prone to blood clots but they don't have blood clot yet but we still put in a filter sometimes why well in some forced start lock pretty large studies what they showed was that the evidence to the

occurrence of PE is quite high right after a trauma but what we know is that that love decreases over time and obviously you can't get blood centers to a trauma patient and so that's controversial

whether we should have put a filter in a trauma patient and for how long and which trauma patients and when do we take it out and so we're looking at all these things as to when is it appropriate and when are we doing harm I

recently just wrote on this actually a sort of a point-counterpoint in chest on the benefits and risks of agassi filters and so the moral of this past three-minute conversation is its controversial there's no right answer

and I think the idea is to know your patient know the filter know the risk so you can have sort of an intelligent discussion with the patient so that's

all the way of background so let's talk about why we remove filters in the first

place well filters I do believe are appropriate for some patients and do a good job but they ain't risk-free so what do we know about filters filters can break filters can move filters can promote blood clots here's an example of

a paper that was written looking at the risk of filter complications and here's an example the filter in the heart there have been deaths where the leg of the filter breaks off perforates the heart patient size of a pericardial tamponade

here's an example the filter that was mal deployed it either ruptured through the vein and went into the no-man's land space extravascular space in the wretch pardon iam or they put it in the wrong vein sometimes they go Natalie Ain will

mirror the IVC and if you don't know what you're looking for you don't do a run or you're in a rush it's deployed there and obviously that can be problematic like we talked about DVT can occur with filters here's an example of

filters that completely caught it off and so this patient can have tremendous post floetic or post-traumatic syndrome with leg swelling and ulceration and and these patients can be quite miserable if they clawed off their entire IVC and

here's an example of a good old Greenfield filter in the heart which obviously no none of us want to see and for those of you who have sort of if any of you are home during the day and watch TV and see all the commercials for IVC

filters don't be fooled it is not one specific filter lots of filters have complications and in fact I tell patient kara what filter I put in obviously the filter I put in you I believe in it is not one hundred percent risk-free so

don't be fooled about that so even when

filters aren't causing symptomatic problems they can still have what's called asymptomatic complications specifically filters can penetrate the IVC and this isn't a one-off thing this

is very common I see this all the time and they penetrate depending on the filter type everywhere from just sort of a little tenting of the IVC to where they go through and through and actually perforate a solid organ next to it some

cases I have a lot of my patients that get erosion into their spine and the filter leg forms a bony reaction and you can actually see sclerosis around there most of it is asymptomatic but it's very as heck not only that patients know that

our patients we seek have filters that can penetrate into the arteries in fact we're presenting a abstract today right after this talk on the safety of removing filters that have penetrated arteries and so these can all be scary

albeit most of the time asymptomatic surprisingly so but patients are obviously concerned as as they should be here's an autopsy specimen of a Greenfield filter that perforated to Kaiba and is actually sticking out part

of the leg of stickin out of the IVC and then blood clots this is a this is one of my patients who just has massive thrombosis you can see that red arrow is showing a huge blood clot right under the filter again did this filter save

the patient's life or did this filter caused a huge IVC thrombosis I don't know so there are those out there who

say well because we know from the prep ecstatic see filters can promote blood clots should all these filters patients

who are have a filter in for a while be on anticoagulation well again the problem is most the time when we place a filter it's because the patient can't be on anticoagulation and so if we're putting the patient anticoagulation what

are we doing here why do we put the filter in the first place now clearly patients can get through an acute period and then be blood center candidates the problem is blood centers are not risk-free and so if you're on a blood

thinner only because you have a filter in I asked the question why don't we get the filter out and so these issues sort of end up being a case by case basis and being really sort of patient centric and what we know is an

actually guideline support this is that dancers know we don't play patients on blood centers just cut they have a filter in for all the reasons we mentioned that it's not risk-free and again mostly patients do fine although

there is an increased risk so really why do we remove filters I will tell you I think this is the number one reason globally we've started at least in the States we've started being more cognizant of it I think there are very

good medical reasons but this is sort of a medical legal reason in 2010 the SDA came out and issued a letter of communication and what they said was we noted that there have been increased complications with IVC filters optional

IVC filters and therefore we recommend that the physician implanting the filter be responsible for removal the filter once it is no longer indicated and back before 2010 a lot of it was sort of a place of filter and see you later and

good luck and now the motivation which i think is the right thing to do has been to okay now these are our patients we need to follow them up and this was actually reissued recently too and what's interesting is where I'm also

presenting we also have abstracted on the use of IVC filters after this communication and what's interesting is the use of ibc filters has decreased since 2010 and I think a lot of times it's because there's more awareness that

filters are not risk-free that there's complications and even the FDA is well aware of it so this has impact in real clinical situations and if you google IVC filter this is usually one of the first windows you'll get to be quite

honest and if you watch TV and I have tons of patients who come to my clinic and say I'm here because of you know the commercial all right let's talk about it and I'm very upfront and honest about what filters they have and what I

perceive is their risk and there are some filters that I say there's no question this is there's a risk everything but is a pretty good filter and there are some filters I say we need to get this folder idea so we asked why

remove five you see filters let's talk about when to remove IVC filters there is a complex algorithm that's been published there's been a lot of debate about this I'm a simple man this is complicated for me all right so here's

how I think about IVC filters what are you still at risk for PE ok that's what seems like a legitimate question for me do you have a life expectancy greater than six months I'm not going to make you undergo a procedure if your terminal

because the chances of you having a complication from your IVC filter in the last six months of your life is pretty low and so we want to keep you out of the hospital not do more things to you and can you be on anticoagulation and in

short i summarize all this by saying by thinking better like this if this patient came to me today would I put a filter in you if the answer is no by definition you have lost indication for IVC filtration and that is a big first

step and that's sort of how I used to teach my fellows and that's how i teach my visitation extenders and my technologists to sort of think about what i put a filter in this patient well of course not well guess what then they

don't need a filter and then the next question is is it worth it so just because you don't need a filter doesn't mean we should remove the filter and what I mean by that is everything's a risk-benefit analysis if I have a 95

year old patient with a two-month-old denali which is a very easy filter to remove I like to Denali I like some of the and I'm not on contract with anyone but I'd like said Denali I like to cook and they're easy filters move two months

old that's like a chip shot it's a 10-minute case but if you're 95 I'm probably leave that filter in on the other hand a trapeze filter is a very difficult filter in fact is a permanent filter it is not an optional filter to

remove it is very difficult it requires bigsheets laser extraction sometimes but if you're 35 we're going to do it and so everything's sort of a patient-centric risk-benefit analysis on when to remove a filter not only that the condition the

filter matters if i look at this filter it is completely horizontal the ends are completely embedded in both directions I have no access to this filter can i remove this filter yep it's going to be easy nope and so if the patient is doing

well trucking along has had this filter for 20 years I'm probably gonna leave it go if the patient's 40 and has this eight years I'm probably I'm take it out so everything sort of is on case-by-case

basis to some degree here's an example of a patient that we actually published on this is was a six year old filter what do you notice about this IVC filter it's not any IVC it's an SVC filter and this patient had an SVC filter place

which we do not I do not place and we recommend not placing but she was having chronic chest pain and the reason is these legs had perforated the IVC and was pokin her in the mediastinum this is a high-risk procedure and we had a long

discussion about the risk for you know rupture of the heart and serve pericardium's and but it was worth it and we got it out and she did fine so everything's sort of a risk-benefit analysis in a discussion with the

overview so let's talk specifics and these are specifics when we're in the room what are we doing why are we doing it what sort of tools will we need and that's obviously where you become

invaluable to us so how to remove nth filters in general well the first thing is pre-procedure we check to make sure the patient is on anticoagulation if they need to be so if I'm taking out a filter because they can get blood

thinners now I need to make sure they're on blood centers oh the O's counterpoint to that is if you have any of your docs that you work with are concerned about taking filters out with and coagulation I'll make the point that you don't have

to be studies have shown that actually you can remove filters especially standard filters that you know are fairly straightforward while the patient on Santa correlation in fact I will remove a filter up to an inr of three

now if the complex and I need laser I probably will titrate that a little bit but I don't cancel a patient just cut they show up with a nine hour of 25 during a filter retrieval and in fact for complex filter travels I

anticoagulation on the table for reasons we'll talk about other pre-procedure preparation well obviously if they're allergic to contrast you can mitigate that either with co2 or I this can be used or just give them a steroid prep

and that will that will help with that and then sedation is this going to be a challenging filter is this patient can be able to tolerate a fairly big sheep and so the idea of anesthesia versus sedation becomes

important so when filters first came out first optional filters came out they they didn't have a hook that we're all sort of used to now and so we had to use a cone and basically the cone was exactly as described here it's a cone

that went over the filter you should close it it sort of closed the filter and you removed it nowadays filters have hooks most of all of them at this point and so we use snares to grasp the hook and chief it often will use a coaxial

sheet for straightforward filters you grasp the filter you cheated you take it out now it's important to know what type of filter you use and important know what type of filter you remove because each filters remove differently for

example here is in optional filter quote unquote even though this acts as a permanent filter after about a month it has a hook but you can see that there are six ation barbs pointed in this direction so and the hope is on the

bottom so if you go in and try to retrieve this from a jugular approach you are going to be surprised that you can't do that quite easily it is a several approach retrieval and it's one of the few filters that require or that

offer a several approach retrieval and so you have to know what kind of filter you have and what some kind of filter you're removing so we start by access figure out femoral jugular we do a cablegram why don't we do a cablegram we

do a cablegram to assess clot that's really the main reason we also do it to see how to filter looks make sure sort of prognosticate if this is going to be a 10 minute case or our case but if there's clot in there that is a sign

that we probably need to stop and the question is how much is too much so we see it all the time where we look and we see throughout thrombus within the filter the question is we don't know how old it is we don't know how much is and

there have been some studies to help us quantify so you know if you have a filter that looks like this it has 10 cc's of Claude and I don't use that terribly of that frequently what I say is I do a gestalt and say if this is

more than twenty five percent of the filter cone we stop we stop and I bring the patient back here's an example of a patient where that's a lot of clot and the concern is if you take the filter out yes you may

get lucky and you may capture the clot and remove it but you may get really unlucky and you may take the filter out and it flies and we we've heard stories a patients who have died on the table either because they didn't look or they

took it out and and didn't catch the clot so it does denote venous thromboembolic disease again smallclothes can be removed safely if you see a clot greater than twenty-five percent consider sort of stopping the

procedure now that doesn't mean the patient has to live with a filter the rest of their lives often what I'll do is I'll stop the procedure and i will put the patient on anticoagulation and bring them back in six weeks and one of

three things happens in six weeks once the clot is totally gone or which is perfect keep on blood thinners take up filter to the clot is much smaller or the same and then you can pick compare your films and say oh well it clearly is

old by definition I was here six weeks ago and I see it was there before it's there now so it's not an acute Claude or three has gotten worse in which case you've got other things to talk about with that patient and things like drama

lysis or stenting might be more appropriate so once you do the venogram you've said okay everything is clean everything is clear let's proceed the first step is to snare and thus narrowing device as you know there's

many different kind of snares there's a gooseneck and plug whose necks there there's a cloverleaf snare and all those can be used advanced over the hook get an iced inch and this is an important point when we're hooking the filter this

is what we want this is what we want getting the snare around the apex or the neck of the filter is insufficient and the reason is if you think about sort of force and vectors as you're lifting the filter up unless you have it straight

like this in which case we'll go straight up as you raise it up it'll torque it'll tilt and then all of a sudden your sheath is actually hitting the side of the filter and that's not going to work unless you have a huge

sheathing and so you really want to work hard hard to snare the filter and sort of March off march out March up until you're at the very tippy tip top apex of the filter is shown here and then even

after you sneer you still have to know your filters so some filters are removed by pulling some filters are removed by sheathing some filters removed by she pulling and so you have to know so for example the select filter by cooking the

denali filtered by barred have these platinum markers or cranial anchors that sort of attached to the wall and so if you just pull them you're going to scrape the hell of the wall and so what you do is you sheath half of it or she's

all of it and then you detach that from the wall and then you can pull so here's an example of a recovery filter which does not have a hook and in this one you just collapse it and pull because there's no anchors and so the technique

to actually remove it varies by the filter itself this crux filter which is sort of the tennis racket looking filter it's actually no longer on the market it also has its own sort of unique way to remove here's an example the Meridian

filters or the denali or it iterations and so there's a lot of different filters out there and so it is incumbent on us to know what we're removing and how to remove it in the first place less we turn an easy procedure into a harder

procedure because we're doing the wrong thing here's more example sort of a tulip filter you can tell a tulip filter by these petals so the legs are actually connected on the bottom that's why it's called the tulips it's a beautiful

analogy and makes you feel like you're in the middle of spring and it's important to recognize because the tulip filter is a great filter but what happens is as you increase wall contact you increase fibrosis and sort of

scarring and what I mean by that is if you just have a eunuch conical filter that touches the cave a wallet just the leg points you know your cable will grow into it there but if you have these petals these legs that now are totally

contacted in cave us it's going to start growing into the legs and so tulips tend to be a slightly harder filter to remove after a certain amount of time just because they grow into it now that said they're great filters they do their job

there's a little harder remove so if you think about it what would be the hardest filter remove well I showed you a picture of these by comical filters so if you think about those by conical filters they have complete arms

that are attached to each other all of which have straight lines contacting the wall so the IVC grows into the entire filter and so that is a very challenging filter remove and that's why the op deze and trapeze which is the only by conical

filters we have op deze is an optional filter trapeze is a permanent filter after about a month they behave the same removing an opti filter after a year i might as well be removing a permanent filter because it's so scarred in and

these are things that we need to be cognizant of because otherwise you look and you say oh I've got a six month old filter retrieve all perfect this week wick and I've seen that time and time again with people say let's fix my knob

tease I'll just go in and two hours later it's unsuccessful and then they call me and I say well you set sinapis you're not getting that out without special sort of techniques and this is the op deze filter again you can look at

all that wall contact with the IBC which is which causes a lot of scar tissue and there's the crux alright so after we take it out traditionally we do another vina Graham even though that's controversial too there's an article out

of Penn questioning whether or not we need to do these repeat venogram I always do it is literally 10 cc's of contrast and point zero zero 1 seconds of floor oh I'm okay doing them just for my own peace of mind if it's a complex

retrieval there's no question I do them because I need to know if I there was a complication and so what complications are we looking for we're looking for a thrombosis which is actually the thing I'm most worried about we're looking for

tearing of the cava or injury to the Kaiba and we're looking for stenosis here's an example of a patient who took out the filter and you can see it's that cave it's pretty narrow because you get all this sort of scar tissue through

there so we talked about how to do

standard removal let's talk about how to do complex removals all right so check it on time so what makes a complex filter a complex filter well there's a hoping it could be the filter itself it

could be the position of the filter it could be the patient so here's an example the tilted filter so the filters completed tilted to the example I gave you below before you can have a embedded filter where the filter has actually

scarred into the Kaiba and you could have a permanent filter which was never meant to be removed and so the engineering of that filter is different if you think about it from an engineering standpoint if I told you you

had event invent a medical device that was going to be removed then by definition you are going to invent it and engineer it so that it is easily removed if you don't have those considerations for permanent filters

then they're absent and when you try to remove them all the advantages you have that users with an optional aren't there so for example the trapeze filter I showed you those Barb's that sort of keep it in place the trapeze filter is a

permanent filter and so it's got barbs on both sides and so if you try to pull it up the barbs are going to stop you but if you try to pull it down the lower barbs are going to stop you so it's not designed to be removed at all so we have

to sort of use special tricks to remove them so what's required to complex filters well I think you really need expertise this is not something you just sort of you want to do time you want to invest time not only in the procedure

itself make sure you have enough time to do it right but also in learning the different text techniques and you have to have interest because these can be some some tedious procedures and and once you do a couple you're going to be

the filter person so what are some advanced techniques I'll go through a few just to give you sort of a flavor for some things and it could be at something as simple as a curved catheter and so if you have a filter that's

tilted if you put a snare down it's going to go straight down the middle and it'll completely miss the K the filter hook so if you just put a curved mpa some sort of guide cap it actually moves the snare to the side of the wall and

then often you can snare it that's a more challenging case obviously pretty easy but that's sort of the next level of complexity other things you can do you can do what's called balloon a parallel balloon technique where you put

a balloon down inflate it and try to get that off the wall I would tell you those two techniques I very rarely use nowadays and now the reason is I sort of skip to the more they're a little bit more advanced but

I think they're faster and and the success rate is much easier specifically there's something called an insight to loop snare technique it's also called a sling technique and that's where instead of using a true snare you form your own

snare and you take a reverse curve catheter hook it under the filter and then you sneer a glide wire the free end and you externalise it through the jugular sheet and so basically of a wire going in the body around the filter and

then wire coming right back out so you have to that both ends of the wire stick out the jugular sheath and once you've done in that is you've formed a sling around the filter and that allows you to straighten it out and hopefully sheets

the filter alright here's an example of what it looks like in real life the hook or should be the wire underneath the filter apex and through a snare you can externalise it I tell you from a from a text standpoint I need my text help for

this and the move is key when I snare it we you have to advance wire from one end as you pull the snare down Oh or out and the reason is it's the guide wire so if I just if I snare my glide wire and I pull it it's going to slip right off so

it's sort of a move countermove so I'm watching my text hands as they move the filter or those mooks use me they move the wire in I am watching them and I'm moosh motioning with a snare at the same thought and you really want sort of that

free end because again if you're just pulling it's gonna slip out here's a diagram of it here's an example of where you can use it without a hook so here's a patient with a permanent Greenfield filter and instead of you know trying to

get around the hook you get around the entire filter and that can sort of give you sling leverage now sometimes you'll see the filter apex itself isn't embedded but only a tiny amount of filters embedded the problem is from a

snare standpoint it doesn't matter you will not get a snare around that because you that fiber and she that fibrous scar tissue is going to prevent a snare from ever getting behind the filter and so you can use the same sling technique or

in slightly limbs insight to Luke snare technique but instead of going under the filter apex you're actually going right between where this yellow arrow is between the filter and the wall that's called a hangman technique and I know

it's sort of people like well what's the difference it's actually a big difference instead of going underneath the entire filter you're really just going underneath the scar tissue and all things considered that is the best

technique and the reason is one it gives you the best leverage because you're literally you're almost mimicking snaring the apex of the tip snaring the filter the apex or two if you can't do it you can rip the fibers tissue and if

you rip the fibrous tissue now you've got a filter that's free and you can just snare like normal I will show you technically it's much more difficult to get in this little tiny yellow spot than it is to get under the entire apex at

hopkins leaves called at the crack of left knee which I assume was complimentary but it was a very sort of difficult small spot and the device that is really sort of revolutionized our practice over the past you know five

years it's been the end of bronchial forceps so forceps these four steps are not meant for intravascular use they are meant for and a bronco use some people use myocardial forceps some people use GI forceps but they're forceps meant for

some other part of the body but what we learned is these four steps it can actually be placed into the IVC safely and use to do one of three things either grab the filter directly to eat away at the fibers tissue so literally the term

is you're nibbling you're nibbling away the scar tissue to free it up or three you can sort of nudge the filter until you sort of our breaking up some of that scar tissue and this has allowed us to remove some crazy filters that we would

never have been able to in the past and you can really sort of grab it with these forceps there is a learning curve for these forceps there clearly is some higher risk for these four steps use but um but they clearly give us advantages

that we hadn't had before so the forceps go at least through a 12 French but always that I forceps I'm at least 16 French I placed it through I've actually think it's placed in 11 French before but you're it's a waste here so confined

so 16 French 45 centimeter sheep at least other advanced techniques so for example for the op deze or filtered there something called a Dueling sheaves technique where you to put in coaxial big sheets off and

I'll do an 18 French and a 14 inside just keep in mind you need for French size difference in the cooks line sheet which is what we use so you cannot put a 16 to an 18 which isn't true with the smaller sizes so in the smaller size is

you only need two French but once you get to the aortic size achieve of you need for French so it's a 14 13 18 and we'll do a Dueling sheets where we'll dissect out some of the soft tissue scarring with one sheet and then overlap

with the big sheet dissect out and it's sort of a back and forth to and fro motion to dissect with these sheets again off-label use some of the cardiologists have these devices that are she's that are serrated that they

use for a pacemaker or aicd lead extraction that can be used for filters the learning curve there is obviously you know that's not something you would just do that's been described as well these she's with sort of this rotating

blade over it so what happens when you

so here's a patient of mine he had a filter place for I think was about two or three years old as you can see from the right-sided column I was able to

shoot it I was able to pull it I was able to get about ninety percent of it and you can tell for my sheets I had a pretty big sheep I a coaxial big arse sheets in there and I'm a big guy with size 14 or 15 shoes and I my foot on the

table polling and it would not budge and I'm like this guy's key was going to come out before this filter comes out so what are your choices and to top it off by the way who's a marathon runner and this cave this filter actually had

thrombosed and he was symptomatic from it so again you weigh the risks and the benefits you say well we could stop and you say it is what it is you have a permanent filter or but depending on the patient you say okay let's do something

else and that's something else is a laser and again like four steps that sort of been advanced forward and filter retrievals laser has also been advanced for now a laser she's now for those of you who do laser atherectomy it's the

same device it's a spectranet but it's a different disposable so the laser fiber for laser atherectomy is the fiber this is a laser sheath so the sheath with circumferential laser energy around it and it's actually used for

lead extractions that's what it's designed for for pacemaker lead extractions but we used it very successfully in the IVC filter world and what it does is it photo ablaze the scar tissue around the filter and so you can

sort of use it as a sheet capture it and then very slowly activate and photo blade all that scar tissue all and these cases are very humbling because previously when we stood first started learning this you would spend two hours

getting a filter out and I'd say huh all right let's bring it back with laser and it was a three second case it was out now I tell you most laser cases are in three seconds there's some other complexities to it but a lot of time

lasers let you do things that other things that other devices and tools couldn't so we got the filter out angioplasty dad he did great and in fact three months later he was all fans of regulation completely he said he felt

just so much better he ended up running the Boston Marathon within three to six months after to filter out which he attributes to having the filter out and that's not uncommon I've had more than a handful of patients tell me I feel

better now the filters out now whether it's psychological psychosomatic or whether it's because you're actually increasing blood flow back to the heart increased venous return and they feel better it is not an uncommon thing to

say for patients who have had filters and chronically so we've talked about

optional filter removal I will mention permanent filter removals again this is not something that I think most centers do or should do but and it's not right

for the vast majority of patients I turned down but first select patients I think it is reasonable again you need expertise you need sort of specialized skills and emergency repair because these filters that are chronically

embedded can certainly cause complications and so we published on this and we've talked about this and so basically the move is you capture the filter from belleville and below there are no hooks because again these are

permanent filters not meant to be removed you can form insightly loop snare and you come in and you either dueling sheets oh or you take the laser out to sort of remove and photo blaze these tissue now

I mention those Barb's that are sticking in both ends so the nice thing that the laser is you either completely photo blade them off or you use a big enough sheath where you can collapse them knowing that you're collapsing

instructor that's not meant to be collapsed and afterwards obviously you have to deal with whatever consequences you have after the filter removal here's an example that trap you filter and you can see there's a lot of soft tissue

over it patients you know it is a very safe procedure and the complication rate is extraordinarily low if you know in right hands here's a filter didn't know what filter to shout it out Simon night now nice our little friend with a hat

Simon all night now filter same thing a permanent filter because I checked it out with forceps and used laser retraction extraction for the filter removal and you can remove in a Simon night now filter as well so how do we

manage complications from filters which is something we always need to be cognizant of everything we do the thing to keep in mind and this is a beautiful illustration by will Kuo who sort of pioneered laser filter retrieve a lot of

Stanford is he says don't forget and we often forget when you are sheathing a filter you're actually a chronically embedded filter you're actually collapsing the Kaiba and so what happens is the cave as you're pulling on it will

pull in and you can see you actually narrow it quite a bit and so the major complication i worry about during filter retrieval is not perforation or cables injury it's thrombosis that I take the filter out and I have a whole bunch of

clot because I basically collapsed the filter for so long so the two moves that are key for any complex filter is one I antic regulate the patient's if I know I'm going to be pulling for more than a couple seconds or minutes I antic

regulate patient slight edge coagulation no problem and the other thing is if I'm having trouble shooting I stop and let the cave Oh relax I'm not doing this for 25 10 minutes I'm pulling for a little bit stop relax let everything blood flow

go pull for a little bit stop and relax let the blood flow go and those I think our key moves here's an example out of the literature of cable thrombosis to be honest after will at Stanford got a lot of these experiences I think most of us

have been you have to learn from his experience and have not had cable from boces because we know how to avoid them as best weekend caval injury this is a patient that I actually just treated two

months ago she had an eight year old filter tulip filter that we were moved and afterward she had a pretty big IVC pseudoaneurysm it's the second suitor aneurysm I've ever seen after filter retrieval the first one we published and

wrote up these patients are often asymptomatic and in fact if they're a systematic you can leave him alone and what we found is they seal not only do they feel on their own they seal on their own quickly and this is a patient

that we wrote up and it's the patient where right after the left-hand side you can see that they have got hematoma right above their kidneys but they were stable and then we repeated the CT the next day and you can see the hematomas

better and they just have a little pseudoaneurysm there and they repeated the CT the next day and a pseudoaneurysm is gone and so as long as the patient is asymptomatic and stable you usually can leave these alone now that said we

always have occlusion balloons stent grafts sort of available in case badness ensues and the other question to ask yourself is when do I stop you can be in a filter retrieval six hours if you wanted to but at some point you're

probably not helping the patient and so the idea of when do I stop and come back or when do I stop and tell the patient you know what you have a permanent filter and that's okay I think are important questions and don't forget as

we're doing this you can make things worse really quickly the filter can be mangled and which case instead of having a filter that was permanent you have some object in the Kaiba that's obstructing flow and now you're sort of

obligated to do something else and so that's something you always want to sort of reevaluate every every step of the way am i doing something right should I stop the other thing to keep in mind is why are you there here's an example the

patient with a trapeze filter i saw items seen for filter removal I saw him because he had occlusion of his caiva and post-traumatic syndrome and so I tried to remove his his trapeze filter and it wasn't going and I said you know

what that's okay we can still treat him and so you just stent right through it and so the technique of stenting through filters is actually well established and data shows that patients do fine and so if I have a patient who

filter can't come out or I don't think it's worth it you stand right through them for symptom relief now I never sent her a filter just because but if they need to if you need to restore in line flow that is a fine technique to use and

it's a reasonable way to get around it so you still have options even if the filter can't be removed so and the the biggest point about preventing complications or obviously filters get your patients back sooner we know that a

six-month old filter is almost always easier to remove than a six year old filter and so there are lots of ways to do this the technique we've employed both at Hopkins and also now in Charlotte is we have a filter clinic

every patient we place a filter in gets an automatic appointment in three months to seem in clinic we seem in clinic we talk about their filter and there's three decisions one yeah you're done with your filters you don't need it

let's take it out too mm I'm not so sure I think you might still need your filter let's see you back in three months or three I think you need your filter forever or it's not worth taking it out in you let's leave it in so not only do

you get to track your patients but it also becomes the referral center so I get national referrals to my filter clinic because it's a complex filter clinic and so not only is it in the best interest a shin care but it also is a

good way to sort of elevate your skills and get national referrals and sort of local referrals for patients with complex filters so I say if you place it you got to chase it and you don't chase it watch the commercials during the day

and you'll figure out who will chase

acceptance guidelines for place and obviously filters is important to affect complications and mitigate the risks advanced techniques exist to remove

filters but risk benefit and really patient centric approach is critical to make sure we're doing the right thing for the patient and of course we probably can remove all types of filters we most certainly should not remove all

filters and that's it I appreciate your attention the invitations been a pleasure I'm happy to answer any questions you have [Applause] what do you place any permanent filter

yourself now I don't yeah I just know okay I don't although that is also controversial there's actually an algorithm that I think it with pen netting maybe develop determine when a patient's most appropriate for a

permanent filter when a patient with purgatory optional filter to be honest I'm very happy with the optional folders we have and I'm very happy with our follow up some okay not like the criminal we you speak to the

collaborative relationship you have a doctor since he's a surgeon at his facility which is very unusual idea so nationwide you know I think intervention radiology for less away for filters and filter retrievals and out to the other

specialties get involved at Charlotte I have a unique relationship with a trauma surgeon who not only place it filters the previous filters but he's been going for 20 years and he's published the lodge he's a pretty well respected

obviously a very niche part of us that's surgical practice and when I joined the practice obviously one of my concerns was this is my area of expertise and as my niche is there going to be some some turf battles and I think the moral of

story is you know he's collaborative on collaborative and the line that he that he says which i think is very epic oh is we either fight over a hundred patients or we collaborate to help a thousand patient and that is sort of always been

my motto ever my training all the way through Hopkins and now I think that's a legitimate point and so we sort of our partners on this and so he'll refer mutations and and will do them together if you know if there's assistance needed

so so yes don't think just because if you're in a hospital that your your irs don't do this it doesn't mean that it it can't be done in fact complex full retrieval the nice way to sort of approach the other specimens and say hey

we collaborate because I can do some of the stuff lettings important point any other questions thank you [Applause] [Music]

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