Removal of Permanent IVC Filters: Techniques and Case Presentation

Inferior vena cava (IVC) filter placement is the treatment of choice in the prevention of pulmonary thromboembolism in patients with deep venous thrombosis and a contraindication to anticoagulation or anticoagulation therapy failure.[1] Decision to place a permanent or retrievable IVC filter depends on many factors, including the patient's presentation, indication for filter placement, age, medical history, and filter availability in the angiography suite.[2] Permanent IVC filters were designed to remain in the IVC after placement, while retrievable filters were designed to allow the option for removal once the filter is no longer considered necessary.[2] [3] A recent publication has reported that retrievable IVC filters have a higher risk of complications when compared to permanent filters.[3] The FDA has recommended the removal of retrievable filters when they are no longer required.[4] These findings and recommendations make permanent IVC filters a more viable choice for patients requiring long-term protection.

Permanent IVC filters include: Vena-Tech (B. Braun Interventional Systems Inc, Bethlehem, Pennsylvania; [Fig. 1]); Titanium and Stainless Steel Greenfield filters (Boston Scientific Inc, Mississippi; [Fig. 2]); TRAPEASE IVC filter (Cordis Inc, Bridgewater, New Jersey; [Fig. 3]); Simon Nitinol (BD Inc, Tempe, Arizona; [Fig. 4]); and Bird's Nest filter (Cook Medical Inc, Bloomington, Indiana; [Fig. 5]).[5] Permanent IVC filters still in use include the Vena-Tech, TRAPEASE, and Greenfield filters. Simon-Nitinol and Bird's Nest vena cava filters are no longer commercially available in the United States, but there are still some patients who carry these devices. The best imaging modalities to identify and evaluate an IVC filter according to our institution's protocol are the plain abdominal film and CT abdomen and pelvis. Additional preprocedural imaging techniques reported in the literature include lower extremity ultrasound and Doppler evaluation, CT venography, and spot radiographs at the time of retrieval procedure.[1] [5] [6] [7] Diagnostic and interventional radiologists need to be familiar with the imaging features of permanent IVC filters.

Fig. 1 Photograph of Vena-tech IVC filter. (Adapted with permission from 2019 B. Braun Interventional Systems, Inc. All rights reserved.)

Fig. 2 Photograph of Stainless Steel Greenfield Filter. (Adapted with permission from 2024 Boston Scientific, Inc. All rights reserved.)

Fig. 3 Fluoroscopy image of a retrievable Optease IVC filter. A TRAPEASE IVC filter has a similar appearance, except there is no retrieval hook (circle).

Fig. 4 Fluoroscopy image of a Simon-Nitinol Filter. The IVC filter is tilted with strut penetration.

Fig. 5 Photograph of Bird's Nest Filter. (Adapted with permission from 2017 Cook Medical, Inc. All rights reserved.)

There are several advanced techniques for the removal of a permanent IVC filter.[1] [8] [9] Permanent filters are engineered to remain at the IVC deployment site,[2] [3] [5] which may complicate the retrieval procedure. Removal of a permanent IVC filter requires advanced techniques, which by definition include the use of anything other than the simple snare retrieval technique.[1] [8] [9] Advanced techniques for IVC filter removal include the use of endobronchial forceps, sling technique, Tight Rail device, lasers, and filter repositioning techniques with balloons, catheters, and wires.[1] [8] Previous reports have confirmed that the use of advanced techniques for IVC filter removal is associated with a higher complication rate, increased fluoroscopy time, and radiation exposure compared to the standard snare technique. Removal of a retrievable IVC filter using standard techniques carries a 0.5% risk of complications. By comparison, advanced techniques can carry a 5.3% risk of complication.[1] [3] [9] [10] [11] IVC filter removal complications include hemorrhage, distortion or fracture of the filter, development of venous pseudoaneurysms, renal artery to IVC fistula, stenoses, and breach of the IVC wall integrity.[1] [8] [9] [10] [11] [12] Removal of permanent IVC filters can be controversial as the risks may outweigh the benefits.[13] Thus, careful patient selection is important when considering the removal of a permanent IVC filter, and proper procedure planning is important to improve patient outcomes.

Removal of a permanent IVC filter is not recommended if the patient is asymptomatic or if the filter is causing no complications.[13] [14] If removal of a permanent IVC filter is being considered, the best course of action is to be cautious, confirm that there is a clinical indication for removal, and discuss in detail the risks and benefits of the procedure with the patient and family members to avoid any miscommunication or misunderstandings.[15] All aspects must be considered when making this decision, including the patient's clinical presentation, age, medical history, and the current filter status and position. Accepted indications for permanent IVC filter removal include filter fracture and penetration through the IVC wall into adjacent structures such as the spine, duodenum, retroperitoneum, lumbar arteries, right renal artery, or aorta.[1] [6] [7] [8]

Imaging is imperative for procedure planning. Filter removal techniques can be selected based on imaging findings, and possible complications or procedural difficulties can be anticipated. A careful operator should be able to anticipate the material that will be necessary to perform a difficult filter removal based on evaluation of imaging before proceeding. Adequate preoperative imaging workup according to our institution's protocol includes an abdominal film series and a triple-phase CT scan of the abdomen and pelvis. The IVC filter should be thoroughly interrogated on preoperative imaging, including integrity, positioning, degree of tilt, presence of penetration through the IVC wall, or other complications ([Figs. 6],[7],[8]).[1] [6] [7] [8] If the abdominal film shows a filter fracture, a chest X-ray should be obtained to determine if filter fragments have migrated to the chest ([Fig. 9]). Identifying filter complications on preoperative imaging aids procedure planning, and any significant findings can be communicated with the patient and family before intervention.

Fig. 6 CT image of IVC filter prong penetration. Preoperative coronal contrast-enhanced CT demonstrated a filter prong penetrating the right renal artery (arrow).

Fig. 7 Abdominal radiograph of IVC filter fractures. Preoperative abdominal radiograph demonstrated multiple fractures and loose components in an Optease filter.

Fig. 8 Magnified abdominal radiograph of IVC filter fractures shown in Fig. 7.

Fig. 9 CT image of embolized IVC fractured fragment. Preprocedural axial contrast-enhanced CT image of the lower chest demonstrated a filter fragment embedded in the right heart (circle).

The purpose of this article is to present advanced IVC filter removal techniques and present a case demonstrating the removal of a Greenfield IVC filter. A brief description of advanced IVC filter removal techniques, including the snare technique, loop-snare technique, modified hangman technique, biopsy forceps technique, laser-assisted technique, and TightRail Rotating Dilator Sheath technique, is followed by the case presentation, including the clinical scenario, indication for removal, removal technique, and outcome.

Publikationsverlauf

Artikel online veröffentlicht:
16. September 2025

• References

• 1 Daye D, Walker TG. Novel and advanced techniques for complex IVC filter retrieval. Curr Treat Options Cardiovasc Med 2017; 19 (04) 28
• 2 Eifler AC, Lewandowski RJ, Gupta R. et al. Optional or permanent: clinical factors that optimize inferior vena cava filter utilization. J Vasc Interv Radiol 2013; 24 (01) 35-40
• 3 Andreoli JM, Lewandowski RJ, Vogelzang RL, Ryu RK. Comparison of complication rates associated with permanent and retrievable inferior vena cava filters: a review of the MAUDE database. J Vasc Interv Radiol 2014; 25 (08) 1181-1185
• 4 Endovascular Today website. FDA updates safety communication on IVC filter retrieval. Published online May 6, 2014. Accessed December 7, 2024 at: https://evtoday.com/news/fda-updates-safety-communication-on-ivc-filter-retrieval
• 5 Winokur RS, Bassik N, Madoff DC, Trost D. Radiologists' field guide to permanent inferior vena cava filters. AJR Am J Roentgenol 2019; 213 (04) 762-767
• 6 Grewal S, Lewandowski RJ, Ryu RKW, Desai KR. Inferior vena cava filter retrieval: patient selection, procedural planning, and postprocedural complications. AJR Am J Roentgenol 2020; 215 (04) 790-794
• 7 Dinglasan LAV, Oh JC, Schmitt JE, Trerotola SO, Shlansky-Goldberg RD, Stavropoulos SW. Complicated inferior vena cava filter retrievals: associated factors identified at preretrieval CT. Radiology 2013; 266 (01) 347-354
• 8 Kuyumcu G, Walker TG. Inferior vena cava filter retrievals, standard and novel techniques. Cardiovasc Diagn Ther 2016; 6 (06) 642-650
• 9 Quencer KB, Smith TA, Deipolyi A. et al. Procedural complications of inferior vena cava filter retrieval, an illustrated review. CVIR Endovasc 2020; 3 (01) 23
• 10 Ahmed O, Kim YJ, Patel MV. et al. A single-institutional comparative analysis of advanced versus standard snare removal of inferior vena cava filters. J Vasc Interv Radiol 2020; 31 (01) 53-60.e1
• 11 Al-Hakim R, Kee ST, Olinger K, Lee EW, Moriarty JM, McWilliams JP. Inferior vena cava filter retrieval: effectiveness and complications of routine and advanced techniques. J Vasc Interv Radiol 2014; 25 (06) 933-939 , quiz 940
• 12 Ferral H. Renal artery to inferior vena cava arteriovenous fistula after retrieval of an 8-year-old fractured Optease inferior vena cava filter. J Vasc Interv Radiol 2020; 31 (01) 179-182
• 13 Warner CJ, Richey EA, Tower DE. et al. Inferior vena cava filter retrieval provides no advantage in the average patient. J Vasc Surg Venous Lymphat Disord 2015; 3 (02) 142-146
• 14 Clements W. Inferior vena cava filters in the asymptomatic chronically occluded cava: to remove or not remove?. Cardiovasc Intervent Radiol 2019; 42 (02) 165-168
• 15 Ahmad Y, Funaki B, Jilani S, Ahmed O. Inferior vena cava filter litigation review: an analysis of medicolegal cases pertaining to inferior vena cava filters. J Vasc Interv Radiol 2022; 33 (11) 1295-1300.e6
• 16 Al-Hakim R, McWilliams JP, Derry W, Kee ST. The hangman technique: a modified loop snare technique for the retrieval of inferior vena cava filters with embedded hooks. J Vasc Interv Radiol 2015; 26 (01) 107-110
• 17 Nakashima M, Kobayashi H, Takenouchi Y, Nakayama T, Kobayashi M. Successful cases of difficult inferior vena cava filter retrieval with the use of biopsy forceps: biopsy forceps technique. SAGE Open Med Case Rep 2014; 2: 2050313-X14547610
• 18 Zhong A, Trerotola SO, Stavropoulos SW. Endobronchial Forceps Retrieval Of Embedded Inferior Vena Cava Filters: Retrieval Of 535 Filters At A Single Center. J Vasc Interv Radiol 2023; 34 (04) 529-533
• 19 Alhussaini A, Alahmad MA, Alomaim MM, Alzahrani MY, Alghamdi AS, Arabi M. Effectiveness and safety of laser-assisted removal of inferior vena cava (IVC) filters in a single tertiary care center. Cureus 2022; 14 (12) e32809
• 20 Kuo WT, Doshi AA, Ponting JM, Rosenberg JK, Liang T, Hofmann LV. Laser-assisted removal of embedded vena cava filters: a first-in-human escalation trial in 500 patients refractory to high-force retrieval. J Am Heart Assoc 2020; 9 (24) e017916
• 21 Charalel RA, Darcy MD. Retrieval of a long-standing inferior vena cava filter using the tightrail rotating dilator sheath. J Vasc Interv Radiol 2017; 28 (08) 1197-1199