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A single center 9-year experience in IVC filter retrieval - the importance of an IVC filter registry

A single center 9-year experience in IVC filter retrieval - the importance of an IVC filter registry Background: To evaluate Inferior vena cava (IVC) filter retrieval practices over a 9-year period at an academic hospital with a prospectively maintained IVC filter registry. Method: An IVC filter registry was maintained prospectively within our institution. We reviewed cases between August 2011 and June 2020, following filter status, retrieval plans, and eventual retrieval date. The validity of the database was cross referenced with a Picture Archiving and Communication System and patient records. Results: Three hundred forty-three patients had IVC filters inserted. Three filter types were used, Celect (Cook Medical) in 189, Gunther Tulip (GT) (Cook Medical) in 65, ALN (ALN) in 89. 196 (57%) filters were retrieved, 108 (31.5%) were made permanent, 36 (10.5%) died before retrieval, and 3 (1%) were yet to be retrieved. Retrieval rates were 92.5% overall (86% for GT, 93% for Celect and 94.5% for ALN). The mean dwell time for successful retrieval was 59 days with the majority of insertions (85%) removed in under 100 days. Failed initial retrieval occurred in 23 patients, 10 (43%) were retrieved at second attempt, 13/23 filters remained in-situ and were deemed permanent. Conclusion: The removal of IVC filters, when indication for insertion has past, is no longer the sole responsibility of the referring physician but also the responsibility of the Interventionalist. Our retrieval rates of 92.5% of eligible IVC filters highlights the value of maintaining a prospective IVC filter registry. Introduction insertion of an inferior vena cava (IVC) filter as the most Venous thromboembolism (VTE) is a collective term for suitable option for the treatment of VTE. Greenfield deep vein thrombosis (DVT) and pulmonary embolism established the IVC filter in 1973 as means of preventing (PE); these are common conditions associated with sig- PE by intercepting potential emboli originating in or dis- nificant rates of patient morbidity and mortality. The tal to the IVC. The introduction of retrievable filters in overall VTE estimated average annual incidence rate 2003 expanded the utility of IVC filters in patients with among persons of European ancestry ranges from 104 to transient indications and has coincided with increased 183 per 100,000 person-years.[1]. IVC filter insertion.[2]. The standard care given for VTE is oral anticoagula- IVC filters which are not retrieved can pose a risk to pa- tion therapy, however in a subset of cases oral anticoa- tients because of their association with complications such gulation fails to prevent VTE or anticoagulation is as vena cava wall perforation, thrombosis or stenosis, as contraindicated; at this point clinicians may find the well as filter fracture or migration.[3–7] In light of the po- tential risk non-retrieved filters pose against the general * Correspondence: marksheehan@rcsi.ie population; the U.S. Food and Drug Administration Royal College of Surgeons in Ireland, Dublin, Ireland (FDA) released a safety notice in 2010, which alerted Department of Radiology, Beaumont Hospital, Dublin, Ireland © The Author(s). 2022 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Sheehan et al. CVIR Endovascular (2022) 5:15 Page 2 of 6 Interventionalists implanting these medical devices as to on insertion and (3) the ‘unspecified’ group - the deci- their shared responsibility with physicians in following up sion whether the filter was permanent or to be retrieved with each individual patient to retrieve these devices as was not possible to make at the time of insertion. The soon as deemed clinically appropriate.[8] This prompted status of the filter was reviewed regularly with the refer- the establishment of an IVC registry in our institute, to ring physician. A final filter status for the ‘unspecified’ prospectively record and track retrievable IVC filters that was made within 3 months and recorded when a final were inserted. decision was made after consultation with the referring The FDA released a subsequent notice in May of 2014 physician. with a mathematical model which suggested that once All patients who had an IVC filter inserted at our in- PE risk has resolved, the risk/benefit profile starts to stitution were recorded in the registry and thus were eli- favour the removal of the IVC filter within 29 to 54 days gible for inclusion. A small number of patients had IVC of insertion.[9] Angel et al. produced a systematic review filters retrieved at our institution but their filters were in 2011, including 37 studies and over 6800 patients, on inserted elsewhere and thus were excluded as there was IVC filter practices and quoted a mean retrieval rate of insufficient data available. 34%, and mean dwell times of 72 days.[6] More recently IVC filter retrieval rates were calculated as follows: total CIRSE (Cardiovascular and Interventional Radiology retrieved filters/ (total filters inserted – ineligible for re- Society of Europe) and BSIR (British Society of Interven- trieval) x 100 (Fig. 1). Ineligibility for retrieval occurred if tional Radiology) have shown improved filter rates when a filter was decided to be left permanently (excluding a they set up online registries for institutes with retrieval failed attempted retrieval - who were deemed eligible) and rates quoted of up to 92%.[10, 11] However, there is evi- those cases who died prior to retrieval attempt were also dence to support that with dedicated follow-up retrieval considered ineligible. Patients with a filter yet to be re- rates approach 60%.[4]. trieved i.e. loss to follow up, were considered eligible and The aim of this study is to review our retrieval prac- are included in the retrieval rate calculation. This method tices over a 9-year period to determine the retrieval rates of calculation has been documented in previous for IVC filters using a prospectively managed IVC filer studies.[4]. database with secondary outcome measures including dwell times, insertion indications, and reasons of per- Results manent filter insertions. There were 343 patients entered into the database (174 male and 169 female) over the 9-year period. The mean Methods age for men was 59.8 years (range 19–87) and for An IVC filter registry was prospectively collated within women was 58.8 years (range 18–88). All IVC filter in- our institution. The responsibility of database mainten- sertions were performed in our institution, 7 filters were ance is shared between a nominated Interventional Radi- retrieved in an external institute, the remaining filters ology (IR) fellow and departmental IR administration were retrieved in our hospital. staff. Details of the database were stored on an Microsoft The IVC filter types inserted were the Celect filter Excel Spreadsheet. (Cook Medical, Bloomington, Indiana) in 189, the Gun- We reviewed the database from inception in August ther Tulip (GT) (Cook Medical, Bloomington, Indiana) 2011 until June 2020. We assessed the registry against a in 65, ALN (ALN, Ghisonaccia, France) in 89. Picture Archiving and Communication System and elec- The access routes for insertion approach were the tronic patient records to ensure data entry was accurate. right internal jugular vein in 278 cases (81%), right com- Data entry consisted of IVC filter status, dwell time, re- mon femoral vein in 58 cases (17%) and the left com- trieval date, retrieval complications, insertion indications, mon femoral vein in 7 cases (2%). A diagnosis of access route used, malignancy diagnosis, indications for malignancy at the time of filter insertion was reported in permanent filters, failed attempts and extra manoeuvres 115/343 (33.5%) patients. 30 of these 115 patients (26%) performed for retrieval. had a permanent IVC filter inserted de novo. Limited life Before filter insertion, patients were streamed into 3 expectancy independently or combined (Table 1) consti- different patient groups; (1) those filters placed with an tuted 53 (49%) permanent filters with 9/53 (17%) also ‘intent to retrieve’, (2) filters deemed to be ‘permanent’ having a malignancy status. Fig. 1 Sheehan et al. CVIR Endovascular (2022) 5:15 Page 3 of 6 Table 1 Indications for Permanent Filters (n = 108) Of the 48 patients in the ‘unspecified plan’ group a later decision with regard to the filter being retrieved Indications for Permanent Filters Number of Cases or deemed permanent was made within 3 months of Limited Life Expectancy 30 (27.7%) filter insertion after discussion of the clinical condi- tion of the patient with the referring physician. Of Long-term CI (Contraindication) to AC 28 (25.9%) (Anti-Coagulation) these 48 patients, filters were assigned permanent sta- Failed Retrieval 13 (12%) tus in 35 due to deteriorating clinical illness and poor life expectancy and 13 wereassigned to theintentto VTE (Venous Thromboembolisim) on 10 (9.3%) therapeutic AC retrieve group. Of the latter 13 patients, 6 filters were retrieved ,6 died before IVC retrieval and 1 was lost Patient Preference 4 (3.8%) to follow up. Multiple 23 (21.3%) - Limited Life Expectancy + Long-term CI to AC 13 (12.6%) In the ‘intent to retrieve’ group, 190 (81.2%) of 234 fil- - Limited Life Expectancy + VTE on AC 10 (9.7%) ters were retrieved either on first or second attempt. 30 Overall total 108 (12.8%) patients of the 234 died prior to retrieval, 12 (5.1%) were made permanent and 2 (0.9%) were lost to follow up. Indications for insertion of IVC filters were separated As stated, 61 filters were deemed permanent from the into 6 categories: contraindication to anticoagulation in time of insertion, all 61 remained in situ. On final re- setting of VTE in 147 (43%), pre-operative prophylaxis view, filters were assigned the status of permanent in (Patients with a previous history of VTE undergoing 108 (31.5%), (42 Gunther Tulip, 44 Celect, and 22 ALN). major surgery) in 117 (34%), pharmaco-mechanical The clinical circumstances under which the determin- thrombectomy in 47 patients for iliofemoral DVT (14%), ation for the filter to remain permanently is shown in VTE on therapeutic anticoagulation in 20 (6%), extensive Table 1. This means that a permanent status was applied VTE in 5 (1%) and multiple indications in 7 (2%), as to a filter in 47 patients, who before insertion were shown in (Table 2). streamed initially into the ‘intent to retrieve’ group or Of the 343 filters inserted, 196 (57.1%) filters were re- ‘unspecified plan’ group. trieved, 108 (31.5%) filters were deemed permanent, 36 Unsuccessful retrieval at the first attempt occurred in (10.5%) patients died during follow-up, and 3 (0.9%) pa- 23 patients. Table 5 shows the causes for failed retrievals tients were yet to be retrieved or lost to follow up. The on the first attempt. 13 (57%) patients who had an un- overall retrieval rate was 92.5% (Fig. 2), with a retrieval successful retrieval on the first attempt went on to be- rate of 86% for GT, 93% for Celect and 94.5% for ALN come permanent after discussion with the patient and (Table 3). referring teams (these cases were then considered a The mean dwell time for successful retrieval was 59 ‘failed retrieval’) and 10 (43%) were successfully retrieved days (median 42, range 2-390 days) with the majority of on the second attempt. Advanced manoeuvres were used insertions (85%) removed in under 100 days (Table 4). in 19 cases overall with 13 (68%) resulting in successful Before insertion, 61 patients were streamed into the retrieval. 9 (39%) of the 23 initial failed attempts had ad- ‘permanent filter’ group, 48 were streamed into the ‘un- vance manoeuvres performed. In filters with thrombus specified plan’ group and the remaining 234 were at the time of retrieval, the patients remained on antic- streamed into the ‘intent to retrieve’ group. oagulation and a further date for retrieval planned in 2– 3 weeks time. Retrieval on second attempt was success- Table 2 Indications for Filter Insertion (n = 343) ful in 50% (5/10) of these cases. Indications for Filter Insertion Number of Cases (%) The vast majority of retrievals was performed using CI (Contraindication) to AC (Anti-Coagulation) 147 (42.7%) local anaesthetic only, typically 10mls of 1% lidocaine. In Pre-operative prophylaxis 117 (34.1%) some cases, light conscious sedation was used, a com- bination of Fentanyl and Midazolam were administered. Pharmaco-mechanical thrombectomy (PMT) 47 (13.7%) Retrievals performed under general anaesthetic usually VTE (Venous Thromboembolisim) on AC 20 (5.8%) occurred when the patient was already intubated in an Extensive VTE 5 (1.7%) intensive care setting. The ALN extraction device (ALN, Multiple 7 (2.0%) Ghisonaccia, France) was the preferred method of re- - CI to AC + extensive VTE 2 (0.6%) trieval, although a range of snare devices were also used - CI to AC + PMT. 2 (0.6%) - Pre-operative + VTE on AC 1 (0.3%) routinely depending on operators preference. - PMT + extensive VTE 1 (0.3%) The most commonly employed advanced manoeuvre - pre-operative + CI to AC 1 (0.3%) was the loop snare technique, this involves engaging a Overall total 343 reverse curve catheter in the struts of the filter and Sheehan et al. CVIR Endovascular (2022) 5:15 Page 4 of 6 Fig. 2 inserting a hydrophilic wire cranially. The wire is then importance of having a retrieval date in place as soon as snared and externalized, thus used as a counter force as the IVC filter has been inserted. Sutphin et al. compared the co-axial sheath is passed over the collapsed IVC fil- three patient cohorts, firstly a baseline group with a re- ter. Another advanced manoeuvre performed in two trieval rate of 8%, secondly a “letters” cohort with a re- cases involved passing a wire between the endothelia- trieval rate of 40% (the referring physician is contacted lized hook and wall of the IVC. A balloon venoplasty by letter) and finally a third “Prospective” cohort with a was performed in an attempt to separate the hook from retrieval rate of 52% (these patients were scheduled for a the IVC wall and thus allow for the hook to be snared. clinic appointment at the time of the IVC insertion).[4] A semi rigid forceps with a larger 16 French sheath was Similarly Minocha et al. demonstrated an increase of used successfully in 3 patients when some of the above 29–60% after an IVC clinic and prospective database retrieval methods failed. were implemented.[12]. There is no definitive nomenclature documented in Discussion the literature for the calculation of the retrieval rate and It is the shared responsibility of the referring physician care needs to be taken when comparing retrieval rates. and the interventional radiologist to ensure that IVC fil- We have reported a retrieval rate of 92.5%, which means ters are removed at the earliest juncture once the indica- we removed 92.5% of the IVC filters that were eligible tion for placement has resolved. While the use of IVC for retrieval, the formula of which can be seen in Fig. 1. filters reduces the risk of VTE in the short-term it in- This formula for calculation was also used by Sutphin creases the risk of DVT in the long term [4, 9]. et al.[4] Minocha et al. reported a retrieval rate of 29% The use of IVC filter databases or registries have be- in pre-clinic years to 60% in post-clinic years for op- come common place within the IR community [10, 11] tional/temporary filters, however it does not include the since recommendations from the FDA was published in 33 patients who had filters made “permanent” after in- 2010 advising the removal of retrievable IVC filters as sertion and therefore would have a retrieval rate of 91% soon as possible.[8] Different methods of improving re- using our calculations.[12] In 2015 CIRSE produced an trieval rates have been investigated, examples include online registry for multiple international centers and prospective registries, letters to referring physicians, published a similar retrieval rate of 92% for eligible re- scheduling IVC retrieval dates at the time of insertion trievable filters.[10] Similar high retrieval rates have been and even IVC filter clinics. In our institute it was the re- reported by De Gregorio et al. (SERVEI- REFiVeC regis- sponsibility of the IR who inserted the filter to document try) removing 76.9% of all retrievable IVC filters but in the registry the planned retrieval date and schedule when augmented for deaths or change of status to per- the patient for same. Non-specified retrieval plans were manent the adjusted retrieval rate is of 94.15%.[13]De documented in 14% (n = 48) of the total cases, in the Gregorio et al. highlights well the heterogenous nature cases lost to follow up 33% (n = 1/3) had a non-specific of comparing rates between papers due to different retrieval plan documented. This in itself highlights the study designs. Table 3 Retrieval Rate by Filter Type (n = 343) Filter Type Filter Status Total Retrieval Retrieved Permanent In situ Deceased Failed * Successful retrieval Gunther Tulip 18 42 0 5 65 3 86% Celect 126 44 2 17 189 8 93% ALN 52 22 1 14 89 2 94.5% Overall total 196 108 3 36 343 13 92.5% * Failed category totals are a subset of the permanent category totals Sheehan et al. CVIR Endovascular (2022) 5:15 Page 5 of 6 Table 4 Mean dwell time by Filter Type (n = 209) Filter Type Successful cases Failed Cases Length of Time until retrieval Quantity Mean No. of days until retrieval Quantity Mean No. of days until attempted retrieval Max days Min days Gunther Tulip 18 50 3 63 144 15 Celect 126 58 8 73 336 2 ALN 52 67 2 81 390 4 Total 196 59 13 72 However these high retrieval rates are not seen across as the national neurosurgical center many of our pa- the board, Sarostek et al. reported a retrieval rate of tients unfortunately have a limited life expectancy. This 8.5% on 679 retrievable IVC filters in a large single cen- reason dominates the reason for permanent insertion ter institute.[14] As discussed with the introduction of (49%). Being a neurosurgical center also results in a high IVC clinics, letters to physicians and registries has number of trauma or neurooncological patients requir- greatly improved these figures. [4, 10–12] ing prophylactic IVC filter insertion prior to major intra- 108 filters were made permanent, 13 of these were due cranial procedures in the setting of a current or previous to failed retrieval (these were included in the calculation VTE (34.1%). Permanent filters lead to complications as failed retrievals) In 7 of these 13 failed retrievals, no such as filter migration or fracture, penetration outside advanced manoeuvres were attempted. The mean dwell of the vena cava wall and IVC stenosis or occlusion.[5] time for these failed retrievals were 63 days for GT fil- Further by improving retrieval practices and reviewing ters, 73 for Celect and 81 for ALN filters. At greater the indications for the conversion of retrievable filters to dwell times advanced maneuvers become essential to en- permanent, the institution can save on costs. Janne sure high successful retrieval rates are maintained. This d’Othee et al. created a cost analysis model which dem- is supported by Kuo et al. which reported 100% success- onstrated that retrievable versus permanent filter place- ful retrieval in a series of 50 patients where advanced ment is financially beneficial even if only 41% of filters manoeuvres were performed after standard methods had are removed.[17]. previously failed.[15] In a review of advanced techniques, Limitations of this study include, the reliance on the IR Desai et al. illustrated that after 7 months of filter being fellow and IR administration staff to prospectively and in situ, the chances of the standard retrieval methods correctly collate data in a timely manner. As fellows failing is high, with a calculated risk of 40.9% which con- change every year, this is likely not optimal as there is loss tinues to rise with increasing dwell time.[16] This evi- of continuity. We think that the ideal person to monitor dence underscores the importance of both attempting the database would be an IR practice nurse or physician advanced maneuvers when standard methods fail, as well associate but unfortunately these were not available to us. as the necessity of reducing mean dwell time which can We transitioned from the Celect filter to the ALN dur- be done with regular follow up. ing the course of the study because of issues with filter Although technically all IVC filters we insert are re- leg penetration seen with the Celect filter.[18] trievable, 108 of the filters we inserted were made per- The prospective database also highlights the difficulty in manent (Table 1). When comparing to other studies this assigning a status in terms of ‘intent to retrieve’, ‘perman- may seem high, for example Gregorio et al. reported ent status’ or ‘unspecified’ to patients at the time of filter 11.5% of IVC filters inserted were permanent; however, insertion. 47 patients who initially were in the unspecified group or intent to retrieve group were later converted to Table 5 Reasons for failed initial retrieval (n = 23) the ‘permanent’ group. This indicates that the database re- Reason for failed initial retrieval Number of Cases quires attention on a frequent basis and communication to referring physicians and patients must be ongoing. Thrombus in filter 10 (43.5%) Endothelialized 5 (21.7%) Conclusions Re-inserted above filling defect 2 (8.7%) The removal of IVC filters, when indication for insertion Filter tilted/ Unable to snare 1 (4.4%) has past, is no longer the sole responsibility of the refer- Access route thrombosed 1 (4.4%) ring physician but also the responsibility of the Interven- Multiple 4 (17.4%) tionalist. Our retrieval rates of 92.5% of eligible IVC - Endothelialized and thrombus in filter 3 (13.0%) filters highlights the value of maintaining a prospective - Endothelialized and unable to snare 1 (4.4%) IVC filter registry with regular communication to refer- Overall total 23 ring physicians and patients. Sheehan et al. CVIR Endovascular (2022) 5:15 Page 6 of 6 Abbreviations 9. FDA. Removing retrievable inferior vena cava filters: FDA safety IVC: Inferior Vena Cava; GT: Gunther Tulip; VTE: Venous thromboembolism; communication (2014) Available at: http://www.fda.gov/MedicalDevices/Sa DVT: Deep vein thrombosis; PE: Pulmonary embolism; FDA: Food and Drug fety/AlertsandNotices/ucm396377.htm Administration; CIRSE: Cardiovascular and Interventional Radiology Society of 10. Lee MJ, Valenti D, de Gregorio MA, Minocha J, Rimon U, Pellerin O (2015) Europe; BSIR: British Society of Interventional Radiology; IR: Interventional The CIRSE retrievable IVC filter registry: retrieval success rates in practice. Radiology Cardiovasc Intervent Radiol 2015; 38:1502–1507 11. Uberoi R, Tapping C, Chalmers N, Allgar V (2013) British Society of Interventional Radiology (BSIR) Inferior Vena Cava (IVC) Filter Registry. Acknowledgements Cardiovasc Intervent Radiol 2013; 36:1548–1561 No further acknowledgements. 12. Minocha J, Idakoji I, Riaz A, Karp J, Gupta R, Chrisman HB et al (2010) Improving inferior vena cava filter retrieval rates: impact of a dedicated Authors’ contributions inferior vena cava filter clinic. Journal of vascular and interventional MS – Primary author of manuscript and Data collection. K C - Data radiology: JVIR. 2010;21(12):1847-51 collection and Data Analyses. C O’ B - Data collection. A M – Primary 13. De Gregorio MA, Guirola JA, Urbano J et al (2020) Spanish multicenter real - operator of procedures, Data Collection. M G – Primary operator of life registry of retrievable vena cava filters (REFiVeC). CVIR Endovasc. 2020; procedures, Data Collection. A K – Primary Operator of procedures, Data 3(1):26. doi:https://doi.org/10.1186/s42155-020-00114-5 Collection. M L- Primary Operator of procedures, Senior Author and Editor of 14. Sarosiek S, Crowther M, Sloan JM (2013) Indications, complications, and paper. The author(s) read and approved the final manuscript. management of inferior vena cava filters: the experience in 952 patients at an academic hospital with a level I trauma center. JAMA Intern Med. 2013 Funding Apr 8;173(7):513-7. doi: https://doi.org/10.1001/jamainternmed.2013.343 This paper was not supported by any funding. 15. Kuo WT, Robertson SW, Odegaard JI, Hofmann LV (2013) Complex retrieval of fractured, embedded, and penetrating inferior vena cava filters: a Availability of data and materials prospective study with histologic and electron microscopic analysis. Journal The datasets generated and/or analysed during the current study are not of vascular and interventional radiology: JVIR. 2013;24(5):622 – 30.e1 publicly available due patient confidentiality but are available from the 16. Desai KR, Pandhi MB, Seedial SM, Errea MF, Salem R, Ryu RK et al (2017) corresponding author on reasonable request. Retrievable IVC Filters: Comprehensive Review of Device-related Complications and Advanced Retrieval Techniques. Radiographics: a review Declarations publication of the Radiological Society of North America, Inc. 2017;37(4): 1236-45 Ethics approval and consent to participate 17. Janne d’Othée B, Faintuch S, Reedy AW, Nickerson CF, Rosen MP (2008) Compliance with Ethical Standards. All procedures performed in studies Retrievable versus permanent caval filter procedures: when are they cost- involving human participants were in accordance with the ethical standards effective for interventional radiology? Journal of vascular and interventional of the institutional and/or national research committee and with the 1964 radiology: JVIR. 2008;19(3):384 – 92 Helsinki declaration and its later amendments or comparable ethical 18. Zhou D, Moon E, Bullen J, Sands M, Levitin A, Wang W (2014) Penetration of standards. Celect inferior vena cava filters: retrospective review of CT scans in 265 patients. AJR Am J Roentgenol. 2014 Mar;202(3):643-7 Consent for publication For this type of study formal consent is not required. For this type of study Publisher’sNote consent for publication is not required. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Competing interests The authors declare they have no conflict of interest. Received: 28 December 2021 Accepted: 24 February 2022 References 1. Heit JA, Spencer FA, White RH (2016) The epidemiology of venous thromboembolism. Journal of thrombosis and thrombolysis. 2016;41(1):3–14 2. Jaberi A, Tao MJ, Eisenberg N, Tan K, Roche-Nagle G (2020) IVC filter removal after extended implantation periods. The surgeon: journal of the Royal Colleges of Surgeons of Edinburgh and Ireland. 2020;18(5):265-8 3. Tse G, Cleveland T, Goode S (2017) Ten-year experience of retrievable inferior vena cava filters in a tertiary referral center. Diagnostic and interventional radiology (Ankara, Turkey). 2017;23(2):144-9 4. Sutphin PD, Reis SP, McKune A, Ravanzo M, Kalva SP, Pillai AK (2015) Improving inferior vena cava filter retrieval rates with the define, measure, analyze, improve, control methodology. Journal of vascular and interventional radiology: JVIR. 2015;26(4):491-8.e1 5. REPIC Study Group (2005) Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d’Embolie Pulmonaire par Interruption Cave) randomized study. Circulation. 2005 19;112(3):416 – 22. doi: https://doi.org/1 0.1161/CIRCULATIONAHA.104.512834 6. Angel LF, Tapson V, Galgon RE, Restrepo MI, Kaufman J (2011) Systematic review of the use of retrievable inferior vena cava filters. J Vasc Interv Radiol. 2011 Nov;22(11):1522–1530.e3. doi: https://doi.org/10.1016/j.jvir.2011.08.024 7. Charles HW, Black M, Kovacs S et al (2009) G2 inferior vena cava filter: retrievability and safety. J Vasc Interv Radiol 2009; 20:1046 – 1051 8. FDA (2010) Removing retrievable inferior vena cava filters: initial communication. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png CVIR Endovascular Springer Journals

A single center 9-year experience in IVC filter retrieval - the importance of an IVC filter registry

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Abstract

Background: To evaluate Inferior vena cava (IVC) filter retrieval practices over a 9-year period at an academic hospital with a prospectively maintained IVC filter registry. Method: An IVC filter registry was maintained prospectively within our institution. We reviewed cases between August 2011 and June 2020, following filter status, retrieval plans, and eventual retrieval date. The validity of the database was cross referenced with a Picture Archiving and Communication System and patient records. Results: Three hundred forty-three patients had IVC filters inserted. Three filter types were used, Celect (Cook Medical) in 189, Gunther Tulip (GT) (Cook Medical) in 65, ALN (ALN) in 89. 196 (57%) filters were retrieved, 108 (31.5%) were made permanent, 36 (10.5%) died before retrieval, and 3 (1%) were yet to be retrieved. Retrieval rates were 92.5% overall (86% for GT, 93% for Celect and 94.5% for ALN). The mean dwell time for successful retrieval was 59 days with the majority of insertions (85%) removed in under 100 days. Failed initial retrieval occurred in 23 patients, 10 (43%) were retrieved at second attempt, 13/23 filters remained in-situ and were deemed permanent. Conclusion: The removal of IVC filters, when indication for insertion has past, is no longer the sole responsibility of the referring physician but also the responsibility of the Interventionalist. Our retrieval rates of 92.5% of eligible IVC filters highlights the value of maintaining a prospective IVC filter registry. Introduction insertion of an inferior vena cava (IVC) filter as the most Venous thromboembolism (VTE) is a collective term for suitable option for the treatment of VTE. Greenfield deep vein thrombosis (DVT) and pulmonary embolism established the IVC filter in 1973 as means of preventing (PE); these are common conditions associated with sig- PE by intercepting potential emboli originating in or dis- nificant rates of patient morbidity and mortality. The tal to the IVC. The introduction of retrievable filters in overall VTE estimated average annual incidence rate 2003 expanded the utility of IVC filters in patients with among persons of European ancestry ranges from 104 to transient indications and has coincided with increased 183 per 100,000 person-years.[1]. IVC filter insertion.[2]. The standard care given for VTE is oral anticoagula- IVC filters which are not retrieved can pose a risk to pa- tion therapy, however in a subset of cases oral anticoa- tients because of their association with complications such gulation fails to prevent VTE or anticoagulation is as vena cava wall perforation, thrombosis or stenosis, as contraindicated; at this point clinicians may find the well as filter fracture or migration.[3–7] In light of the po- tential risk non-retrieved filters pose against the general * Correspondence: marksheehan@rcsi.ie population; the U.S. Food and Drug Administration Royal College of Surgeons in Ireland, Dublin, Ireland (FDA) released a safety notice in 2010, which alerted Department of Radiology, Beaumont Hospital, Dublin, Ireland © The Author(s). 2022 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Sheehan et al. CVIR Endovascular (2022) 5:15 Page 2 of 6 Interventionalists implanting these medical devices as to on insertion and (3) the ‘unspecified’ group - the deci- their shared responsibility with physicians in following up sion whether the filter was permanent or to be retrieved with each individual patient to retrieve these devices as was not possible to make at the time of insertion. The soon as deemed clinically appropriate.[8] This prompted status of the filter was reviewed regularly with the refer- the establishment of an IVC registry in our institute, to ring physician. A final filter status for the ‘unspecified’ prospectively record and track retrievable IVC filters that was made within 3 months and recorded when a final were inserted. decision was made after consultation with the referring The FDA released a subsequent notice in May of 2014 physician. with a mathematical model which suggested that once All patients who had an IVC filter inserted at our in- PE risk has resolved, the risk/benefit profile starts to stitution were recorded in the registry and thus were eli- favour the removal of the IVC filter within 29 to 54 days gible for inclusion. A small number of patients had IVC of insertion.[9] Angel et al. produced a systematic review filters retrieved at our institution but their filters were in 2011, including 37 studies and over 6800 patients, on inserted elsewhere and thus were excluded as there was IVC filter practices and quoted a mean retrieval rate of insufficient data available. 34%, and mean dwell times of 72 days.[6] More recently IVC filter retrieval rates were calculated as follows: total CIRSE (Cardiovascular and Interventional Radiology retrieved filters/ (total filters inserted – ineligible for re- Society of Europe) and BSIR (British Society of Interven- trieval) x 100 (Fig. 1). Ineligibility for retrieval occurred if tional Radiology) have shown improved filter rates when a filter was decided to be left permanently (excluding a they set up online registries for institutes with retrieval failed attempted retrieval - who were deemed eligible) and rates quoted of up to 92%.[10, 11] However, there is evi- those cases who died prior to retrieval attempt were also dence to support that with dedicated follow-up retrieval considered ineligible. Patients with a filter yet to be re- rates approach 60%.[4]. trieved i.e. loss to follow up, were considered eligible and The aim of this study is to review our retrieval prac- are included in the retrieval rate calculation. This method tices over a 9-year period to determine the retrieval rates of calculation has been documented in previous for IVC filters using a prospectively managed IVC filer studies.[4]. database with secondary outcome measures including dwell times, insertion indications, and reasons of per- Results manent filter insertions. There were 343 patients entered into the database (174 male and 169 female) over the 9-year period. The mean Methods age for men was 59.8 years (range 19–87) and for An IVC filter registry was prospectively collated within women was 58.8 years (range 18–88). All IVC filter in- our institution. The responsibility of database mainten- sertions were performed in our institution, 7 filters were ance is shared between a nominated Interventional Radi- retrieved in an external institute, the remaining filters ology (IR) fellow and departmental IR administration were retrieved in our hospital. staff. Details of the database were stored on an Microsoft The IVC filter types inserted were the Celect filter Excel Spreadsheet. (Cook Medical, Bloomington, Indiana) in 189, the Gun- We reviewed the database from inception in August ther Tulip (GT) (Cook Medical, Bloomington, Indiana) 2011 until June 2020. We assessed the registry against a in 65, ALN (ALN, Ghisonaccia, France) in 89. Picture Archiving and Communication System and elec- The access routes for insertion approach were the tronic patient records to ensure data entry was accurate. right internal jugular vein in 278 cases (81%), right com- Data entry consisted of IVC filter status, dwell time, re- mon femoral vein in 58 cases (17%) and the left com- trieval date, retrieval complications, insertion indications, mon femoral vein in 7 cases (2%). A diagnosis of access route used, malignancy diagnosis, indications for malignancy at the time of filter insertion was reported in permanent filters, failed attempts and extra manoeuvres 115/343 (33.5%) patients. 30 of these 115 patients (26%) performed for retrieval. had a permanent IVC filter inserted de novo. Limited life Before filter insertion, patients were streamed into 3 expectancy independently or combined (Table 1) consti- different patient groups; (1) those filters placed with an tuted 53 (49%) permanent filters with 9/53 (17%) also ‘intent to retrieve’, (2) filters deemed to be ‘permanent’ having a malignancy status. Fig. 1 Sheehan et al. CVIR Endovascular (2022) 5:15 Page 3 of 6 Table 1 Indications for Permanent Filters (n = 108) Of the 48 patients in the ‘unspecified plan’ group a later decision with regard to the filter being retrieved Indications for Permanent Filters Number of Cases or deemed permanent was made within 3 months of Limited Life Expectancy 30 (27.7%) filter insertion after discussion of the clinical condi- tion of the patient with the referring physician. Of Long-term CI (Contraindication) to AC 28 (25.9%) (Anti-Coagulation) these 48 patients, filters were assigned permanent sta- Failed Retrieval 13 (12%) tus in 35 due to deteriorating clinical illness and poor life expectancy and 13 wereassigned to theintentto VTE (Venous Thromboembolisim) on 10 (9.3%) therapeutic AC retrieve group. Of the latter 13 patients, 6 filters were retrieved ,6 died before IVC retrieval and 1 was lost Patient Preference 4 (3.8%) to follow up. Multiple 23 (21.3%) - Limited Life Expectancy + Long-term CI to AC 13 (12.6%) In the ‘intent to retrieve’ group, 190 (81.2%) of 234 fil- - Limited Life Expectancy + VTE on AC 10 (9.7%) ters were retrieved either on first or second attempt. 30 Overall total 108 (12.8%) patients of the 234 died prior to retrieval, 12 (5.1%) were made permanent and 2 (0.9%) were lost to follow up. Indications for insertion of IVC filters were separated As stated, 61 filters were deemed permanent from the into 6 categories: contraindication to anticoagulation in time of insertion, all 61 remained in situ. On final re- setting of VTE in 147 (43%), pre-operative prophylaxis view, filters were assigned the status of permanent in (Patients with a previous history of VTE undergoing 108 (31.5%), (42 Gunther Tulip, 44 Celect, and 22 ALN). major surgery) in 117 (34%), pharmaco-mechanical The clinical circumstances under which the determin- thrombectomy in 47 patients for iliofemoral DVT (14%), ation for the filter to remain permanently is shown in VTE on therapeutic anticoagulation in 20 (6%), extensive Table 1. This means that a permanent status was applied VTE in 5 (1%) and multiple indications in 7 (2%), as to a filter in 47 patients, who before insertion were shown in (Table 2). streamed initially into the ‘intent to retrieve’ group or Of the 343 filters inserted, 196 (57.1%) filters were re- ‘unspecified plan’ group. trieved, 108 (31.5%) filters were deemed permanent, 36 Unsuccessful retrieval at the first attempt occurred in (10.5%) patients died during follow-up, and 3 (0.9%) pa- 23 patients. Table 5 shows the causes for failed retrievals tients were yet to be retrieved or lost to follow up. The on the first attempt. 13 (57%) patients who had an un- overall retrieval rate was 92.5% (Fig. 2), with a retrieval successful retrieval on the first attempt went on to be- rate of 86% for GT, 93% for Celect and 94.5% for ALN come permanent after discussion with the patient and (Table 3). referring teams (these cases were then considered a The mean dwell time for successful retrieval was 59 ‘failed retrieval’) and 10 (43%) were successfully retrieved days (median 42, range 2-390 days) with the majority of on the second attempt. Advanced manoeuvres were used insertions (85%) removed in under 100 days (Table 4). in 19 cases overall with 13 (68%) resulting in successful Before insertion, 61 patients were streamed into the retrieval. 9 (39%) of the 23 initial failed attempts had ad- ‘permanent filter’ group, 48 were streamed into the ‘un- vance manoeuvres performed. In filters with thrombus specified plan’ group and the remaining 234 were at the time of retrieval, the patients remained on antic- streamed into the ‘intent to retrieve’ group. oagulation and a further date for retrieval planned in 2– 3 weeks time. Retrieval on second attempt was success- Table 2 Indications for Filter Insertion (n = 343) ful in 50% (5/10) of these cases. Indications for Filter Insertion Number of Cases (%) The vast majority of retrievals was performed using CI (Contraindication) to AC (Anti-Coagulation) 147 (42.7%) local anaesthetic only, typically 10mls of 1% lidocaine. In Pre-operative prophylaxis 117 (34.1%) some cases, light conscious sedation was used, a com- bination of Fentanyl and Midazolam were administered. Pharmaco-mechanical thrombectomy (PMT) 47 (13.7%) Retrievals performed under general anaesthetic usually VTE (Venous Thromboembolisim) on AC 20 (5.8%) occurred when the patient was already intubated in an Extensive VTE 5 (1.7%) intensive care setting. The ALN extraction device (ALN, Multiple 7 (2.0%) Ghisonaccia, France) was the preferred method of re- - CI to AC + extensive VTE 2 (0.6%) trieval, although a range of snare devices were also used - CI to AC + PMT. 2 (0.6%) - Pre-operative + VTE on AC 1 (0.3%) routinely depending on operators preference. - PMT + extensive VTE 1 (0.3%) The most commonly employed advanced manoeuvre - pre-operative + CI to AC 1 (0.3%) was the loop snare technique, this involves engaging a Overall total 343 reverse curve catheter in the struts of the filter and Sheehan et al. CVIR Endovascular (2022) 5:15 Page 4 of 6 Fig. 2 inserting a hydrophilic wire cranially. The wire is then importance of having a retrieval date in place as soon as snared and externalized, thus used as a counter force as the IVC filter has been inserted. Sutphin et al. compared the co-axial sheath is passed over the collapsed IVC fil- three patient cohorts, firstly a baseline group with a re- ter. Another advanced manoeuvre performed in two trieval rate of 8%, secondly a “letters” cohort with a re- cases involved passing a wire between the endothelia- trieval rate of 40% (the referring physician is contacted lized hook and wall of the IVC. A balloon venoplasty by letter) and finally a third “Prospective” cohort with a was performed in an attempt to separate the hook from retrieval rate of 52% (these patients were scheduled for a the IVC wall and thus allow for the hook to be snared. clinic appointment at the time of the IVC insertion).[4] A semi rigid forceps with a larger 16 French sheath was Similarly Minocha et al. demonstrated an increase of used successfully in 3 patients when some of the above 29–60% after an IVC clinic and prospective database retrieval methods failed. were implemented.[12]. There is no definitive nomenclature documented in Discussion the literature for the calculation of the retrieval rate and It is the shared responsibility of the referring physician care needs to be taken when comparing retrieval rates. and the interventional radiologist to ensure that IVC fil- We have reported a retrieval rate of 92.5%, which means ters are removed at the earliest juncture once the indica- we removed 92.5% of the IVC filters that were eligible tion for placement has resolved. While the use of IVC for retrieval, the formula of which can be seen in Fig. 1. filters reduces the risk of VTE in the short-term it in- This formula for calculation was also used by Sutphin creases the risk of DVT in the long term [4, 9]. et al.[4] Minocha et al. reported a retrieval rate of 29% The use of IVC filter databases or registries have be- in pre-clinic years to 60% in post-clinic years for op- come common place within the IR community [10, 11] tional/temporary filters, however it does not include the since recommendations from the FDA was published in 33 patients who had filters made “permanent” after in- 2010 advising the removal of retrievable IVC filters as sertion and therefore would have a retrieval rate of 91% soon as possible.[8] Different methods of improving re- using our calculations.[12] In 2015 CIRSE produced an trieval rates have been investigated, examples include online registry for multiple international centers and prospective registries, letters to referring physicians, published a similar retrieval rate of 92% for eligible re- scheduling IVC retrieval dates at the time of insertion trievable filters.[10] Similar high retrieval rates have been and even IVC filter clinics. In our institute it was the re- reported by De Gregorio et al. (SERVEI- REFiVeC regis- sponsibility of the IR who inserted the filter to document try) removing 76.9% of all retrievable IVC filters but in the registry the planned retrieval date and schedule when augmented for deaths or change of status to per- the patient for same. Non-specified retrieval plans were manent the adjusted retrieval rate is of 94.15%.[13]De documented in 14% (n = 48) of the total cases, in the Gregorio et al. highlights well the heterogenous nature cases lost to follow up 33% (n = 1/3) had a non-specific of comparing rates between papers due to different retrieval plan documented. This in itself highlights the study designs. Table 3 Retrieval Rate by Filter Type (n = 343) Filter Type Filter Status Total Retrieval Retrieved Permanent In situ Deceased Failed * Successful retrieval Gunther Tulip 18 42 0 5 65 3 86% Celect 126 44 2 17 189 8 93% ALN 52 22 1 14 89 2 94.5% Overall total 196 108 3 36 343 13 92.5% * Failed category totals are a subset of the permanent category totals Sheehan et al. CVIR Endovascular (2022) 5:15 Page 5 of 6 Table 4 Mean dwell time by Filter Type (n = 209) Filter Type Successful cases Failed Cases Length of Time until retrieval Quantity Mean No. of days until retrieval Quantity Mean No. of days until attempted retrieval Max days Min days Gunther Tulip 18 50 3 63 144 15 Celect 126 58 8 73 336 2 ALN 52 67 2 81 390 4 Total 196 59 13 72 However these high retrieval rates are not seen across as the national neurosurgical center many of our pa- the board, Sarostek et al. reported a retrieval rate of tients unfortunately have a limited life expectancy. This 8.5% on 679 retrievable IVC filters in a large single cen- reason dominates the reason for permanent insertion ter institute.[14] As discussed with the introduction of (49%). Being a neurosurgical center also results in a high IVC clinics, letters to physicians and registries has number of trauma or neurooncological patients requir- greatly improved these figures. [4, 10–12] ing prophylactic IVC filter insertion prior to major intra- 108 filters were made permanent, 13 of these were due cranial procedures in the setting of a current or previous to failed retrieval (these were included in the calculation VTE (34.1%). Permanent filters lead to complications as failed retrievals) In 7 of these 13 failed retrievals, no such as filter migration or fracture, penetration outside advanced manoeuvres were attempted. The mean dwell of the vena cava wall and IVC stenosis or occlusion.[5] time for these failed retrievals were 63 days for GT fil- Further by improving retrieval practices and reviewing ters, 73 for Celect and 81 for ALN filters. At greater the indications for the conversion of retrievable filters to dwell times advanced maneuvers become essential to en- permanent, the institution can save on costs. Janne sure high successful retrieval rates are maintained. This d’Othee et al. created a cost analysis model which dem- is supported by Kuo et al. which reported 100% success- onstrated that retrievable versus permanent filter place- ful retrieval in a series of 50 patients where advanced ment is financially beneficial even if only 41% of filters manoeuvres were performed after standard methods had are removed.[17]. previously failed.[15] In a review of advanced techniques, Limitations of this study include, the reliance on the IR Desai et al. illustrated that after 7 months of filter being fellow and IR administration staff to prospectively and in situ, the chances of the standard retrieval methods correctly collate data in a timely manner. As fellows failing is high, with a calculated risk of 40.9% which con- change every year, this is likely not optimal as there is loss tinues to rise with increasing dwell time.[16] This evi- of continuity. We think that the ideal person to monitor dence underscores the importance of both attempting the database would be an IR practice nurse or physician advanced maneuvers when standard methods fail, as well associate but unfortunately these were not available to us. as the necessity of reducing mean dwell time which can We transitioned from the Celect filter to the ALN dur- be done with regular follow up. ing the course of the study because of issues with filter Although technically all IVC filters we insert are re- leg penetration seen with the Celect filter.[18] trievable, 108 of the filters we inserted were made per- The prospective database also highlights the difficulty in manent (Table 1). When comparing to other studies this assigning a status in terms of ‘intent to retrieve’, ‘perman- may seem high, for example Gregorio et al. reported ent status’ or ‘unspecified’ to patients at the time of filter 11.5% of IVC filters inserted were permanent; however, insertion. 47 patients who initially were in the unspecified group or intent to retrieve group were later converted to Table 5 Reasons for failed initial retrieval (n = 23) the ‘permanent’ group. This indicates that the database re- Reason for failed initial retrieval Number of Cases quires attention on a frequent basis and communication to referring physicians and patients must be ongoing. Thrombus in filter 10 (43.5%) Endothelialized 5 (21.7%) Conclusions Re-inserted above filling defect 2 (8.7%) The removal of IVC filters, when indication for insertion Filter tilted/ Unable to snare 1 (4.4%) has past, is no longer the sole responsibility of the refer- Access route thrombosed 1 (4.4%) ring physician but also the responsibility of the Interven- Multiple 4 (17.4%) tionalist. Our retrieval rates of 92.5% of eligible IVC - Endothelialized and thrombus in filter 3 (13.0%) filters highlights the value of maintaining a prospective - Endothelialized and unable to snare 1 (4.4%) IVC filter registry with regular communication to refer- Overall total 23 ring physicians and patients. Sheehan et al. CVIR Endovascular (2022) 5:15 Page 6 of 6 Abbreviations 9. FDA. Removing retrievable inferior vena cava filters: FDA safety IVC: Inferior Vena Cava; GT: Gunther Tulip; VTE: Venous thromboembolism; communication (2014) Available at: http://www.fda.gov/MedicalDevices/Sa DVT: Deep vein thrombosis; PE: Pulmonary embolism; FDA: Food and Drug fety/AlertsandNotices/ucm396377.htm Administration; CIRSE: Cardiovascular and Interventional Radiology Society of 10. Lee MJ, Valenti D, de Gregorio MA, Minocha J, Rimon U, Pellerin O (2015) Europe; BSIR: British Society of Interventional Radiology; IR: Interventional The CIRSE retrievable IVC filter registry: retrieval success rates in practice. Radiology Cardiovasc Intervent Radiol 2015; 38:1502–1507 11. Uberoi R, Tapping C, Chalmers N, Allgar V (2013) British Society of Interventional Radiology (BSIR) Inferior Vena Cava (IVC) Filter Registry. Acknowledgements Cardiovasc Intervent Radiol 2013; 36:1548–1561 No further acknowledgements. 12. Minocha J, Idakoji I, Riaz A, Karp J, Gupta R, Chrisman HB et al (2010) Improving inferior vena cava filter retrieval rates: impact of a dedicated Authors’ contributions inferior vena cava filter clinic. Journal of vascular and interventional MS – Primary author of manuscript and Data collection. K C - Data radiology: JVIR. 2010;21(12):1847-51 collection and Data Analyses. C O’ B - Data collection. A M – Primary 13. De Gregorio MA, Guirola JA, Urbano J et al (2020) Spanish multicenter real - operator of procedures, Data Collection. M G – Primary operator of life registry of retrievable vena cava filters (REFiVeC). CVIR Endovasc. 2020; procedures, Data Collection. A K – Primary Operator of procedures, Data 3(1):26. doi:https://doi.org/10.1186/s42155-020-00114-5 Collection. M L- Primary Operator of procedures, Senior Author and Editor of 14. Sarosiek S, Crowther M, Sloan JM (2013) Indications, complications, and paper. The author(s) read and approved the final manuscript. management of inferior vena cava filters: the experience in 952 patients at an academic hospital with a level I trauma center. JAMA Intern Med. 2013 Funding Apr 8;173(7):513-7. doi: https://doi.org/10.1001/jamainternmed.2013.343 This paper was not supported by any funding. 15. Kuo WT, Robertson SW, Odegaard JI, Hofmann LV (2013) Complex retrieval of fractured, embedded, and penetrating inferior vena cava filters: a Availability of data and materials prospective study with histologic and electron microscopic analysis. Journal The datasets generated and/or analysed during the current study are not of vascular and interventional radiology: JVIR. 2013;24(5):622 – 30.e1 publicly available due patient confidentiality but are available from the 16. Desai KR, Pandhi MB, Seedial SM, Errea MF, Salem R, Ryu RK et al (2017) corresponding author on reasonable request. Retrievable IVC Filters: Comprehensive Review of Device-related Complications and Advanced Retrieval Techniques. Radiographics: a review Declarations publication of the Radiological Society of North America, Inc. 2017;37(4): 1236-45 Ethics approval and consent to participate 17. Janne d’Othée B, Faintuch S, Reedy AW, Nickerson CF, Rosen MP (2008) Compliance with Ethical Standards. All procedures performed in studies Retrievable versus permanent caval filter procedures: when are they cost- involving human participants were in accordance with the ethical standards effective for interventional radiology? Journal of vascular and interventional of the institutional and/or national research committee and with the 1964 radiology: JVIR. 2008;19(3):384 – 92 Helsinki declaration and its later amendments or comparable ethical 18. Zhou D, Moon E, Bullen J, Sands M, Levitin A, Wang W (2014) Penetration of standards. Celect inferior vena cava filters: retrospective review of CT scans in 265 patients. AJR Am J Roentgenol. 2014 Mar;202(3):643-7 Consent for publication For this type of study formal consent is not required. For this type of study Publisher’sNote consent for publication is not required. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Competing interests The authors declare they have no conflict of interest. Received: 28 December 2021 Accepted: 24 February 2022 References 1. Heit JA, Spencer FA, White RH (2016) The epidemiology of venous thromboembolism. Journal of thrombosis and thrombolysis. 2016;41(1):3–14 2. Jaberi A, Tao MJ, Eisenberg N, Tan K, Roche-Nagle G (2020) IVC filter removal after extended implantation periods. The surgeon: journal of the Royal Colleges of Surgeons of Edinburgh and Ireland. 2020;18(5):265-8 3. Tse G, Cleveland T, Goode S (2017) Ten-year experience of retrievable inferior vena cava filters in a tertiary referral center. Diagnostic and interventional radiology (Ankara, Turkey). 2017;23(2):144-9 4. Sutphin PD, Reis SP, McKune A, Ravanzo M, Kalva SP, Pillai AK (2015) Improving inferior vena cava filter retrieval rates with the define, measure, analyze, improve, control methodology. Journal of vascular and interventional radiology: JVIR. 2015;26(4):491-8.e1 5. REPIC Study Group (2005) Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d’Embolie Pulmonaire par Interruption Cave) randomized study. Circulation. 2005 19;112(3):416 – 22. doi: https://doi.org/1 0.1161/CIRCULATIONAHA.104.512834 6. Angel LF, Tapson V, Galgon RE, Restrepo MI, Kaufman J (2011) Systematic review of the use of retrievable inferior vena cava filters. J Vasc Interv Radiol. 2011 Nov;22(11):1522–1530.e3. doi: https://doi.org/10.1016/j.jvir.2011.08.024 7. Charles HW, Black M, Kovacs S et al (2009) G2 inferior vena cava filter: retrievability and safety. J Vasc Interv Radiol 2009; 20:1046 – 1051 8. FDA (2010) Removing retrievable inferior vena cava filters: initial communication.

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Published: Mar 5, 2022

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