Chapters Transcript Video Timing and Techniques for Safe Retrieval Back to Symposium All right, so we're going from that great background to just technical stuff, which is you put them in and you gotta take them out. So we'll touch on a bunch of different stuff. So, um Market still seems to be growing in the face of um logic for perhaps reduced utilization so we still need to focus on who, when and where and most importantly removal so we're gonna talk about those types of things uh now US is still kind of the central hub for this with uh about a third of all global filters that are going in or money is related to it. So, um Different societies have kind of come together about shared guidelines. There was a paper that was about 10 years earlier than this that showed that there were specialty differences in terms of guidelines and also compliance with certain specialists, endovascular specialists moving in. To this that we're placing filters out of guidelines and such, but essentially there has been a reasonable and good coherence across anybody who touches the space to say we all relatively agree on who should get these and removals and indications and otherwise and that's a public good. So why talk about complications? Well, uh, it was 2011 when that uh FDA, uh, um. Uh, message came out after a paper in annals, and it, and we were aware that there were problems with filters, but this just shows you the impact of a high impact journal, particularly outside of the practicing specialty to medicine at large, and that made that fundamental sort of pivot and sea change which reported fractures across all filters and scary pictures and some complications as well, um, and there was a sudden oh my we need to turn to this. Um, in terms of, uh, filters, the word of perforation and penetration become scary words. Um, perforation, by definition, every filter leg goes out through the cava in order to hold what is, uh, a penetration and arbitrary 3 millimeters, but the real thing we're talking about is contact with other things that cause complications in and of themselves like aorta or, um. You, uh, periodically find a patient who's been suffering with chronic unexplained abdominal, uh, or back pain, and you happen across that CT and they've got a filter leg that has, uh, reached across and is in contact with periosteum and has a periosteum reaction and you take that filter out and it's the most satisfying magic trick you'll have in 6 months because that pain disappears. So this is just to emphasize the point that we heard. If you place them, you have to take them out, and that means having a system in place. And there was a period in the literature where there was a giant bolus of filter retrieval papers. We're sort of past that. This is well trod path and at the same time, a lot of papers on how to create mechanisms and clinics and focus upon these things and building them into your discharge records and messaging primary physicians and having them now understand. That if they see filter in a chart that it's their role as well they have some shared responsibility to say do I need to make a referral as well so placing these means it's not filter and go, but it's filter and follow. So legal and regulatory implications um if you have spent in the last decade any time in a hotel room somewhere and turn on the television on the local cable channel at uh one a.m. you've seen some legal ad that says if you've had a filter placed, you know, and it's always the same voice and the same type of thing from somebody trying to raise a class action suit. So luckily these noises have become a bit smaller, but if nothing else they focused us on doing our job better in terms of uh getting these uh filters out. So, um, Be aware that the MOD database, which is, uh, uh, provider uploading and industry uploading of data by its nature, um, underestimates the amount of events, so it's a useful confirmatory tool, but it cannot by its semi voluntary reporting method, um, represent the true incidence of. And prevalence of issues related to any medical device adverse events so good to look at it nice to write papers for we're duty bound to report and we can readily as providers ourselves upload data and I have just to see what it's like as well, but this really doesn't describe the totality and scale of the events. So, um, as we said, it's become sort of a focus for lawyers for, uh, saying that, uh, there are pieces and you have to chase them and all sorts of entertaining papers and. And it's a classic academic place where people have sort of defined themselves. There is no filter that I can take out. I can take out harder ones than you. I have the most extreme things and these are again the sort of ego self-aggrandizing things that that uh that that that we do as practitioners to somehow stand apart or divide ourselves. I prefer the much more democratic. approach which is we really don't need to think about the most extreme approaches we need to figure out a way to have most people be able to do most of these things or recognize when there's a pivot point and refer to someone who does the rest and then also remember that all optional uh filters, what that means is that they can stay in permanently, that we're not seeking 100% removal. Filters do not have to come out in everybody, and they are designed to be permanent, and there are patients who don't need to get it out. You are at a certain age, you have an advanced malignancy. You have a reduced lifespan. Those things are known. We don't have to put filter removal in the middle of your chemo or immunotherapy as a mandatory goal. We still have, we still have to kind of keep in mind. So, um, I mentioned why lawyers got involved because this seemed like a tasty target so be it, but let's, uh, and, uh, most filter manufacturers have been pointed to as, uh, as evil rather than providing a useful device in appropriate settings that we now need to manage afterwards. So, um, whether you're using an application or whether you use your medical record system, whether you have internal databases at the absolute minimum, I think procedure dictations and medical record notes and otherwise need to have mandatory statements that say this is an optional filter, here's a timeline here's how you can refer back here or somewhere. Else and put those things into records so that people are used to seeing these reports and get into the habit of triggering these things um and and we um uh as um just one practice actively reach out to patients as well it's just part of our routine follow up so however you define your practice this is a mandatory piece. So turning to the technical stuff which is the bulk of this lots of different ways to get these things out from snare kits, um, to customized tools to elevating things, um, and escalating and what I'm gonna do with the time forward is just show you a bunch of examples. And some reminders of the ways to approach these types of things. So, um, when do you escalate? I think of this as sort of as a, as a, as a three step approach standard comes out if I see a Denali filter then. Uh, in that patient, and I kind of sigh, uh, a sigh of relief and I say great because I've taken out ones that have been in there for, um, as long as the Denali filter has been in and even in someone with jugular vein occlusions in whom I took the filter out from an axillary vein approach and after 12 years it came out like it was a week ago. So there are certain ones where you look at and say, all right, odds are great that this is not gonna turn into drama to the other end of the spectrum which is. The optis filter, which I personally no longer really try to take out if at all possible because you think about 6 horizontal or vertical lines that have all penetrated outside of the vena cava and you see all 6 of them outside of the vena cava and that means that in removal you have to pull the vena cava in and create 6 vertical cuts through the cava by definition to get that back inside. So we're gonna slice the cava in order to take this out. So better not to place that filter in and better to think carefully whether that filter needs to come out when you face it versus alternatives if it's a recantalization as I had to do recently, there are filters, as, uh, as Mark Lesnan had shown you that can be plastered to the side if necessary. So straightforward and then some setup of advanced techniques sling. Things like that, but if I'm gonna go up to forceps and such, and I'll pivot and return generally with MAC or occasional general anesthesia just for discomfort, and to me that's the cut point in the procedure. So what are those types of things? I'll show you some diagrams from an article that I published a long time ago with, uh, one of my, uh, junior colleagues, um, which basically was sort of the first atlas of pictures over here, um, from. Uh, deflecting approach, what we call the sort of the stiff man approach to, um, a sling approach to otherwise, and we'll look at a few of these kinds of pictures over here. So, um, the stiff man approach occasionally works in which means in a certain type of filter if you get a wire alongside you can kind of bend it off to the side and then coaxialally come down with your sling and just nudge it away if the nose or the conical end is not embedded. So it's a quick one to find out. The sling approach means that you um uh get a hydrophilic wire down, grasp it on the other side of the filter, and then pull it up. Whether you do it with a catheter or just the wire and grasp it with a snare, it's a means of distracting it from the wall of the vena cava or grabbing it by the neck and pulling it off to the side in order to be able to free it up and make it accessible to your snare or recovery cone. Occasionally there's a, there's a role for a balloon to push the filter aside. Um, pretty rare that I'll use this, but it has been a problem solver, which is why we illustrated to just sort of create a space for the embedded, uh, head of the filter, um. And uh and, and occasionally um having to come from both sides to be able to pull or distract the conical shaped filter and then obviously the forceps technique that I'll touch on and we heard about beforehand. So some examples of these, you know, first, what do you do if you have a little bit of clot inside? Well, the little bit of clot is probably the same little bit of clot that we release after every long car ride or plane ride as well. That's the purpose, um, you know, of our, of the body's physiologic filter, if you will, which is our, our half a tennis court of cross sectional area of, of pulmonary arteries. So, um, in those kinds of cases I'll simply take it out. Um, when you get to larger amounts, then you get to these kinds of cases, and this is, uh, a patient whose lower extremity edema you can see in, uh, in the, uh, picture before the Blue Arrow. I was recantalyzing the occluded iliac veins on the pictures on the left and to my surprise you find this horrifying picture of that large clot. The time, uh, it's, you know, you can call it the widow maker, you can call it the MX missile. This is where, you know, we're moving our mobile nuclear missiles. We have one encompassing his entire filter and extending beyond it an unexpected finding during a DVT recantalization made it up on the fly. I placed a filter above it. Um, I took out that lower filter. We recantalyzed it. We did some mechanical clean up of the clot. There was obviously a clot that remained in the vena cava, and then I came back six weeks later, uh, after a CT that showed that with that increased flow that the cable clot had disappeared. I took out his top filter. The point of that is this is the most extreme example that I've seen, or at least remember in which with flow and reduction. And anticoagulation residual clot will disappear. So if you have unexpected clot that is above your threshold for, uh, I didn't expect this. I'm not sure what to do. Anticoagulate, come back again likelihood it's gone or debulk it some and come back, always a possibility, um, the old recovery, uh, cone works well on filters with hooks as well. So if you're snare, if you're out of snares, um, this works fine and I've taken out, uh, virtually all filters with hooks as well when there was a supply shortage of, uh, snares as well. Um, so this should play. Uh, you may, uh, there are some videos embedded and you may have to trigger them for me in the back because the control is not launching, uh, filters over here. Thank you. All right, so we tested it and now it doesn't play. There we go. So, uh, uh, snare at the top and the legs are caught, there's that forward motion that pulls them out and. We'll just keep going, so routine retrieval, snare on the hook, compress it. There are occasions if you're gonna take up these filters out that aren't ancient and have not completely penetrated all walls of the cava, hopefully we see that filter largely disappear. Then there are reasons to pull from below and sometimes to distract in both directions, but remember that you're pulling the cava in. And you may be tearing the cava depending on the number of penetrated legs, um, but there are occasions to pull from both directions, um, realize that after these chronic filters, particularly with that one, that there may be a secondary cable stenosis, particularly in complex removals. In uncomplicated removals, there have been nice papers in nearly 250 patients in follow-up single institutions showing that you don't need to do a follow-up cava. It's a simplified retrieval in that patient you can do a cavagram if you want, but you need not, uh, in more complex retrievals, um, there may be secondary stenosis, and it is worth doing that to look for that, um, and address it at the time, not to full caliber, but to a smaller diameter. Than the full size of the cava, there are these occasional things where you will actually encounter a filter in this position and wonder, you know, how did I get here and how do you address that and these are gonna be sort of the grasping tools that we talked about which is they may be snares, they may be loops, or they may be actual forceps approaches depending on how you like to approach it and when. Um, in this case, started with a snare to reposition it, turn it, uh, in a, in a, uh, sling approach, reposition it, and then take it out. One thing to remember about using the snare approach is that not every filter is the same. There are filters that have hard to see invisible secondary architecture, like for example, some of the stainless steel filters that have smaller arcs below the legs, and depending on where you're snaring, you may be pulling on one of those. You may not be able to get your snare all the way to the top. You may be distorting the filter, bending legs, causing a whole series of complications where we've probably all found ourselves with this filter looking like this sideways and saying, how do I get it into some position that allows me to get out of the room and save face? So remembering that there's a second level of architecture and some of these types of filters can avoid problems. So, um, even just the slightest bit of repositioning, not. From this sort of extreme can allow you to get the filter uh away and then it's up and out and then look for that stenosis and it becomes actually a relatively mundane removal even with that exaggerated uh uh repositioning largely because um this was a very nice Nol filter. Now the wire and sling approach realized that the reason that we're really doing this or what I call sort of the hangman approach. I don't know if this uh is well can you play that video? All right, I can't explain to you why we tested these multiple times and uh at this moment they don't, um, but what you can see on that still image is that you catch it around the neck and you can't necessarily catch it at the top because that's still embedded so that's why I call the hangman approach where you've got it by the neck and you're pulling on it and, and, uh, it's not necessarily going into the same size sheath that you start with unless you enlarge it, but you can distract it and pull it away and. Do that delicate thing of saying I'm gonna release it and I hope it's in a better position and then I'm gonna re-snare it and be pretty confident that you can because you've pulled it away from the cable wall so that's just that tearing through of that fibrous cap or whatever that tissue is releases it and makes it a mundane, uh, filter and there we go on one I see it on uh one screen happening there. Thanks for getting that going. And then it's a matter of slowly either slowly releasing or tipping the filter and pulling it out in the standard fashion and then it's up and out and this I would consider a relatively mundane aspect of routine filter retrieval in phase one, not having to come back with any extra anesthesia or otherwise. Thanks for getting that going. So, um, the, the, uh, that's a, um, a picture to illustrate that occasionally secondary nearly impossible to see architecture that some filters have and if you've snared below those other aspects then you're gonna pull up a leg or tip the filter or do things that uh um may be um challenging. To say the least, um, filters will, uh, come out, and here's just an example of that tissue that, uh, you have to pull out. There are laser sheaths to be able to cut and burn away. I tend not to use that, but there are real advocates of that. I haven't necessarily found that tool to be essential for me. Mechanical ones work fine, but it's really good to be aware of them. Um, here's an illustrative and important point. This is a filter placed in December of 2013, conventional Nal Denali type filter. You can see it between the, uh, surgical hardware. Um, and in 12 2014, 1 year later, it's intact, one month later, there's a broken leg. And I have the oblique views that I haven't included from December of 2014, a year quiet, one month later there's that broken leg, so there isn't necessarily a time frame and there isn't the ability to say, well, it was good for this much time, it's gonna be good forever. I think it just emphasizes the point that. That when we capture these patients back they no longer have a need for continued filter removal you simply get them out barring other circumstances so now we have that leg um and it does emphasize remembering that um that original 2011 annals paper had shown pictures of. Legs that had migrated into the heart and the pulmonary artery, so it is reasonable to um uh carefully examine every remove filter on the table and count the legs, make sure you have it out and if you do that, then maybe you don't need a chest radiograph, but if you don't do that, then having a chest radiograph and a careful look should be part of every protocol one way or the other, and we have to be sure that we have it out in entirety by other means. So, um, if you can play these, there are 3 videos over here, um, that basically show grabbing a leg. Yeah, blame them in any order you want. Just start them all if you would. And that's just a snare grasping the leg and um just remember that you need an ultra strong grip on these things. There is no hook on them you're simply grabbing the leg and any slight release on the back means that that leg that you've grasped is going to be in the pulmonary artery so strong grip always means you never ask why didn't I do it this time. And then it's just a piece that comes out. So, um Looks mundane It's an option filter, um, and yet this filter that looks relatively straight, um, had had 3 prior people try to take this out. One of those tries had been 3 hours and this patient was so traumatized by the experience that I had to um. Get general anesthesia to do this procedure just because of that, and you can see that it looks like it ought to be straightforward, but we're flopping all around it. The, uh, the nose of the filter is simply not accessible. It's clearly embedded, and then it's the forceps we try to sling first that didn't distract enough, and then we use the forceps. These are videos that'll run if you can start them. Um, I just wanna make a general cautionary note for those of you haven't used forceps. There are these sort of delicate terms like micro dissection, which a very good friend of mine uses, which sounds again a bit grandiose this idea where you can just sort of nibble at the. But realize what we're doing is we have the strongest grasping rigid tool in an endovascular situation blindly, um, tearing away at a 3D structure that we're seeing basically whose outlines we don't see in black and white, which means plenty of opportunity for I think happen having things happen that aren't widely reported. Approach this thing with caution and delicately try to grab and constantly think. Am I holding the filter? Am I pushing it sideways? Am I tearing the cava? Am I distorting it? Or if the thing is embedded, could I actually torque the vena cava? I've seen people create a twist in the bikina in the vena cava, horrifying kind of complications. This is an absolutely critical tool, but you want to approach this with caution. I'll generally be up at a 14 to 16 French sheath with a very small buddy wire and the forceps alongside of this and backup plans as to what to do if we get into, shall we say, tiger country. Um, and there are situations where you grasp it and you actually even have to come out from below. This is one of my least favorite filters to take out. Looks like it should be straight forward with the hook, but it's a far different proposition than a Nal Denali. So we have to grasp it, pull it, constrain it, and get it out from below actually. So, um, exotic snare loops for things that are outside of the vena cava to tear and pull them into position, um, and then, um, in some cases even flip it. This is the situation that looks great after you're done, but there are the possibilities you get into the middle of this thing you have it sideways and you're wondering whether you can get out of the room with a solution. So this is, this is a technique, um. But think about tearing, think about control, um, certainly one that I've used, and this is the world's worst filter. This was a recumbent bike Olympic athlete on the US team, and he presented with this filter for retrieval. I stopped counting after 23 pieces. Um, and they were everywhere and there's the cable stenosis. This one went to surgery, and those are the surgical removals, and that's my balloon dilation of his occluded cava and then the stent that we placed thereafter. I'd like to say that it was because he was bent over on that bike, uh, but who the heck knows? Still the world's worst filter. And finally, the filter that you haven't seen before, uh, or the penultimate one, and then the last one. Anybody know what this is? So if you've seen this, then you can avoid this. This is the danger of placing the vena cava filter from the jugular vein and repositioning the sheath and not realizing that you've gone into that right gonadal vein that I showed you for gonadal vein embolization and have deployed the filter in the right gonadal vein. Every few years somebody shows this as if they discovered this. These cases have been around for decades. We just keep making these errors every so often. You can avoid it by being aware of it, of reaffirming that you're in the vena cava rather than just pushing something in. There it is, vena cava filter, right ovarian vein. So, and finally, the last picture. Anybody? So in this case I think they were filtering something different. Maybe they were filtering bad thoughts because you look at this and you see that is not a vena cavagram, that's a myelogram. Those are spinal roots, so this is an epidural filter. And somebody and you can see it faintly in the background, this is a very old case and somebody had managed to get from a femoral vein out into paravertebral veins and actually push the filter and deploy it there and you think that this is crazy, but you will find even recent reports of um transfemoral venous catheters. Including even dialysis catheters that have reached the epidural space just by going into that ascending lumbar vein and taking a few unnecessary turns. So Filter placement, filter removal, giving you a bit of tour to build on top of that great review of the data that uh preceded me. Thank you very much. Published Created by
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