Successful balloon protection technique in retrieving non-deployed IVC filter
Our patient was a 36 year-old female with past medical history significant for AIDS, hypothyroidism, diabetes mellitus type 2, and end-stage renal disease (ESRD) treated with dialysis; her AV fistula used her left femoral vein. The patient came to the hospital for abdominal pain and diarrhea and had an extensive stay due to her multiple comorbidities, receiving care from multiple specialists including nephrology, infectious disease, and interventional radiology. Ultrasound of the abdomen revealed a small infrarenal IVC thrombus, which was initially managed with anticoagulation, however, due to significant recurrent AV fistula bleeding, anticoagulation was discontinued. The decision was made to place an IVC filter. On the day of placement she had an elevated BUN and creatinine at 31 and 6.25, respectively, as well as an elevated PTT of 64.5. The rest of her labs and physical exam were normal. The right femoral vein was accessed utilizing ultrasound guidance and an IVC filter sheath (Option, Argon) was placed. An inferior venacavogram was performed which demonstrated normal anatomy and appropriate inferior vena cava diameter. There was a small filling defect along the left infrarenal lateral wall of the IVC, consistent with a small thrombus (Figure 1). The filter was deployed below the level of the lowest renal vein, above the small IVC thrombus. The filter remained completely collapsed after retracting the sheath, but fortunately did not migrate (Figure 2). An inferior venocavogram performed in multiple projections demonstrated the filter positioned within the IVC and not within an IVC tributary, such as a lumbar or gonadal vein. The filter introducer sheath was then exchanged for a 16-French sheath through which a 32 mm semicompliant Coda balloon (Cook Medical) was advanced. The balloon was then inflated above the level of the renal veins to protect from filter migration into the heart or pulmonary arteries. With the balloon inflated, a venogram was performed which showed adequate contrast flow through the IVC and enough balloon diameter to trap the filter if it were to migrate superiorly (Figure 3). We first pursued filter retrieval from an internal jugular approach in a patient with known chronic central venous occlusion caused by years of central venous catheter use for hemodialysis. Venography revealed complete SVC occlusion with extensive neck and upper chest collaterals. Attempts at recanalizing the SVC from both a left and right IJ approach were unsuccessful. Next, a gooseneck snare was advanced through the right common femoral vein sheath and manipulated around the filter body while simultaneously trapping the filter with the IVC balloon. The snare was then carefully maneuvered inferiorly to engage the inferior aspect of the filter legs. (Figure 4). The sheath was then advanced over the filter, and the filter was retrieved. An inferior venacavogram was then performed which showed no IVC injury or new thrombus.