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• W2110930425 abstract "Herein, we describe a case in which a Recovery nitinol filter (Bard Peripheral Vascular, Tempe, Ariz), positioned in the superior aspect of a left-sided inferior vena cava (IVC), was not amenable to removal with the Recovery Cone Removal System (Bard Peripheral Vascular). A loop snare was successfully used to retrieve the filter. A 66-year-old woman scheduled for surgical resection of a Pancoast tumor was discovered at preoperative contrast medium–enhanced computed tomography (CT) of the thorax to have asymptomatic left pulmonary artery thromboembolism. Abdominal and pelvic CT revealed a left-sided infrarenal IVC that emptied into the left renal vein, and no right-sided infrarenal IVC. The suprarenal IVC was right-sided. One day before surgery, a Recovery filter was deployed in the left-sided IVC with its tip at the level of the inferior aspect of the left renal vein. A right femoral approach was used. Nine days after filter insertion, anticoagulant therapy was prescribed and filter removal requested. Cavography revealed that the filter tip had tilted leftward into the inflow of the left renal vein and that at least one of the filter’s right lateral upper arms was now hooked into the inferior aspect of the outflow of the left renal vein (Figure, part a). Considering the anatomy, it was decided that attempts at retrieval using the Recovery Cone Removal System would likely be unsuccessful. Exchange was made for a long 12-F vascular sheath (Cook, Bloomington, Ind). A 25-mm-diameter Amplatz Goose Neck snare (ev3, Plymouth, Minn) was inserted and its curved 6-F snare catheter used to select the left renal vein. The snare loop was opened in the left renal vein and the filter tip was captured upon withdrawal of the snare system (Figure, parts b and c). Moderately rapid upward force was successful in freeing the arms and legs of the filter from their caval wall sleeves, and then the filter was removed via the jugular sheath (Figure, part d). Gross inspection after removal revealed that the filter was intact with no thrombus. Completion vena cavography showed no abnormality. Removal of an optional vena cava filter from a left-sided IVC was first described in 2004 (1Brountzos E.N. Kaufman J.A. Lakin P.L. Guenther Tulip filter retrieval from a left-sided inferior vena cava.Cardiovasc Intervent Radiol. 2004; 27: 58-60PubMed Google Scholar). A Günther Tulip filter (Cook) was retrieved without difficulty 17 days after insertion via the right internal jugular vein by using a 25-mm-diameter Amplatz Goose Neck snare. In 2005, Richard and colleagues (2Richard III, H.M. Lowe S.R. Malloy P.C. Retrieval of Bard Recovery filter from left-sided inferior vena cava.J Vasc Interv Radiol. 2005; 16 ([letter]): 1039-1041Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar) described retrieval of a Recovery filter from a left-sided IVC without difficulty 53 days after insertion by using the Recovery Cone Removal System via a jugular vein. The images from that report show that the Recovery filter had been deployed in the mid-lower aspect of the left-sided infrarenal IVC, more than one filter length below the left renal vein. In our patient, the Recovery filter had been deployed with its tip at the level of the inferior aspect of the left renal vein, resulting in an acute misalignment between the right-sided suprarenal IVC and the superior aspect of the left-sided infrarenal IVC in which our filter was deployed. Instructions for use for the Recovery filter state that the filter tip should be positioned 1 cm below the lowest renal vein. Placement of the Recovery filter too cephalad in our case may have contributed to subsequent filter tip tilting and contralateral hooking of an arm into the renal vein, thereby further exacerbating the acute misalignment. In future cases where an optional filter is used in a left-sided IVC with a plan for subsequent filter removal by means of a jugular approach, we recommend that the filter be positioned lower in the infrarenal cava to avoid an acute misalignment or step-off; in this manner, the standard retrieval cone may be used successfully to remove a Recovery filter, and selection of the left renal vein may not be required when using a loop snare to remove a Günther Tulip filter, for example. Alternatively, as suggested by Brountzos and colleagues (1Brountzos E.N. Kaufman J.A. Lakin P.L. Guenther Tulip filter retrieval from a left-sided inferior vena cava.Cardiovasc Intervent Radiol. 2004; 27: 58-60PubMed Google Scholar), suprarenal placement of an optional filter may be considered in the presence of a left-sided infrarenal IVC. To our knowledge, the use of a loop snare to remove a Recovery filter has not been described. In fact, the Information for Use booklet packaged with the Recovery filter includes the warning, “Only use the Recovery Cone Removal System to remove the Recovery Filter.” A recent report by Stavropoulos et al (3Stavropoulos S.W. Solomon J.A. Trerotola S.O. Wall-embedded Recovery inferior vena cava filters: imaging features and technique for removal.J Vasc Interv Radiol. 2006; 17: 379-382Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar), however, describes the safe and successful removal of Recovery filters with their tips tilted and embedded within caval walls in four patients by using rigid bronchoscopy forceps. We surmise that removal of the Recovery filter with a loop snare instead of the retrieval cone may be safe and effective in other circumstances, and perhaps even in uncomplicated cases. We note at our institution that an Amplatz Goose Neck snare is substantially less expensive than a Recovery Cone Removal System. Several studies, however, describe a high success rate for Recovery filter retrieval with the Recovery Cone Removal System. There have been several adjunctive techniques described to aid in removing a Recovery filter with the retrieval cone. Asch (4Asch M.R. Initial experience in humans with a new retrievable inferior vena cava filter.Radiology. 2002; 225: 835-844Crossref PubMed Scopus (194) Google Scholar) described the “guide wire-assisted technique,” in which a wire placed via the central lumen of the cone is directed near the filter tip, preferably toward the side of the filter with the shortest distance between the filter tip and the caval wall. Centering a tilted Recovery filter tip with a tip-deflecting wire has also been described (5Hagspiel K.D. Leung D.A. Aladdin M. Spinosa D.J. Matsumoto A.H. Angle J.F. Difficult retrieval of a Recovery IVC filter [letter].J Vasc Interv Radiol. 2004; 15: 645-647Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar). In our patient, such adjunctive techniques would be unlikely to correct the large degree of acute misalignment between a retrieval cone and the filter tip because of several factors: the acute step-off between the axes of the right-sided suprarenal IVC and the left-sided infrarenal IVC, the cephalad location of the filter tip within the left renal vein inflow, hooking of a right-sided filter arm into the left renal vein outflow, and tilting of the filter tip leftward. We believe that, in our case, the use of a loop snare was the simplest and safest effective technique for Recovery filter removal and that snare retrieval of Recovery filters may be potentially useful in other situations." @default.
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• W2110930425 title "Retrieval of a Tilted Recovery Filter from a Left-sided Inferior Vena Cava with a Loop Snare" @default.
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• W2110930425 doi "https://doi.org/10.1016/j.jvir.2007.02.028" @default.
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