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Bedside intravascular ultrasound-guided vena cava filter placement

2003; Elsevier BV; Volume: 38; Issue: 3 Linguagem: Inglês

10.1016/s0741-5214(03)00471-3

1097-6809

Eric D. Wellons, John H. Matsuura, Frederick W. Shuler, J Franklin, David Rosenthal,

Ultrasound in Clinical Applications

Inferior vena cava (IVC) interruption has long been accepted treatment to prevent pulmonary embolism.1Greenfield L.J. Michna B.A. Twelve-year clinical experience with the Greenfield vena caval filter.Surgery. 1988; 104: 706-712PubMed Google Scholar Technologic advances have converted IVC interruption from an operative procedure to a percutaneous endovascular technique performed under fluoroscopic guidance in the radiology suite, operating room, or catheterization laboratory. Intravascular ultrasound (IVUS) is a minimally invasive and accurate method of interrogating the IVC.2Bonn J. Liu J.B. Eschelman D.J. Sullivan K.L. Pinheiro L.W. Gardiner Jr, G.A. Intravascular ultrasound as an alternative to positive-contrast vena cavography prior to filter placement.J Vasc Intervent Radiol. 1999; 10: 843-849Abstract Full Text PDF PubMed Scopus (34) Google Scholar, 3Ashley D.W. Gamblin T.C. Burch S.T. Solis M.M. Accurate deployment of vena cava filters comparison of intravascular ultrasound and contrast venography.J Trauma. 2001; 50: 975-981Crossref PubMed Scopus (36) Google Scholar, 4Matsuura J.H. White R.A. Kopchok G. Nishinian G. Woody J.D. Rosenthal D. et al.Vena caval filter placement by intravascular ultrasound.Cardiovasc Surg. 2001; 9: 571-574Crossref PubMed Scopus (20) Google Scholar, 5Oppat W.F. Chiou A.C. Matsumura J.S. Intrasvascular ultrasound-guided vena cava filter placement.J Endovasc Surg. 1999; 6: 285-287Crossref PubMed Scopus (46) Google Scholar Bedside placement of an inferior vena cava filter (IVCF) under IVUS surveillance is simple and safe, and averts the need to transport critically ill patients, use of contrast medium, and radiation exposure. We evaluated the potential for bedside IVCF placement under real-time IVUS guidance only. Between January 1 and October 1, 2002, 45 patients who were transportation risks underwent placement of IVCF. The indications for filter placement included contraindication to anticoagulation therapy (n = 16), pulmonary embolus (n = 7), and multisystem trauma (n = 22). In a Phase I trial, IVCF were placed in the cardiac catheterization laboratory. Under aseptic conditions, two femoral venipunctures were made, 1 cm apart, and two 0.035-inch Glidewires (Terumo, Somerset, New Jersey) were passed into the superior vena cava under fluoroscopic surveillance. An 8F sheath was introduced over one Glidewire (IVUS wire) and a 6F sheath was introduced over the second (filter wire). A 10 MHz intravascular ultrasound probe (Jomed Inc, Rancho Cordova, California) was passed to the level of the right atrium. Venous anatomy was interrogated with a pullback technique that enabled easy identification of the liver, hepatic veins, renal artery, and renal veins; the IVC diameter was measured at the infrarenal location. The IVUS probe was placed at the level of the most inferior renal vein, and a contrast medium–enhanced venogram was obtained through the filter delivery sheath to validate location of the renal veins and measure the diameter of the vena cava. A Simon-Nitinol IVCF (Bard Radiology, Covington, Ga) or Trapease IVCF (Cordis Corp, Miami, Fla) was deployed under simultaneous fluoroscopic and IVUS surveillance. The IVUS probe, filter catheter, guide wires, and sheath were removed, and pressure was applied until hemostasis was achieved. In a Phase II trial, filters were placed under real-time IVUS guidance only, at the patient's bedside. Under aseptic conditions, two femoral venipunctures were made approximately 1 cm apart, and 0.035-inch Glidewires were introduced. 8F and 6F sheaths were inserted, and the vena cava was interrogated with IVUS and the IVC diameter was measured as in Phase I. The renal veins were identified, and the probe was pulled back to the level of the lowest renal vein. The IVC filter sheath was introduced over the second guide wire and advanced beyond the IVUS probe. As the filter was advanced in the sheath, the IVUS identified its passage beyond the renal veins. The sheath and filter were pulled back to a point adjacent to the IVUS probe and, under real-time IVUS surveillance, the filter was deployed (Fig 1, Fig 2). After insertion, the filter carrier, IVUS probe, and sheaths were removed and pressure was applied as in Phase I.Fig 2Real-time image of tip of inferior vena cava filter as it is being deployed.View Large Image Figure ViewerDownload (PPT) All patients underwent femoral vein color flow duplex ultrasound scanning within 2 weeks of IVCF placement, to assess femoral vein patency. Anteroposterior abdominal radiographs were obtained in all Phase II patients, to evaluate IVCF location. In Phase I, 10 consecutive patients underwent successful IVUS-guided juxtarenal IVCF placement, documented at contrast-enhanced venography. Six Simon-Nitinol filters and four Trapease filters were inserted. No venous anomalies were noted on contrast-enhanced venograms, and no periprocedural complications or femoral vein thromboses were identified at color flow duplex ultrasonography. In phase II, 94% of patients (33 of 35) underwent successful IVUS-guided placement of IVCF. Nineteen Trapease IVCF and 16 Simon-Nitinol IVCF were used. In 1 patient an IVCF was placed in the ipsilateral common iliac vein, which was identified on an abdominal radiograph; the patient underwent a second successful bedside IVUS-guided IVCF via the contralateral femoral vein. In another patient IVC thrombus was noted with IVUS at the time of attempted filter placement. This patient was taken to the catheterization laboratory for venographic confirmation and IVCF placement via a jugular approach. Mean time of deployment was 15 minutes (range, 10-42 minutes), and, as anticipated, procedure time became shorter with more experience. Mean IVC size was 22 mm (range, 18-28 mm) in all 45 patients. Postoperative radiographs documented all filters at the second lumbar spine level, without tilting. No other periprocedural complications occurred, and only one femoral vein thrombosis was identified at color flow duplex ultrasonography during follow-up. Pulmonary embolism remains a significant cause of death in critically ill patients. IVCF placement with fluoroscopy with contrast-enhanced venography is the standard deployment technique; however, this requires transportation of critically ill patients to the catheterization laboratory, angiography suite, or operating room. Alternative surveillance techniques have been advocated, to avert use of nephrotoxic contrast agents and transportation of these critically ill patients.6Tola J.C. Holtzman R. Lottenberg L. Bedside placement of inferior vena cava filters in the intensive care unit.Am Surg. 1999; 65: 833-838PubMed Google Scholar, 7Sing R.F. Jacobs D.G. Heniford B.T. Bedside insertion of inferior vena cava filters in the intensive care unit.J Am Coll Surg. 2001; 192: 570-575Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 8Van Natta T.L. Morris Jr, J.A. Eddy V.A. Nunn C.R. Rutherford E.J. Neuzil D. et al.Elective bedside surgery in critically injured patients is safe and cost-effective.Ann Surg. 1998; 227: 618-626Crossref PubMed Scopus (74) Google Scholar Carbon dioxide bedside fluoroscopy is one technique, but requires a portable fluoroscopy unit capable of performing venography, and in most hospital settings (ie, intensive care unit, patient room) this is cumbersome, at best.9Sing R.F. Stackhouse D.J. Jacobs D.G. Heniford B.T. Safety and accuracy of bedside carbon dioxide cavography for insertion of inferior vena cava filters in the intensive care unit.J Am Coll Surg. 2001; 192: 168-171Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Transabdominal color flow duplex ultrasonography is another technique that has been used to evaluate the IVC; however, it can be limited by poor visualization due to obesity, bowel gas, or abdominal wounds, making IVCF placement difficult.8Van Natta T.L. Morris Jr, J.A. Eddy V.A. Nunn C.R. Rutherford E.J. Neuzil D. et al.Elective bedside surgery in critically injured patients is safe and cost-effective.Ann Surg. 1998; 227: 618-626Crossref PubMed Scopus (74) Google Scholar, 10Sato D.T. Robinson K.D. Gregory R.T. Gayle R.G. Parent F.N. DeMasi R.J. et al.Duplex directed caval filter insertion in multi-trauma and critically ill patients.Ann Vasc Surg. 1999; 13: 365-371Abstract Full Text PDF PubMed Scopus (42) Google Scholar, 11Nunn C.R. Neuzil D. Naslund T. Bass J.G. Jenkins J.M. Pierce R. et al.Cost-effective method for bedside insertion of vena caval filters in trauma patients.J Trauma. 1997; 43: 752-758Crossref PubMed Scopus (72) Google Scholar, 12Conners M.S. Becker S. Guzman R.J. Passman M.A. Pierce R. Kelly T. et al.Duplex scan-directed placement of inferior vena cava filters a five-year institutional experience.J Vasc Surg. 2002; 35: 286-291Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar IVUS-guided IVCF placement, however, is an intriguing alternative to conventional guidance techniques in critically ill patients for whom transport may be hazardous. Bedside placement of IVCF guided with IVUS has been reported by Ebaugh et al13Ebaugh J.L. Chiou A.C. Morasch M.D. Matsumura J.S. Pearce W.H. Bedside vena cava filter placement guided with intravascular ultrasound.J Vasc Surg. 2001; 34: 21-26Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar and Oppat et al,14Oppat W. Morasch M.D. Matsumura J.S. Vena caval filter placement in critically ill patients using intravascular ultrasound.in: Yao J.S.T. Pearce W.H. Modern vascular surgery. McGraw-Hill, New York2000Google Scholar and their most recent experience advocates a single femoral vein puncture technique. With this technique, the IVUS catheter identifies the renal and iliac veins; “premeasurement” is performed to identify the IVCF landing zone, which is marked on the drapes with two Steri-Strips (3M, St Paul, Minn). The IVUS catheter is removed, the IVCF catheter is passed blindly over a super stiff guide wire, and the filter is discharged.13Ebaugh J.L. Chiou A.C. Morasch M.D. Matsumura J.S. Pearce W.H. Bedside vena cava filter placement guided with intravascular ultrasound.J Vasc Surg. 2001; 34: 21-26Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 14Oppat W. Morasch M.D. Matsumura J.S. Vena caval filter placement in critically ill patients using intravascular ultrasound.in: Yao J.S.T. Pearce W.H. Modern vascular surgery. McGraw-Hill, New York2000Google Scholar Although this technique is innovative and has been used successfully, use of a super stiff guide wire in the thin-walled IVC, the necessity to use a 12F sheath, and blind deployment of the IVCF make this technique potentially hazardous. The double-puncture technique is simple and safe, and enables continuous real-time ultrasonography of the IVC and renal veins to ensure precise filter deployment. Indeed, with real-time IVUS surveillance, filter deployment accuracy is enhanced because the filter can be manipulated early in its deployment. A possible disadvantage of this technique is the need for two femoral vein punctures and the inherent concern of femoral vein thrombosis. With the use of 8F and 6F sheaths, the defect in the femoral vein is essentially the same as with other larger percutaneous delivery systems, and postprocedure femoral vein thrombosis occurred in only 1 of our 45 patients. In addition, it is possible that the IVUS probe could lodge in the struts of the IVCF. The profile of the IVCF and IVUS probe and the suppleness of the IVC, however, make this unlikely, and in our experience it has not occurred. Inadvertent deployment of the filter in the ipsilateral iliac vein occurred early in our experience, when the filter and sheath were pulled out rather than maintaining correct catheter position. Now we continually visualize the tip of the filter with IVUS to ensure that caudal migration does not occur. Bedside placement of IVCF in critically ill patients is becoming more common. Major concerns of bedside placement are cost and potential missed venous anomalies. At our institution, use of the IVUS probe adds approximately $600 to the hospital cost of IVCF placement, which is offset by the expense incurred in use of the radiology suite or operating room and use of anesthesia personnel. However, data were not available for a completely accurate cost comparison between techniques. Venous anomalies remain a pitfall for both transabdominal ultrasound and IVUS-guided methods. Technical clues such as significant size differential between the suprarenal and infrarenal IVC or large branches below the renal veins serve as indications for venacavography. Furthermore, the percentage of venous abnormalities is sufficiently small that the benefits of bedside placement should outweigh the risk of a missed anomaly. IVUS-guided IVCF placement is an intriguing alternative to conventional fluoroscopic and transabdominal ultrasound-directed techniques. IVUS enables accurate measurement of IVC diameter, localizes the renal veins, averts the need for contrast agents, and eliminates the need to transport critically ill patients. Further assessment of this technique is warranted. In: Bedside intravascular ultrasound-guided vena cava filter placement. (Wellons ED, Matsuura JH, Shuler FW, Franklin JS, Rosenthal D.: J Vasc Surg 2003;38:455-8)Journal of Vascular SurgeryVol. 38Issue 5PreviewSeveral reports have demonstrated the efficacy of inferior vena cava filter (IVCF) placement with intravascular ultrasound guidance (IVUS). The majority of these procedures, however, have been done in concert with contrast venography and/or fluoroscopic guidance. The purpose of this report was to evaluate the potential for bedside IVCF placement with “real-time” IVUS guidance only. Full-Text PDF Open Archive