All Those IVC Filters

Thousands of filters were placed over the past decade and the cows are coming home to roost. My feeling is that if a removable filter goes in, there must be an appointment or mechanisms in place to arrange for it to come out, anticoagulation must be started as soon as feasible, and kept on as long as possible if the filter is to remain in. Failure is infrequent for the conical designs, and not an issue if the filter is removed. How long after implant that a filter can be removed seems to be a moving target. In my personal experience, I have safely removed them out to two years, but I have partners who have gone beyond that by multiples. Two rare late failure modes of IVC filters can be devastating and life threatening.

IVC Perforation

This patient developed a vague upper abdominal pain and plain radiography showed the filter on a tilt. CT shows the legs of this Simon Nitinol filter extending into the right kidney and duodenum.

The 3 D VR images assisted in operative planning –as is my habit, it rotate the image into the surgeons-eye perspective to plan the incision.

The green arrows point to the exposed legs of the filter once the right colon and duodenum were rotated out of the way. The duodenum required only a serosal suture. The vena cava above and below the filter and both renal veins had to be controlled to remove the filter which was extirpated in pieces. I have had to do this about once a year or two. The youngest patient I operated on was a 20 year old who had a filter placed after a car accident at 17, but never had it removed. The legs of the filter had eroded into his duodenum causing an abscess.

Iliocaval Thrombosis

The figure below shows two panels with a Trapease filter associated with an iliocaval thrombosis. This patient had cardiovascular collapse and severe bilateral lower extremity edema after a long car ride.

Venography showed iliocaval thrombosis. Thrombolysis was started and the second panel on right of Figure 1 shows the result.

Large WallStents were used to support the recanalized iliocaval system from the common femoral veins to the filter. A Palmaz stent was deployed across the filter (Figure 2).

Figure 3 shows the final result. Interestingly, stents placed across the inguinal ligament into the common femoral vein seem to do fine in contrast to those placed in the artery. IVUS is necessary to confirm good results. Acceptable short term, and durable mid to long term results are reported.

Remove Them While You Can

Filters should be considered a short term therapy to decrease the risk of pulmonary embolism, and should be removed as soon as it is safe. There seems to be no magic time interval beyond which removal cannot be attempted. If permanent filter placement is planned, it should only be for established indications.


The final frontiers -the open surgical niches


There are several areas yet to be satisfactorily traversed by endovascular technology and the common femoral artery is one area. While not completely a no stent zone, stents and interventions in the CFA do poorly compared to the open surgical alternative. As vascular surgeons we know that the key to inflow problems is the produnda femoris arteria and she does not tolerate being ignored, stented across, or ballooned too much. I have tabulated some areas that are still in the purview of open surgery in no particular order :

1: systemic infection
2: failure of stent grafts
3: rupture/hemorrhage/trauma
4: thoracic outlet obstructions
5: cancer
6: SVC syndrome after failure of interventions
8: popliteal entrapment
9: hypothenar hammer syndrome
10: very large thoracoabdominal or juxtarenal aortic aneurysms (until we get FDA approved off the shelf devices)
11: dialysis access
12: extreme limb salvage
13: severe aortic occlusive disease
14: CKD on the cusp of dialysis
15: congenital vascular disease
17: trauma/contaminated fields
18: low risk patients
19: common femoral artery
20: subclavian artery/innominate artery
21: carotid endarterectomy -for now

The list is open ended and you may add in the comments below, but the list in some parts is esoteric. The data is sobering if you read “Predicted shortfall in open aneurysm experience for vascular surgery trainees,” by Dua et al in the 10/2014 JVS. When I trained, I graduated with about 50 open AAA under my belt. Dua et al are predicting 10 per trainee in 2015, and 5 per trainee by 2020.

Who will do my open AAA?



Big Data


The NYT reports the increasing use of hospital EMRs and registries to help make clinical decisions based on experience not yet published. Of course we must use all the tools available within our databases which is an extension of our knowledge. But I also get the other side of the argument.

link to NYT article


Order your el aneurismo shirts


Link Here

The graphic is a painting I did several years ago meant to be a market sign for a vascular surgeon in some faraway place. I get no proceeds from their sale, but if I do, they will be turned over to a vascular related charity or foundation.