How to place IVC filter

 

Use Cook Gunther Tulip IVC filter kit

Specific Jugular access or Femoral access, kit is different and could place IVC filter wrong way ( has happened to famous attendings)

 

For femoral approach, V/S style

Typical indication inability to anticoagulate d/t trauma/head bleed and DVT and/or PE

Prep and drape R groin

Lidocaine anesthesia

Access R CFV using micropuncture, demarcate inf. Aspect of femoral head or iden SFJ

Slide bentson wire up into IVC

Advance 10F dilator over wire

Advance 8.5 french sheath-dilator over wire into IVC near junction of iliacs

Want to shoot a run at this level ie cavagram to identify anatomy at level of renal veins (can also review prior imaging)

 

How to use CO2 for venography (story within story like Arabian Nights)

Co2 tank comes into room

Use two sterile IV tubings piggybacked

Use 60 cc luer lock syringe to fill with CO2

Use 3 way stopcock on syringe

Basically ask RT to expel some Co2

Fill syringe (60) with Co2 2-3 times and purge, then fill up and lock (can use finger or flowswitch)

 

Through sidearm of sheath, get blood return back

Then infuse Co2 and shoot cavagram DSA

Check anatomy, will see inflow from renals

Make plan for placement at level of vertebrae, usually sup aspect L2

 

Advance sheath to level of placement

Advance IVC filter through sheath

Goal is to unsheathe filter and then deploy

When have filter at correct level, pull sheath back while keeping filter in place

To deploy filter, click safety and then press large button on filter device

Can shoot repeat DSA cavagram post placement

Remove all components from groin

Hold pressure till hemostasis

Case end

 

Cook IFU and website are very informative

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laser assisted IVC Filter removal

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Laser assited IVC filter removal

Aka

Lsr-IVCF-R

 

Goal is to use laser sheath as a form of circumferential tissue ablation to knock off the fibrin sheath encasing the cranial aspect of the filter

 

Access RIJ same as for placement

Wires to use include bentson, amplatz, might need glide if going past obs

 

Do a cavagram initially using pigtail cath below filter to check for thrombus etc, whatever, prolly still will go forward kinda thing

 

Upsize to a fat 18F sheath with air filled valve

-fill valve with air to decrease blood loss, take out air when adding items to sheath

 

advance “laser” sheath through 18F sheath (believe its 14F)

 

advance snare- EN or Loop- through 14F laser sheath

 

goal is to trap filter apical hook

 

addt’l step that can be used: 

loop snare technique:  use reverse curve cath or omni flush to hook caudal aspect of filter, pass glidewire through, snare glidewire into sheath and pull out and then grab filter by the horns by grabbing both free ends of the glidewire, use this in combination with laser sheath

 

once have filter apical hook

advance laser sheath down

hit laser pedal, can always ask rep for help

the laser burns apparently like microns at each go

laser is on for 10s only

slow caudal pressure on sheath while laser is on

should see sheath slowly collapsing filter

at some pint filter is ‘free” (like I once was)

pull sheath to check for filter out intactness

 

now can do repeat cavagram to ass ess for possible ivc injury

if present, not sure what to do other than inflat ebaloon and possibly covered stent if needed but size would have to be humongous

 

could do prolonged inflation to tamp hole

 

ok case end

 

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how to place IVC F tips

in order to decrease tilt

when you releas the filter, as for Cook Celect

when unseheathing, you should almost be leaning back

do not push forard

even if it seems that you are not pushing forward (kinda  a crazy trick)

have to "lean back"

that way it deploys straight

saw this work

as per IB, if the filter is straighter, it will filtrate the IVC better and be more effective

its physics man

be careful in HD pts, your wire may not be where you think it is

half the battle is dealing witha  f**** attending over your head - sg

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how to remove IVCF 

aka IVCF-R

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per IB

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use cook retreival kit

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its a coaxial sheath with a loop snare catheter-wire

the sheath has multiple sidearms, just fluhs them and lock with clave caps (IB does it)

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get access, do a cavagram

get the snare down to the top o fthe filter

mag up

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you want to snare the apical hook]

ift its embedded in tissueyou wont be able to snare it

you want to snare just the hook

once you have the hook, hold tension on the loop and then push the catheter forward

this makes the snare device in a closed config with the hook snared

then tighten the pin vice onthe wire (loop snare wire)

this saves the wire position

then retract on the snare catheter adn then you can lock the tuohy

this locks the snare catheter in a cephalad retraction direction

then you have to serially advance the sheaths to colalpse the filter

you can spin the sheaths to dissect thru the tissue

eventually you may have to pull really hard to collpase the filter and pull it out

after filter out you want to do a cavagram

you may see IVC spasm

if you see a tear you want to advance a large balloon down there and tamp it

however that would be extremel rare to see

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how to drop a filter (like its hot) by SGMD bya

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RIJ stick

145 cm aplatz down to LCIV- put curve on the wire first

go straight to kit- cook celect is my fav right now

advance sheath dilator down to L CIV

do cavogram thru dilator

position filter apex at crus of the inflows of renal veins

mark it on the screen

pull out dilator, advance filter sheath

get it tip to tip

lock it

pull back while holding back tension

keep safety off - my thing

once it looks like drop it like its hot

do a followup cavagram thru the sheath

pull out and donezo

how its done son

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advanced filter retreival tips:

do loop snare

use omin flush exch length glide, 1-2cm snrae to grab wire one across filter

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VERY IMPORTANT:

when have both ends of the wire, use kelly to grasp both and then TWIST

keep twisting to one direction, this will straighten out system and provide severe axial tension to help pull filter out

carefulbecuase you can break pieces of filter off- did this on 4/3/2017

often when you break pieces off, apex becomes free and can snare it again

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IVCF placement - greenfield

for pts who need lifelong filtration

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12F sheath i tlbeive

its pretty much same

the sheath has a aerostatic valve that you have to twist and lock

you advance the filter introducer through the sheath and screw it togehter

then while holding the system still, you use the lock to unlock and then release the filter

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