Volume 25
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Number 6
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June
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2014
Femoral Removal of Meridian Filter in a Patient with Central Venous Occlusion From: Thuong G. Van Ha, MD Steve Zangan, MD Deepa Sheth, MD Jonathan Lorenz, MD Department of Radiology University of Chicago 5841 South Maryland Avenue Chicago, IL 60637
Editor: The Meridian inferior vena cava (IVC) filter (Bard Peripheral Vascular, Inc, Tempe, Arizona) is approved as a permanent device designed for retrieval via an internal jugular vein approach. For retrieval, a blunted hook on the apex of the filter is ensnared; the filter is pulled into a sheath and subsequently removed. We report the removal of this filter via a femoral vein approach in a patient with central venous occlusion that precluded retrieval by the conventional internal jugular vein approach. Interventional review board approval was waived for this type of report. A 73-year-old woman with several medical comorbidities, including short gut syndrome requiring central lines for total parenteral nutrition, diabetes mellitus, and hypertension, developed worsening deep venous thrombosis while taking warfarin. She subsequently underwent placement of a Meridian IVC filter via the right common femoral vein approach at an outside institution. The patient was referred to our interventional radiology service 3 months later for IVC filter removal. The patient reported improvement in lower extremity swelling and was compliant with her oral anticoagulation medication. The patient was instructed to stop taking warfarin 3 days before the procedure. The procedure was performed under moderate sedation. Doppler ultrasound and bilateral cervical venograms obtained at the time of the procedure showed occluded bilateral jugular veins, innominate veins, and superior vena cava. A transfemoral filter removal was planned. Bilateral common femoral venous accesses were obtained. On the right side, an 8-F vascular sheath was placed (Pinnacle; Terumo Medical Corporation, Elkton, Maryland), and on the left side, an 8-F precurved Balkin sheath (Cook, Inc, Bloomington, Indiana) was placed over a 15-mm J-wire (Cook, Inc). From the right side, a 10-mm snare (Amplatz GooseNeck; ev3, Inc, Plymouth, Minnesota) was advanced to the level above the filter to where the contralateral Balkin sheath tip had been placed with the J-wire protruding through; the snare was used to grasp the wire and pull it down to None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.01.011
979
the level below the filter forming the primary curve of the Balkin sheath (Fig a–d). The control of the J-wire with the snare allowed the Balkin sheath to stay in its primary curved position above the filter. For subsequent maneuvers, the snare–guide wire system was kept taut to prevent movement of the Balkin sheath. A second, similar snare was introduced through the Balkin sheath, and the hook of the filter was engaged. With constant pressure on the J-wire snare combination maintaining the Balkin sheath in a curved and stiff position, the filter was sheathed partly by advancing the Balkin sheath. After partial capture of the filter, the filter was pulled into the sheath and out of the patient. A venogram obtained after retrieval showed no contrast extravasation or IVC narrowing. The patient was restarted on warfarin for anticoagulation. At 1-month followup examination, she was doing well without leg swelling or clinical evidence of pulmonary embolism. The design of conical filters prevents feet-first retrieval because the legs would catch on the end of the sheath and prevent sheathing. In our patient, the conventional internal jugular vein approach could not be used because the patient had chronic central venous occlusions. An alternative would be attempting recannulation of the occlusion through the small collateral neck veins as previously described (1) for central venous catheter placement, followed by removal of the filter when access to the IVC was established. A case of filter retrieval through a femoral vein approach was reported with the Günther Tulip filter (Cook, Inc). The authors described a technique in which the Tulip filter legs were collapsed with a snare from a right femoral approach (2). The filter was retracted and pulled down to the right common iliac vein. Antegrade retrieval was performed from an up-and-over left common femoral vein approach. The collapsibility of the Tulip filter was due to the filter design: four legs held together by secondary struts. The legs and the struts collapsed together to a point where the filter was small enough in profile to drag down the ipsilateral iliac vein system. The Meridian filter has six legs and six arms that are joined at the tip but are otherwise not bound together elsewhere. Collapsing the arms and legs together with a single snare to the point that the entire filter could be dragged down safely would be difficult. Collapsing just the legs leaving the arms open may cause damage to the IVC and could deform the filter. In our case, a different method to retrieve the filter from the femoral vein approach was devised. One femoral access allowed introduction of the curved contralateral Balkin sheath to the level above the filter. The left side was chosen because it allowed more room to maneuver as the filter was tilted to the right. The contralateral access allowed snaring a guide wire that had been introduced through the Balkin sheath to form and stabilize the sheath into a curve. The Balkin contralateral sheath was chosen because it was precurved and
980
’
Letters to the Editor
Van Ha et al
’
JVIR
Figure. (a) A Balkin sheath tip (arrow) was advanced via the left groin to the level above the filter, and a snare was introduced (dashed arrows) via the right groin. (b) The free end of the wire was grasped and pulled down with the snare (dashed arrow), forcing the tip of the Balkin sheath to curve downward (arrow). (c) A second snare was introduced through the Balkin sheath to grasp the tip of the filter (arrow). (d) The filter was pulled into the Balkin sheath. The tip of the filter is shown within the Balkin sheath (arrow). The first snare– guide wire combination (dashed arrow) was held taut for the Balkin sheath to maintain its desired curved shape.
Volume 25
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Number 6
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June
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2014
could easily form above the filter. Sizing of the type of precurved sheath to fit the IVC caliber might make it easier to form the curve; for example, a Flexor sheath (Cook, Inc) might be useful in different-caliber vessels. Potential complications from this nontraditional procedure include migration of the filter if it disengages from the snare at any time during the retrieval process, damage to the filter, and possible IVC injury if the legs are not entirely sheathed. The described technique might not work with filters that are made of stiffer material, such as the Celect filter (Cook, Inc). Whether this technique can be applied to filters with penetrating struts is unclear. Before deployment of a filter with intent to retrieve, a potential route for retrieval should be examined with ultrasound or other modalities so that the appropriate device could be placed. Devices designed for femoral retrieval include the OptEase filter (Cordis Corpora-
Blunt Breast Trauma Treated with Endovascular Embolization From: John Yoon, MD Christopher B. Ponce, BA Sohail Contractor, MD Department of Radiology (J.Y., S.C.) Rutgers Biomedical and Health Sciences University H108 150 Bergen Street University Hospital Newark, NJ 07101; and Rutgers New Jersey Medical School (C.B.P.) Newark, New Jersey
Editor: Institutional review board approval is not required at our center for case reports such as this. A 73-year-old female restrained (seat belt) driver was involved in a head-on motor vehicle collision with airbag deployment and presented with blunt trauma to the chest. On arrival to the emergency room, her pulse was 90 beats/min and blood pressure was 130/84 mm Hg. She had bruising at the lower right breast and chest area. The secondary trauma survey was unremarkable, and she had no other injuries. Chest radiograph demonstrated bilateral rib fractures without lung parenchymal or pleural abnormalities. Computed tomography (CT; Fig 1a) showed a large right breast hematoma with an area of contrast medium extravasation in the inferior lateral right breast and axillary soft tissues. During a 5-hour observation period, her blood pressure decreased to 118/80 mm Hg and pulse to 110 beats/min. Reductions in hemoglobin and hematocrit from 13.8 g/dL and 39.3% to 8.5 g/dL and 25.0%, respectively, indicated ongoing hemorrhage. There was no coagulopathy noted. None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.02.003
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tion, Bridgewater, New Jersey) (3) and the Crux filter (Volcano Corporation, San Diego, California) (4).
REFERENCES 1. Funaki B, Zaleski GX, Leef JA, Lorenz JN, Van Ha T, Rosenblum JD. Radiologic placement of tunneled hemodialysis catheters in occluded neck, chest, or small thyrocervical collateral veins in central venous occlusion. Radiology 2001; 18:471–476. 2. Van Ha TG, Keblinskas D, Funaki B, Lorenz J. Removal of Günther Tulip vena cava filter through femoral vein approach. J Vasc Interv Radiol 2005; 16:391–394. 3. Rimon U, Bensaid P, Golan G, et al. Optease vena cava filter optimal indwelling time and retrievability. Cardiovasc Intervent Radiol 2011; 34: 532–535. 4. Smouse HB, Mendes R, Bosiers M, Van Ha TG. The RETRIEVE trial: safety and effectiveness of the retrievable Crux vena cava filter. J Vasc Interv Radiol 2013; 24:609–621.
Physical examination revealed a markedly swollen and tender right breast (Fig 1b). Selective right subclavian angiogram revealed hemorrhage arising from a branch of the lateral thoracic artery (Fig 2a). This branch vessel was selectively catheterized with a 3-F microcatheter (Progreat; Terumo, Somerset, New Jersey) and embolized by using flow-directed embolization with gelatin sponge slurry (Gelfoam; Pharmacia and Upjohn, Kalamazoo, Michigan) and a single 2-mm Nester microcoil (Cook, Bloomington, Indiana). No extravasation was seen on the subsequent angiogram (Fig 2b). She was sent to the surgical intensive care unit, where her vital signs improved (blood pressure, 136/84 mm Hg; pulse, 80 beats/min), and she required no further blood transfusions. Her hemoglobin levels remained stable after the procedure for 72 hours (range, 9.3–10.9 g/ dL). She was subsequently discharged home 5 days after her initial presentation with no further interventions or surgery being performed for the hematoma. Blunt trauma to the chest following motor vehicle accidents is commonly the result of a head-on collision at high speeds with airbag deployment. The “seat belt syndrome” is composed of injuries related to the use of three-point seatbelts (1), and includes soft-tissue and bony injuries to the chest and upper abdominal organs. Injury mechanism is related to the direct compression as well as shearing forces on the trunk. Seat belt injuries producing breast injuries are infrequently seen. In a retrospective study on female blunt breast trauma in a level I trauma center, Sanders et al (2) reported that only 108 of 5,305 women with blunt chest trauma (2%) presented with breast trauma. Of the women with blunt breast trauma, 94% of the cases were related to motor vehicle accidents. The majority of cases (n ¼ 101; 93.5%) required conservative nonoperative or noninterventional care. However, seven patients required treatment related to hemodynamic instability. Six patients were referred for angiography, of which four received embolization, and surgical ligation of the feeding vessel was performed in the seventh patient.
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Number 6
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June
’
2014
Femoral Removal of Meridian Filter in a Patient with Central Venous Occlusion From: Thuong G. Van Ha, MD Steve Zangan, MD Deepa Sheth, MD Jonathan Lorenz, MD Department of Radiology University of Chicago 5841 South Maryland Avenue Chicago, IL 60637
Editor: The Meridian inferior vena cava (IVC) filter (Bard Peripheral Vascular, Inc, Tempe, Arizona) is approved as a permanent device designed for retrieval via an internal jugular vein approach. For retrieval, a blunted hook on the apex of the filter is ensnared; the filter is pulled into a sheath and subsequently removed. We report the removal of this filter via a femoral vein approach in a patient with central venous occlusion that precluded retrieval by the conventional internal jugular vein approach. Interventional review board approval was waived for this type of report. A 73-year-old woman with several medical comorbidities, including short gut syndrome requiring central lines for total parenteral nutrition, diabetes mellitus, and hypertension, developed worsening deep venous thrombosis while taking warfarin. She subsequently underwent placement of a Meridian IVC filter via the right common femoral vein approach at an outside institution. The patient was referred to our interventional radiology service 3 months later for IVC filter removal. The patient reported improvement in lower extremity swelling and was compliant with her oral anticoagulation medication. The patient was instructed to stop taking warfarin 3 days before the procedure. The procedure was performed under moderate sedation. Doppler ultrasound and bilateral cervical venograms obtained at the time of the procedure showed occluded bilateral jugular veins, innominate veins, and superior vena cava. A transfemoral filter removal was planned. Bilateral common femoral venous accesses were obtained. On the right side, an 8-F vascular sheath was placed (Pinnacle; Terumo Medical Corporation, Elkton, Maryland), and on the left side, an 8-F precurved Balkin sheath (Cook, Inc, Bloomington, Indiana) was placed over a 15-mm J-wire (Cook, Inc). From the right side, a 10-mm snare (Amplatz GooseNeck; ev3, Inc, Plymouth, Minnesota) was advanced to the level above the filter to where the contralateral Balkin sheath tip had been placed with the J-wire protruding through; the snare was used to grasp the wire and pull it down to None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.01.011
979
the level below the filter forming the primary curve of the Balkin sheath (Fig a–d). The control of the J-wire with the snare allowed the Balkin sheath to stay in its primary curved position above the filter. For subsequent maneuvers, the snare–guide wire system was kept taut to prevent movement of the Balkin sheath. A second, similar snare was introduced through the Balkin sheath, and the hook of the filter was engaged. With constant pressure on the J-wire snare combination maintaining the Balkin sheath in a curved and stiff position, the filter was sheathed partly by advancing the Balkin sheath. After partial capture of the filter, the filter was pulled into the sheath and out of the patient. A venogram obtained after retrieval showed no contrast extravasation or IVC narrowing. The patient was restarted on warfarin for anticoagulation. At 1-month followup examination, she was doing well without leg swelling or clinical evidence of pulmonary embolism. The design of conical filters prevents feet-first retrieval because the legs would catch on the end of the sheath and prevent sheathing. In our patient, the conventional internal jugular vein approach could not be used because the patient had chronic central venous occlusions. An alternative would be attempting recannulation of the occlusion through the small collateral neck veins as previously described (1) for central venous catheter placement, followed by removal of the filter when access to the IVC was established. A case of filter retrieval through a femoral vein approach was reported with the Günther Tulip filter (Cook, Inc). The authors described a technique in which the Tulip filter legs were collapsed with a snare from a right femoral approach (2). The filter was retracted and pulled down to the right common iliac vein. Antegrade retrieval was performed from an up-and-over left common femoral vein approach. The collapsibility of the Tulip filter was due to the filter design: four legs held together by secondary struts. The legs and the struts collapsed together to a point where the filter was small enough in profile to drag down the ipsilateral iliac vein system. The Meridian filter has six legs and six arms that are joined at the tip but are otherwise not bound together elsewhere. Collapsing the arms and legs together with a single snare to the point that the entire filter could be dragged down safely would be difficult. Collapsing just the legs leaving the arms open may cause damage to the IVC and could deform the filter. In our case, a different method to retrieve the filter from the femoral vein approach was devised. One femoral access allowed introduction of the curved contralateral Balkin sheath to the level above the filter. The left side was chosen because it allowed more room to maneuver as the filter was tilted to the right. The contralateral access allowed snaring a guide wire that had been introduced through the Balkin sheath to form and stabilize the sheath into a curve. The Balkin contralateral sheath was chosen because it was precurved and
980
’
Letters to the Editor
Van Ha et al
’
JVIR
Figure. (a) A Balkin sheath tip (arrow) was advanced via the left groin to the level above the filter, and a snare was introduced (dashed arrows) via the right groin. (b) The free end of the wire was grasped and pulled down with the snare (dashed arrow), forcing the tip of the Balkin sheath to curve downward (arrow). (c) A second snare was introduced through the Balkin sheath to grasp the tip of the filter (arrow). (d) The filter was pulled into the Balkin sheath. The tip of the filter is shown within the Balkin sheath (arrow). The first snare– guide wire combination (dashed arrow) was held taut for the Balkin sheath to maintain its desired curved shape.
Volume 25
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Number 6
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June
’
2014
could easily form above the filter. Sizing of the type of precurved sheath to fit the IVC caliber might make it easier to form the curve; for example, a Flexor sheath (Cook, Inc) might be useful in different-caliber vessels. Potential complications from this nontraditional procedure include migration of the filter if it disengages from the snare at any time during the retrieval process, damage to the filter, and possible IVC injury if the legs are not entirely sheathed. The described technique might not work with filters that are made of stiffer material, such as the Celect filter (Cook, Inc). Whether this technique can be applied to filters with penetrating struts is unclear. Before deployment of a filter with intent to retrieve, a potential route for retrieval should be examined with ultrasound or other modalities so that the appropriate device could be placed. Devices designed for femoral retrieval include the OptEase filter (Cordis Corpora-
Blunt Breast Trauma Treated with Endovascular Embolization From: John Yoon, MD Christopher B. Ponce, BA Sohail Contractor, MD Department of Radiology (J.Y., S.C.) Rutgers Biomedical and Health Sciences University H108 150 Bergen Street University Hospital Newark, NJ 07101; and Rutgers New Jersey Medical School (C.B.P.) Newark, New Jersey
Editor: Institutional review board approval is not required at our center for case reports such as this. A 73-year-old female restrained (seat belt) driver was involved in a head-on motor vehicle collision with airbag deployment and presented with blunt trauma to the chest. On arrival to the emergency room, her pulse was 90 beats/min and blood pressure was 130/84 mm Hg. She had bruising at the lower right breast and chest area. The secondary trauma survey was unremarkable, and she had no other injuries. Chest radiograph demonstrated bilateral rib fractures without lung parenchymal or pleural abnormalities. Computed tomography (CT; Fig 1a) showed a large right breast hematoma with an area of contrast medium extravasation in the inferior lateral right breast and axillary soft tissues. During a 5-hour observation period, her blood pressure decreased to 118/80 mm Hg and pulse to 110 beats/min. Reductions in hemoglobin and hematocrit from 13.8 g/dL and 39.3% to 8.5 g/dL and 25.0%, respectively, indicated ongoing hemorrhage. There was no coagulopathy noted. None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.02.003
981
tion, Bridgewater, New Jersey) (3) and the Crux filter (Volcano Corporation, San Diego, California) (4).
REFERENCES 1. Funaki B, Zaleski GX, Leef JA, Lorenz JN, Van Ha T, Rosenblum JD. Radiologic placement of tunneled hemodialysis catheters in occluded neck, chest, or small thyrocervical collateral veins in central venous occlusion. Radiology 2001; 18:471–476. 2. Van Ha TG, Keblinskas D, Funaki B, Lorenz J. Removal of Günther Tulip vena cava filter through femoral vein approach. J Vasc Interv Radiol 2005; 16:391–394. 3. Rimon U, Bensaid P, Golan G, et al. Optease vena cava filter optimal indwelling time and retrievability. Cardiovasc Intervent Radiol 2011; 34: 532–535. 4. Smouse HB, Mendes R, Bosiers M, Van Ha TG. The RETRIEVE trial: safety and effectiveness of the retrievable Crux vena cava filter. J Vasc Interv Radiol 2013; 24:609–621.
Physical examination revealed a markedly swollen and tender right breast (Fig 1b). Selective right subclavian angiogram revealed hemorrhage arising from a branch of the lateral thoracic artery (Fig 2a). This branch vessel was selectively catheterized with a 3-F microcatheter (Progreat; Terumo, Somerset, New Jersey) and embolized by using flow-directed embolization with gelatin sponge slurry (Gelfoam; Pharmacia and Upjohn, Kalamazoo, Michigan) and a single 2-mm Nester microcoil (Cook, Bloomington, Indiana). No extravasation was seen on the subsequent angiogram (Fig 2b). She was sent to the surgical intensive care unit, where her vital signs improved (blood pressure, 136/84 mm Hg; pulse, 80 beats/min), and she required no further blood transfusions. Her hemoglobin levels remained stable after the procedure for 72 hours (range, 9.3–10.9 g/ dL). She was subsequently discharged home 5 days after her initial presentation with no further interventions or surgery being performed for the hematoma. Blunt trauma to the chest following motor vehicle accidents is commonly the result of a head-on collision at high speeds with airbag deployment. The “seat belt syndrome” is composed of injuries related to the use of three-point seatbelts (1), and includes soft-tissue and bony injuries to the chest and upper abdominal organs. Injury mechanism is related to the direct compression as well as shearing forces on the trunk. Seat belt injuries producing breast injuries are infrequently seen. In a retrospective study on female blunt breast trauma in a level I trauma center, Sanders et al (2) reported that only 108 of 5,305 women with blunt chest trauma (2%) presented with breast trauma. Of the women with blunt breast trauma, 94% of the cases were related to motor vehicle accidents. The majority of cases (n ¼ 101; 93.5%) required conservative nonoperative or noninterventional care. However, seven patients required treatment related to hemodynamic instability. Six patients were referred for angiography, of which four received embolization, and surgical ligation of the feeding vessel was performed in the seventh patient.
