IVUS-Guided VCF Placement
An alternative approach to an increasingly popular vena cava filter placement technique.
The number of articles reporting the safety and clinical usefulness of bedside placement of vena cava filters continues to grow.1-6 Critically ill patients with injuries that increase the risk of deep venous thrombosis and pulmonary embolism are the main indication for this procedure. The concept of bedside placement of vena cava filters brings the filter to the patient, and reduces the risks and inconvenience associated with the transportation of the patient to the operating room or radiology suite. I would like to share our approach and discuss alternative techniques to visualization of the vena cava using standard fluoroscopy.
Our early experimental animal research revealed two important concerns:7 (1) Due to the lack of spatial orientation and difficulty entering the inferior vena cava without fluoroscopy, the jugular approach should be avoided with this technique. (2) Even with proper technique, movement occurred during vena cava filter placement, and therefore “real time” imaging was important in accurate deployment of the device. Consequently, we adopted a technique accessing the ipsilateral femoral vein twice, passing two guidewires into the vena cava.
An 8-F sheath is placed for insertion of the IVUS catheter and vein mapping from the right atrium of the heart to the iliac vein bifurcation. This not only verifies the location of the renal veins, but also aids in the identification of any potential anatomic variations. The IVUS catheter is then positioned at the level of the renal veins, and diameter measurement is obtained to ensure the vena cava diameter is acceptable (<28 mm) (Figure 1). The vena cava filter delivery system is then placed into the vena cava over the second wire and the filter is loaded into the tip of the delivery sheath. The delivery catheter is withdrawn until a strong acoustic shadow is seen, indicating the vena cava filter is passing the IVUS catheter inside the delivery sheath. When the acoustic shadow disappears and advancing the catheter slightly demonstrates reappearance of the acoustic shadow, the tip of the vena cava filter is level with the IVUS catheter tip and, therefore, located just below the level of the renal veins (Figure 2).
Keeping the IVUS catheter steady, the filter is slowly deployed, with constant visualization of the tip of the vena cava filter to ensure accurate deployment (Figure 3). My preference has been use of the OptEase vena cava filter (Cordis Endovascular, a Johnson & Johnson company, Miami, FL), but this technique can be used with other filter devices.
It is also worth mentioning that both IVUS and carbon dioxide venography are alternative techniques for fluoroscopically assisted vena cava filter placement in patients with severe intravenous contrast allergy or renal insufficiency.8 Visualization is very good with carbon dioxide and avoids the need to use contrast agents and prophylaxis with steroids and diphenhydramine in patients with contrast allergy. When using IVUS, I perform the same pullback mapping technique and, once the renal veins are located, I lock the C-arm fluoroscopy unit and mark the tip of the IVUS catheter with a hemostat (Figure 4) as the IVUS catheter is removed and replaced with the vena cava filter delivery catheter. The vena cava filter can then be deployed safely below the hemostat marker (Figure 5).
In my opinion, IVUS is often underutilized in most endovascular practices. This application of IVUS has grown in popularity and offers a service to our critically ill patients. With experience, I believe this approach is more accurate than fluoroscopic placement.
John H. Matsuura, MD, is from The Vascular Disease Institute, Gainesville, Georgia. He has disclosed that he holds no financial interest in any product or manufacturer mentioned herein. Dr. Matsuura may be reached at (770) 534-0110; firstname.lastname@example.org.
1. Wellons ED, Matsuura JH, Shuler FW, et al. Bedside intravascular ultrasound-guided vena cava filter placement. J Vasc Surg. 2003;38:455-457.
2. Wellons ED, Rosenthal D, Shuler FW, et al. Real-time intravascular ultrasound-guided placement of a removable inferior vena cava filter. J Trauma. 2004;57:20-23.
3. Rosenthal D, Wellons ED, Levitt AB, et al. Role of prophylactic temporary inferior vena cava filters placed at the ICU bedside under intravascular ultrasound guidance in patients with multiple trauma. J Vasc Surg. 2004;40:958-964.
4. Ebaugh JL, Chiou AC, Morasch MD, et al. Bedside vena cava filter placement guided with intravascular ultrasound. J Vasc Surg. 2001;34:21-26.
5. Garrett JV, Passman MA, Guzman RJ, et al. Expanding options for bedside placement of inferior vena cava filters with intravascular ultrasound when transabdominal duplex ultrasound imaging is inadequate. Ann Vasc Surg. 2004;18:329-334.
6. Ashley DW, Ganblin TC, McCampbell BL, et al. Bedside insertion of vena cava filters in the intensive care unit using intravascular ultrasound to locate renal veins. J Trauma. 2004;57:26-31.
7. Matsuura JH, White RA, Kopchock G, et al. Vena caval filter placement by intravascular ultrasound. Cardiovasc Surg. 2001;9:571-574.
8. Bonn J, Liu JB, Eschelman DJ, et al. Intravascular ultrasound as an alternative to positive-contrast cavography prior to filter placement. J Vasc Interv Radiol. 1999;10:843-849.