Double series Filters in Treating Inferior Vena Cava Filter-mediated Thrombosis

Double series Filters in Treating Inferior Vena Cava Filter-mediated Thrombosis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Double series Filters in Treating Inferior Vena Cava Filter-mediated Thrombosis Zuanbiao Yu, Songjie Hu, Tiequan Yang, Shuyi Lyv, Dehai Lang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2237453/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: As the exponential increase in the number of inferior vena cava (IVC) filters in China, it has become a major predisposing factor for IVC filters-mediated thrombosis. This is an important risk factor for thrombosis recurrence. What’s more, the long-term implantation of the filter will bring many uncertainties. This study is aim to summarize our experience and introduce a strategy safely in treating IVC filters-mediated thrombosis. Methods: The clinical data were collected and analyzed from seven patients (3 female and 4 male) who suffered IVC filters-mediated thrombosis in our center from August 2018 to June 2022. In this group, the time of IVC filters thrombosis was not exceeding two weeks. According to the location and morphology of the thrombosis in the filter, we adopt two access (Femoral vein or Jugular vein) puncture to implant the supra-renal IVC filter. Then, all steps were performed under the protecting to retrieval the double series IVC filters and thrombosis. Pulmonary Embolism(PE) assessment was taken measure by computed tomography pulmonary angiography (CTPA) . Results: In this study, Technical success rate was 100% to retrieval the double series IVC filters. The volume of IVC filters-mediated thrombosis in those patients was exceeded 1 mL.71.4% (5/7) of cases present the existing thrombosis located in the filters, 1 patient (14.3%, 1/7) has the thrombosis located both inside and floating above the filter, as well as 1 patient (14.3%, 1/7) having thrombosis located both inside and underneath the filter. Six patients removed the suprarenal IVC filters in I stage, and only one patient removed it in II stage. On removing the thrombosis, five patients were removed completely and only two were partially, including 3 patients with the help of catheter-directed thrombolysis(CDT)therapy. No procedure-related complications were observed. The median follow-up time was 22.5 months. No recurrence of thrombus symptoms was reported, B ultrasound and CTPA showed that the blood flow in the inferior vena cava and pulmonary artery were smooth. Conclusions: For the patients who suffered from IVC filters-mediated thrombosis no longer than two weeks, using double series IVC filters to protect the patients is a safe approach and could improve the retrieve rate of IVC filters at early stages. Inferior vena cava filter thrombosis pulmonary angiography Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Prior studies have estimated that Inferior vena cava (IVC) thrombosis occurs in between 2.6% and 4.0% of patients with lower extremity deep vein thrombosis. 1-3 However, as the exponential increase in the number of IVC filters in China, it has become a major predisposing factor to IVC thrombosis. Unfortunately, part of the patients with IVC filters-mediated thrombosis are suffering from significant morbidities including post-thrombotic syndrome (PTS), pulmonary embolism. What's more, concerning about filter complications are also rising as time goes on, such as filter penetration, fracture, tilting. 4-6 Thus, removing the IVC filters in the early stage is the key to reducing such complications. In this study, we summarize our experience on how to treat the IVC filters-mediated thrombosis for those who were existed no more than two weeks, and introduce a strategy safely on using double series IVC filters to protect the patients and improved the retrieve rate of IVC filters at early stage. Methods Patients See Table 1 for patient demographics. Clinical characteristics and imaging findings of patients who underwent double series IVC filters for treating IVC filters-mediated thrombosis in our center from August 2018 to June 2022, were analyzed. There were 3 female and 4 male patients. Of those, 2 patients had history of fracture, 1 had abdominal hematoma, 3 patients had a history of percutaneous mechanical thrombectomy (PMT) treatment, and 1 had a history of surgery with lung cancer. All patients provided written informed consent before the procedure. Table 1 Case data No. Age Gender Medical history Preoperative PE Anticogaulation Index of D-D(IU/L) 1 55y Female Popliteal vein thrombosis was found 2 days before femoral neck fracture No Rivaroxaban 1200 2 82y Male Posterior tibial vein thrombosis was found 2 days before patella fracture Distal branch of right Rivaroxaban 1400 3 43y Female Abdominal hematoma with femoral vein thrombosis for 3 days No No 2300 4 66y Female After PMT for DVT(Left) Distal branch of left Rivaroxaban 1000 5 40y Male After PMT for DVT(Right) Distal branch of left Rivaroxaban 700 6 70y Female After PMT for DVT(Left) No Warfarin 800 7 68y Female Popliteal vein Thrombosis occurred 1 week after lung cancer surgery Distal branch of both Warfarin 1200 Filters And Thrombus All filters (LifeTech Scientific Co. Ltd, Shenzhen, China) are retrievable. In this study, the first time of infrarenal IVC filters were set no more than two weeks. Time of suprarenal filter operation is divided into two stage, I stage is defined as filter implantation and removal were performed in the same operation; II stage is defined as the filter was removed after 2 weeks to the suprarenal filter placement. Filter-associated thrombus was assessed by the radiologist who determined whether the thrombus was likely an embolus caught by the filter, based predominantly on size, cylindrical shape, and apical location. Filter Placement and Retrieval All operations were performed under local anesthesia. Access was established by healthy side of femoral vein, and the angiographic catheter was placed in inferior vena cava to evaluate the location between thrombosis and filters through venography, see (Table 3) below for details. First, if the IVC filters-mediated thrombosis was located in and below the filter ( Fig. 1 ) . And the patient had low risk of bleeding, the catheter-directed thrombolysis (CDT) treatment would be scheduled with Urokinase (500,000 IU, 2ml/h), and monitoring of coagulation function closely. Next, the venography evaluated again and found whether there had the residual thrombosis in IVC filter. The suprarenal IVC filter would be set while the thrombosis was more than 1mL. Usually, if IVC diameter in supra-renal segment was too large for filter placement, the filter would be placed on the supra-renal segment but not released completely in that condition.Then, the infrarenal IVC filter which was placed before ( Fig. 2 ) would be removed out through a 9-Fr Fustar steerable guiding catheter of 55cm in length (LifeTech Scientific Co. Ltd, Shenzhen, China). After step, the IVC imaging would be done again and evaluated the residual thrombosis captured in the suprarenal IVC filter. When the residual thrombosis was less than 1mL, the suprarenal IVC filter would be remove out ( Fig. 3 , Fig. 4 ) . On the contrary, we would wait 2 weeks for evaluation again through venography, and the patient was treated with an oral anticoagulant in this period. However, when the patient was assessed with high risk of bleeding, the suprarenal IVC filter would be placed at the first time. And then, the infrarenal IVC filter would be removed due to the maximum time limit of filter, some thrombus would attach on the filter could also been taken out through the 9-Fr guiding catheter. Finally, the IVC imaging will be evaluated whether to remove the suprarenal IVC filter or not. Second, if the IVC filters-mediated thrombosis was located above filter or there had a floating thrombus above the filter. In this situation, the first step was placed the suprarenal IVC filter by jugular vein access to protect the patients against the PE happened. And next step was the same as those thrombosis which located in and below the filter. See Table 3 for the specific process about how to place and remove the double series IVC filters. Pulmonary Embolism Assessment Validity assessment of PE is the key to treatment of patients. Thus, when the IVC filters-mediated thrombosis removed, images of IVC should be done at the first time. Certainly, the pulmonary artery venography should be taken for the patients who was observed any discomfort, such as shortness of breath in the chest. Besides, the pulmonary artery CT need to examine further after surgery. If thrombosis was existing in branch of pulmonary artery, the anticoagulant therapy should be extended at least 6 months. Follow-up And Accessment Of Outcomes All patients had been clinically evaluated at our institution and imaging during the follow-up period. Including clinical and relevant examination with B ultrasound or CTPA, to showed that the blood flow in the inferior vena cava and pulmonary artery were smooth or not. Statistical Analysis The clinical records, images and digital subtraction angiography were reviewed retrospectively. Parametrical continuous variables are expressed as the mean value ± standard deviation, whereas nonparametric continuous variables are given as the median, Categorical variables are reported as counts with proportions. Results In this group, 5 patients with thrombosis located in the filters, 1 patient (No.3) with part thrombosis located in the filter and others floating above the filter, another 1 patient (No.4) with part thrombosis located in the filter and others bellow the filter. Technical success was achieved in all seven patients. 6 patients removed suprarenal filters in I stage, only 1 (No.3) in II stage. Thrombosis were mostly removed in five patients and partially removed in two patients. There were no related complications happened. 3 patients (No.4, No.5, No.6) assisted with catheter-directed thrombolysis (CDT) treatment, the average of time was 5.3 d. There had 4 patients not assisted with CDT because of the high risk of bleeding. The median follow-up time was 22.5 months. After discharge, 6 patients accepted oral warfarin or rivaroxaban for anticoagulant therapy. Only 1 person (No.3) who had contraindication of anticoagulation and not accepted, however, she was taken rivaroxaban after second discharge. Of those, no recurrence of thrombosis symptoms and the inferior vena cava was smooth through ultrasound during the follow-up period. See Table 2 below for details. Table 2 The technique of using double filters and outcomes No. Positon of thrombus Time of CDT (d) Thrombus clearance of CDT Access of suprarenal filter Time of suprarenal filter(I/II) Postoperative chest depression Postoperative PE 1 In filter / / Femoral Vein I Stage No No 2 In filter / / Femoral Vein I Stage No No progress 3 Part in filter and other floating above the fliter / / Jugular Vein II Stage No Distal branch of left 4 Below the filter and part in the filter 5d > 1mL Femoral Vein I Stage No No progress 5 In filter 5d > 1mL Femoral Vein I Stage No No progress 6 In filter 6d > 1mL Femoral Vein I Stage No No 7 In filter / / Femoral Vein I Stage No No progress Discussion IVC filter devices aim to prevent pulmonary thromboembolism in patients with lower limb deep venous thrombosis. Literature demonstrates that many IVC filters that are placed may not be retrieved, thus increasing the likelihood of future complications. Ramakrishnan G, et al 7 analysised that 1.8% and 3.1% developed immediate and delayed complications in 14,784 patients, and Thrombosis in filter was very common. A systematic review of retrievable IVC filters found that primary complication rates varied widely with thrombosis ranging from 6–30% 8 . Therefore, it brought with many challenges for retrieving filters. In terms of treatment for filter thrombosis, CDT could reduce thrombus burden in filter for those with acute or subacute thrombus 9 , but even someone had the high risk of bleeding and the thrombosis had not removed completely. Such as in our study, 4 patients had not assisted with CDT because of the high risk of bleeding, including 1 person along with abdominal hematoma, and the feature of thrombus tends to be chronic in other 3 persons. Comparing with CDT alone, Li WD, et al. 10 found that CDT combined with aspiration thrombectomy had better performing thanks to a shorter thrombolysis time and a lower urokinase dose required. However, increasing the occurrence of complications, such as acute renal injury and hemoglobinuria. Therefore, it was still necessary to find an effective solution to avoid these risks for patients with IVC filters-mediated thrombosis. In our study, we used suprarenal IVC filter to protect the patient and retrieval double filters successfully accompanied by thrombosis which was found no more than two weeks. The result of this method was satisfactory. Nevertheless, the indications and procedures with using double filters should been grasped. First, how to place and remove the second filter is important. As for the suprarenal IVC filter, seeking a suitable situation for placement would be very important. Before placed the suprarenal IVC filter, we should comprehensively evaluate on imaging of IVC and clarify the situation between the filter and thrombosis. Traditionally, the suprarenal IVC filter placement is preferred by femoral vein access. However, if a free-floating thrombus above the infrarenal filter, jugular vein access is suitable. Sometime, the diameter of the IVC is related to venous return, blood volume, and the respiratory cycle. Compared with an infrarenal IVC, a suprarenal IVC is larger in diameter but shorter in length 11 . When the suprarenal IVC is too larger to deployed the filter, we will choosing in those position but not released completely in order to remove it convenient with the I stage. As for the time to remove the suprarenal IVC filter. In our study, 6 of 7 patients had retrieved at the I stage, only 1 person still had partial thrombosis in suprarenal IVC filter after removing the first filter through venography, 2 weeks later with adequate anticoagulation therapy, she was scheduled to imaging again and showed that the thrombus was significantly reduced, and then, the suprarenal IVC filter was removed out. In our study, the renal vein thrombosis had not encountered in those process. We thought the reasons of that the anticoagulant therapy was followed after placement of the suprarenal IVC filter. Besides, it was more attention to reduce the thrombus escaped into the renal vein. Especially for those thrombosis under the filter. Second, the risk of bleeding for thrombolysis treatment should been evaluated. Especially, for the elderly patients or someone who has low hemochrome and combined with more underlying diseases. During the treatment of CDT, we suggest that the thrombolytic catheter should be inserted across the thrombus. Certainly, clotting function should be closely monitored to evaluate the risk of bleeding. As for whether to thrombolysis treatment or not, it depends on the sign of inferior vena cava angiography. For example, fresh thrombus is usually attached to the vascular wall and will not sway with the breath, however, the old thrombus was mostly located in the middle of the filter. Additionally, it is a critical step on how to removal the thrombus maximize. We exchanged 9F guiding catheter to retrieve the filter and part thrombus adhered on the filter. In this process, the most important thing was keeping a negative pressure of 20 mL syringe to collect the residual thrombus remaining in the 9F catheter. If the suction was not smooth, the guide wire was reserved, and the 9F catheter was washed in vitro and reinserted again. And then, the IVC angiography was been done again to assess whether to remove the suprarenal IVC filter or not. For clear away of the thrombolysis in filter, some scholars 12 have tried with long sheathed thrombectomy, but in fact, it is disadvantage for losing more blood during the process. For further to assess the value and safety of this technique requires additional studies in the future. Furthermore, while the filters retrieval, it should be more attention to observe the patient's blood oxygen saturation and whether there was a transient chest shortness of breath and other symptoms or not. If the patients had those symptoms, venography of pulmonary artery should be taken action as soon as possible, and confirmed the degree of pulmonary embolism or not. Sometimes, thrombus fragmentation by pigtail catheter would helpful with the thrombus filled on the trunk of pulmonary artery. In our study, we not come across this circumstance. Certainly, the present study has several limitations. First, the number of patients are small, further study and observation of large samples are still needed in the later period. In addition, there has many different filter types been used in IVC, so the generalizability of this study may be limited. Conclusions Few reports to date have described the thrombosis in IVC filters-mediated which were placed with no more than two weeks. As shown in the present study, using double series IVC filters to protect the patients are safe and improved the retrieve rate of filters at early stage, further verification and observation of large samples are still needed in the later stage. Declarations Acknowledgements None. Author contributions Z.Y.,S.L. conceived the idea and developed the study concept. Z.Y. collected the data, analyzed, and wrote the manuscript. S.H. edited and commented the manuscript. T.Y., and S.L. helped the data interpretation. D.L, and S.H. supervised this work. All authors read and approved the final manuscript. Funding This research was supported by Ningbo key discipline project (Grand NO.2022-F21) and Zhejiang Provincial Medical and Health Project (Grant No. 2021KY299). Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to ethical principles but are available from the corresponding author on reasonable request. Ethics approval and consent to participate This study was approved by the Research Ethics Committee, Ningbo HuaMei Hospital, University of Chinese Academy of Sciences. All patients provided written informed consent prior to the procedure. All methods were performed in accordance with the relevant guidelines and regulations. Consent for publication Not applicable. Conflicts of interest The authors declare no conflict to interest. References Agnelli G, Verso M, Ageno W, et al. The MASTER registry on venous thromboembolism: description of the study cohort. Thromb Res. 2008; 121:605–610. Kahn SR. The post-thrombotic syndrome: the forgotten morbidity of deep venous thrombosis. J Thromb Thrombolysis. 2006; 21:41–48. Stein PD, Matta F, Yaekoub AY. Incidence of vena cava thrombosis in the United States. Am J Cardiol. 2008; 102:927–929. Wang SL, Siddiqui A, Rosenthal E. Long-term complications of inferior vena cava filters. J Vasc Surg Venous Lymphat Disord 2017; 5(1):33-41. Wei S, Cui H, Feng Z, et al. Inferior Vena Cava Filter Broken and Migrated to Left Ventricle with Destruction of Mitral Valve. Ann Thorac Surg. 2020; 110(3):e153-e155. Hicks Adam C,Sangroula Daisy,Dwivedi Amit J, et al. Inferior vena cava perforation during percutaneous filter removal. Vascular, 2022; Oct 21:17085381221135268. Ramakrishnan Ganesh,Willie-Permor Daniel,Yei Kevin et al. Immediate and Delayed Complications of IVC Filters. J Vasc Surg Venous Lymphat Disord, 2022;Oct 4:S2213-333X(22)00410-3. Desai Kush R,Pandhi Mithil B,Seedial Stephen M, et al. Retrievable IVC Filters: Comprehensive Review of Device-related Complications and Advanced Retrieval Techniques. Radiographics, 2017, 37: 1236-1245. Teter Katherine,Schrem Ezra,Ranganath Neel, et al. Presentation and Management of Inferior Vena Cava Thrombosis. Ann Vasc Surg, 2019, 56: 17-23. Li WD, Li CL, Qian AM, et al. Catheter-directed thrombolysis combined with manual aspiration thrombectomy for acute inferior vena cava filter thrombosis. Int Angiol. 2016; 35(6):605-612. Baheti Aparna,Sheeran Daniel,Patrie James et al. Suprarenal Inferior Vena Cava Filter Placement and Retrieval: Safety Analysis. J Vasc Interv Radiol, 2020; 31: 231-235. Pan Y, Zhao J, Mei J, et al. Retrievable Inferior Vena Cava Filters in Trauma Patients: Prevalence and Management of Thrombus Within the Filter. Eur J Vasc Endovasc Surg. 2016; 52(6):830-837. Table Table 3 is available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Table3.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2237453","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":153171500,"identity":"67f0c3b3-39df-4e47-9097-58e27007324a","order_by":0,"name":"Zuanbiao Yu","email":"","orcid":"","institution":"Hwa Mei Hospital, University of Chinese Academy of Sciences","correspondingAuthor":false,"prefix":"","firstName":"Zuanbiao","middleName":"","lastName":"Yu","suffix":""},{"id":153171503,"identity":"f36cc228-dbe8-4c17-a80a-0b43050692ed","order_by":1,"name":"Songjie Hu","email":"","orcid":"","institution":"Hwa Mei Hospital, University of Chinese Academy of Sciences","correspondingAuthor":false,"prefix":"","firstName":"Songjie","middleName":"","lastName":"Hu","suffix":""},{"id":153171506,"identity":"2a83feed-13da-47ed-955f-2eeb84545182","order_by":2,"name":"Tiequan Yang","email":"","orcid":"","institution":"Hwa Mei Hospital, University of Chinese Academy of Sciences","correspondingAuthor":false,"prefix":"","firstName":"Tiequan","middleName":"","lastName":"Yang","suffix":""},{"id":153171510,"identity":"ccd8160b-9fe6-45f1-ab17-635b81c7a59d","order_by":3,"name":"Shuyi Lyv","email":"","orcid":"","institution":"Hwa Mei Hospital, University of Chinese Academy of Sciences","correspondingAuthor":false,"prefix":"","firstName":"Shuyi","middleName":"","lastName":"Lyv","suffix":""},{"id":153171512,"identity":"79228cfc-d10e-44f6-8cdd-147b2c9b2303","order_by":4,"name":"Dehai Lang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIiWNgGAWjYBACNv7+zw8+VNjI2d8/fPBBQkUNYS18EgfMDGecSTNmuMGWbPDgzDHCWuQYEgykedsOJTbc4DGTfNjCTITDGA4kAG05YMw4uy2tIrGBjYG/vTsBvxbmhgNAv9yRY5Y5fOxG4g4ZBokzZzcQsOVgA9CWZ8ZsDGlpNxLPsDEYSOQS0pLMAPTL4cQehhyzgsQ2ZmK0pEG0zJDIMWMgTovEGTZwIBvwHEuWSDhzjIegX+T7e5jBUWnA3nzw44+KGjn+9l78WjAAD2nKR8EoGAWjYBRgBQBtLE/6HtP59AAAAABJRU5ErkJggg==","orcid":"","institution":"Hwa Mei Hospital, University of Chinese Academy of Sciences","correspondingAuthor":true,"prefix":"","firstName":"Dehai","middleName":"","lastName":"Lang","suffix":""}],"badges":[],"createdAt":"2022-11-04 09:44:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2237453/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2237453/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":29407876,"identity":"cdb8a3bc-edd1-476d-9694-15bcd5f665aa","added_by":"auto","created_at":"2022-11-22 19:31:18","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":32417,"visible":true,"origin":"","legend":"\u003cp\u003eVenography showed that there has thrombus attach on the half of the infrarenal IVC filter.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-2237453/v1/4217471b43e682be95d4e5c8.jpeg"},{"id":29407877,"identity":"588f8781-2ae1-405f-bd7d-5a28543c77e1","added_by":"auto","created_at":"2022-11-22 19:31:18","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":58454,"visible":true,"origin":"","legend":"\u003cp\u003eSuprarenal IVC filter was placed, and infrarenal IVC filter was removed out at the same time.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-2237453/v1/d97f79d055cca80336ff261e.jpeg"},{"id":29407879,"identity":"588ac7e2-0f86-46a8-9d2e-240bc5c748a0","added_by":"auto","created_at":"2022-11-22 19:31:18","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":31063,"visible":true,"origin":"","legend":"\u003cp\u003eSuprarenal IVC filter has collected the thrombus less than 1mL through venography again.\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-2237453/v1/04c41631fdda318c6248390a.jpeg"},{"id":29408324,"identity":"900e6706-ec28-4212-9138-08e9af0e0020","added_by":"auto","created_at":"2022-11-22 19:39:18","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":42012,"visible":true,"origin":"","legend":"\u003cp\u003eThrombi caught in the double series IVC filters using a 9-Fr sheath via the femoral vein. Many thrombi were removed.\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-2237453/v1/a77479f2f4d272b71933c8ab.jpeg"},{"id":33547519,"identity":"39b0090f-6c4a-4d3f-b5b8-f982ae86418c","added_by":"auto","created_at":"2023-02-28 09:29:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":427149,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2237453/v1/66bc290d-28de-447e-a186-9cad61679b8e.pdf"},{"id":29407875,"identity":"0e0df657-e194-4636-af73-a12f7dfd2fa5","added_by":"auto","created_at":"2022-11-22 19:31:18","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":85581,"visible":true,"origin":"","legend":"","description":"","filename":"Table3.docx","url":"https://assets-eu.researchsquare.com/files/rs-2237453/v1/ae50fd16e317a73e1ca90b95.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Double series Filters in Treating Inferior Vena Cava Filter-mediated Thrombosis","fulltext":[{"header":"Background","content":"\u003cp\u003ePrior studies have estimated that Inferior vena cava (IVC) thrombosis occurs in between 2.6% and 4.0% of patients with lower extremity deep vein thrombosis.\u003csup\u003e1-3\u003c/sup\u003e However, as the exponential increase in the number of IVC filters in China, it has become a major predisposing factor to IVC thrombosis. Unfortunately, part of the patients with IVC filters-mediated thrombosis are suffering from significant morbidities including post-thrombotic syndrome (PTS), pulmonary embolism. What\u0026apos;s more, concerning about filter complications are also rising as time goes on, such as filter penetration, fracture, tilting.\u003csup\u003e4-6\u003c/sup\u003e Thus, removing the IVC filters in the early stage is the key to reducing such complications. \u003c/p\u003e\n\u003cp\u003eIn this study, we summarize our experience on how to treat the IVC filters-mediated thrombosis for those who were existed no more than two weeks, and introduce a strategy safely on using double series IVC filters to protect the patients and improved the retrieve rate of IVC filters at early stage.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv class=\"Section2\" id=\"Sec2\"\u003e\n \u003ch2\u003ePatients\u003c/h2\u003e\n \u003cp\u003eSee Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e for patient demographics. Clinical characteristics and imaging findings of patients who underwent double series IVC filters for treating IVC filters-mediated thrombosis in our center from August 2018 to June 2022, were analyzed. There were 3 female and 4 male patients. Of those, 2 patients had history of fracture, 1 had abdominal hematoma, 3 patients had a history of percutaneous mechanical thrombectomy (PMT) treatment, and 1 had a history of surgery with lung cancer. All patients provided written informed consent before the procedure.\u003c/p\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCase data\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedical history\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePreoperative PE\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAnticogaulation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIndex of D-D(IU/L)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePopliteal vein thrombosis was found 2 days before femoral neck fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRivaroxaban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1200\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePosterior tibial vein thrombosis was found 2 days before patella fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDistal branch of right\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRivaroxaban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1400\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbdominal hematoma with femoral vein thrombosis for 3 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2300\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAfter PMT for DVT(Left)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDistal branch of left\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRivaroxaban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAfter PMT for DVT(Right)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDistal branch of left\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRivaroxaban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e700\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAfter PMT for DVT(Left)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWarfarin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e800\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePopliteal vein Thrombosis occurred 1 week after lung cancer surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDistal branch of both\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWarfarin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1200\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eFilters And Thrombus\u003c/h3\u003e\n\u003cp\u003eAll filters (LifeTech Scientific Co. Ltd, Shenzhen, China) are retrievable. In this study, the first time of infrarenal IVC filters were set no more than two weeks. Time of suprarenal filter operation is divided into two stage, I stage is defined as filter implantation and removal were performed in the same operation; II stage is defined as the filter was removed after 2 weeks to the suprarenal filter placement. Filter-associated thrombus was assessed by the radiologist who determined whether the thrombus was likely an embolus caught by the filter, based predominantly on size, cylindrical shape, and apical location.\u003c/p\u003e\n\u003cdiv class=\"Section2\" id=\"Sec4\"\u003e\n \u003ch2\u003eFilter Placement and Retrieval\u003c/h2\u003e\n \u003cp\u003eAll operations were performed under local anesthesia. Access was established by healthy side of femoral vein, and the angiographic catheter was placed in inferior vena cava to evaluate the location between thrombosis and filters through venography, see (Table\u0026nbsp;3) below for details.\u003c/p\u003e\n \u003cp\u003eFirst, if the IVC filters-mediated thrombosis was located in and below the filter \u003cstrong\u003e(\u003c/strong\u003eFig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e. And the patient had low risk of bleeding, the catheter-directed thrombolysis (CDT) treatment would be scheduled with Urokinase (500,000 IU, 2ml/h), and monitoring of coagulation function closely. Next, the venography evaluated again and found whether there had the residual thrombosis in IVC filter. The suprarenal IVC filter would be set while the thrombosis was more than 1mL. Usually, if IVC diameter in supra-renal segment was too large for filter placement, the filter would be placed on the supra-renal segment but not released completely in that condition.Then, the infrarenal IVC filter which was placed before \u003cstrong\u003e(\u003c/strong\u003eFig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e would be removed out through a 9-Fr Fustar steerable guiding catheter of 55cm in length (LifeTech Scientific Co. Ltd, Shenzhen, China). After step, the IVC imaging would be done again and evaluated the residual thrombosis captured in the suprarenal IVC filter. When the residual thrombosis was less than 1mL, the suprarenal IVC filter would be remove out \u003cstrong\u003e(\u003c/strong\u003eFig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e, Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e. On the contrary, we would wait 2 weeks for evaluation again through venography, and the patient was treated with an oral anticoagulant in this period. However, when the patient was assessed with high risk of bleeding, the suprarenal IVC filter would be placed at the first time. And then, the infrarenal IVC filter would be removed due to the maximum time limit of filter, some thrombus would attach on the filter could also been taken out through the 9-Fr guiding catheter. Finally, the IVC imaging will be evaluated whether to remove the suprarenal IVC filter or not.\u003c/p\u003e\n \u003cp\u003eSecond, if the IVC filters-mediated thrombosis was located above filter or there had a floating thrombus above the filter. In this situation, the first step was placed the suprarenal IVC filter by jugular vein access to protect the patients against the PE happened. And next step was the same as those thrombosis which located in and below the filter. See \u003cstrong\u003eTable\u0026nbsp;3\u003c/strong\u003e for the specific process about how to place and remove the double series IVC filters.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec5\"\u003e\n \u003ch2\u003e\u003cstrong\u003ePulmonary Embolism Assessment\u003c/strong\u003e\u003c/h2\u003e\n \u003cp\u003eValidity assessment of PE is the key to treatment of patients. Thus, when the IVC filters-mediated thrombosis removed, images of IVC should be done at the first time. Certainly, the pulmonary artery venography should be taken for the patients who was observed any discomfort, such as shortness of breath in the chest. Besides, the pulmonary artery CT need to examine further after surgery. If thrombosis was existing in branch of pulmonary artery, the anticoagulant therapy should be extended at least 6 months.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eFollow-up And Accessment Of Outcomes\u003c/h3\u003e\n\u003cp\u003eAll patients had been clinically evaluated at our institution and imaging during the follow-up period. Including clinical and relevant examination with B ultrasound or CTPA, to showed that the blood flow in the inferior vena cava and pulmonary artery were smooth or not.\u003c/p\u003e\n\u003cdiv class=\"Section2\" id=\"Sec7\"\u003e\n \u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n \u003cp\u003eThe clinical records, images and digital subtraction angiography were reviewed retrospectively. Parametrical continuous variables are expressed as the mean value\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, whereas nonparametric continuous variables are given as the median, Categorical variables are reported as counts with proportions.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn this group, 5 patients with thrombosis located in the filters, 1 patient (No.3) with part thrombosis located in the filter and others floating above the filter, another 1 patient (No.4) with part thrombosis located in the filter and others bellow the filter. Technical success was achieved in all seven patients. 6 patients removed suprarenal filters in I stage, only 1 (No.3) in II stage. Thrombosis were mostly removed in five patients and partially removed in two patients. There were no related complications happened. 3 patients (No.4, No.5, No.6) assisted with catheter-directed thrombolysis (CDT) treatment, the average of time was 5.3 d. There had 4 patients not assisted with CDT because of the high risk of bleeding.\u003c/p\u003e\n\u003cp\u003eThe median follow-up time was 22.5 months. After discharge, 6 patients accepted oral warfarin or rivaroxaban for anticoagulant therapy. Only 1 person (No.3) who had contraindication of anticoagulation and not accepted, however, she was taken rivaroxaban after second discharge. Of those, no recurrence of thrombosis symptoms and the inferior vena cava was smooth through ultrasound during the follow-up period. See Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e below for details.\u003c/p\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eThe technique of using double filters and outcomes\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePositon of thrombus\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTime of CDT (d)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eThrombus clearance of CDT\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAccess of suprarenal filter\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTime of suprarenal filter(I/II)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePostoperative chest depression\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePostoperative PE\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIn filter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemoral Vein\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI Stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIn filter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemoral Vein\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI Stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo progress\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePart in filter and other floating above the fliter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eJugular Vein\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eII Stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDistal branch of left\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBelow the filter and part in the filter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5d\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;1mL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemoral Vein\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI Stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo progress\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIn filter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5d\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;1mL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemoral Vein\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI Stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo progress\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIn filter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6d\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;1mL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemoral Vein\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI Stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIn filter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemoral Vein\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI Stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo progress\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eIVC filter devices aim to prevent pulmonary thromboembolism in patients with lower limb deep venous thrombosis. Literature demonstrates that many IVC filters that are placed may not be retrieved, thus increasing the likelihood of future complications. Ramakrishnan G, et al\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e analysised that 1.8% and 3.1% developed immediate and delayed complications in 14,784 patients, and Thrombosis in filter was very common. A systematic review of retrievable IVC filters found that primary complication rates varied widely with thrombosis ranging from 6\u0026ndash;30%\u003csup\u003e8\u003c/sup\u003e. Therefore, it brought with many challenges for retrieving filters. In terms of treatment for filter thrombosis, CDT could reduce thrombus burden in filter for those with acute or subacute thrombus\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e, but even someone had the high risk of bleeding and the thrombosis had not removed completely. Such as in our study, 4 patients had not assisted with CDT because of the high risk of bleeding, including 1 person along with abdominal hematoma, and the feature of thrombus tends to be chronic in other 3 persons. Comparing with CDT alone, Li WD, et al.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e found that CDT combined with aspiration thrombectomy had better performing thanks to a shorter thrombolysis time and a lower urokinase dose required. However, increasing the occurrence of complications, such as acute renal injury and hemoglobinuria. Therefore, it was still necessary to find an effective solution to avoid these risks for patients with IVC filters-mediated thrombosis.\u003c/p\u003e\n\u003cp\u003eIn our study, we used suprarenal IVC filter to protect the patient and retrieval double filters successfully accompanied by thrombosis which was found no more than two weeks. The result of this method was satisfactory. Nevertheless, the indications and procedures with using double filters should been grasped.\u003c/p\u003e\n\u003cp\u003eFirst, how to place and remove the second filter is important. As for the suprarenal IVC filter, seeking a suitable situation for placement would be very important. Before placed the suprarenal IVC filter, we should comprehensively evaluate on imaging of IVC and clarify the situation between the filter and thrombosis. Traditionally, the suprarenal IVC filter placement is preferred by femoral vein access. However, if a free-floating thrombus above the infrarenal filter, jugular vein access is suitable. Sometime, the diameter of the IVC is related to venous return, blood volume, and the respiratory cycle. Compared with an infrarenal IVC, a suprarenal IVC is larger in diameter but shorter in length\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. When the suprarenal IVC is too larger to deployed the filter, we will choosing in those position but not released completely in order to remove it convenient with the I stage. As for the time to remove the suprarenal IVC filter. In our study, 6 of 7 patients had retrieved at the I stage, only 1 person still had partial thrombosis in suprarenal IVC filter after removing the first filter through venography, 2 weeks later with adequate anticoagulation therapy, she was scheduled to imaging again and showed that the thrombus was significantly reduced, and then, the suprarenal IVC filter was removed out. In our study, the renal vein thrombosis had not encountered in those process. We thought the reasons of that the anticoagulant therapy was followed after placement of the suprarenal IVC filter. Besides, it was more attention to reduce the thrombus escaped into the renal vein. Especially for those thrombosis under the filter.\u003c/p\u003e\n\u003cp\u003eSecond, the risk of bleeding for thrombolysis treatment should been evaluated. Especially, for the elderly patients or someone who has low hemochrome and combined with more underlying diseases. During the treatment of CDT, we suggest that the thrombolytic catheter should be inserted across the thrombus. Certainly, clotting function should be closely monitored to evaluate the risk of bleeding. As for whether to thrombolysis treatment or not, it depends on the sign of inferior vena cava angiography. For example, fresh thrombus is usually attached to the vascular wall and will not sway with the breath, however, the old thrombus was mostly located in the middle of the filter.\u003c/p\u003e\n\u003cp\u003eAdditionally, it is a critical step on how to removal the thrombus maximize. We exchanged 9F guiding catheter to retrieve the filter and part thrombus adhered on the filter. In this process, the most important thing was keeping a negative pressure of 20 mL syringe to collect the residual thrombus remaining in the 9F catheter. If the suction was not smooth, the guide wire was reserved, and the 9F catheter was washed in vitro and reinserted again. And then, the IVC angiography was been done again to assess whether to remove the suprarenal IVC filter or not. For clear away of the thrombolysis in filter, some scholars\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e have tried with long sheathed thrombectomy, but in fact, it is disadvantage for losing more blood during the process. For further to assess the value and safety of this technique requires additional studies in the future.\u003c/p\u003e\n\u003cp\u003eFurthermore, while the filters retrieval, it should be more attention to observe the patient\u0026apos;s blood oxygen saturation and whether there was a transient chest shortness of breath and other symptoms or not. If the patients had those symptoms, venography of pulmonary artery should be taken action as soon as possible, and confirmed the degree of pulmonary embolism or not. Sometimes, thrombus fragmentation by pigtail catheter would helpful with the thrombus filled on the trunk of pulmonary artery. In our study, we not come across this circumstance.\u003c/p\u003e\n\u003cp\u003eCertainly, the present study has several limitations. First, the number of patients are small, further study and observation of large samples are still needed in the later period. In addition, there has many different filter types been used in IVC, so the generalizability of this study may be limited.\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eFew reports to date have described the thrombosis in IVC filters-mediated which were placed with no more than two weeks. As shown in the present study, using double series IVC filters to protect the patients are safe and improved the retrieve rate of filters at early stage, further verification and observation of large samples are still needed in the later stage.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZ.Y.,S.L. conceived the idea and developed the study concept. Z.Y. collected the data, analyzed, and wrote the manuscript. S.H. edited and commented the manuscript. T.Y., and S.L. helped the data interpretation. D.L, and S.H. supervised this work. All authors read and approved the final manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by Ningbo key discipline project (Grand NO.2022-F21) and Zhejiang Provincial Medical and Health Project (Grant No. 2021KY299).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to ethical principles but are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Research Ethics Committee, Ningbo HuaMei Hospital, University of Chinese Academy of Sciences. All patients provided written informed consent prior to the procedure. All methods were performed in accordance with the relevant guidelines and regulations. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict to interest.\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAgnelli G, Verso M, Ageno W, et al. The MASTER registry on venous thromboembolism: description of the study cohort. Thromb Res. 2008; 121:605\u0026ndash;610.\u003c/li\u003e\n\u003cli\u003eKahn SR. The post-thrombotic syndrome: the forgotten morbidity of deep venous thrombosis. J Thromb Thrombolysis. 2006; 21:41\u0026ndash;48.\u003c/li\u003e\n\u003cli\u003eStein PD, Matta F, Yaekoub AY. Incidence of vena cava thrombosis in the United States. Am J Cardiol. 2008; 102:927\u0026ndash;929.\u003c/li\u003e\n\u003cli\u003eWang SL, Siddiqui A, Rosenthal E. Long-term complications of inferior vena cava filters. J Vasc Surg Venous Lymphat Disord 2017; 5(1):33-41.\u003c/li\u003e\n\u003cli\u003eWei S, Cui H, Feng Z, et al. Inferior Vena Cava Filter Broken and Migrated to Left Ventricle with Destruction of Mitral Valve. Ann Thorac Surg. 2020; 110(3):e153-e155.\u003c/li\u003e\n\u003cli\u003eHicks Adam C,Sangroula Daisy,Dwivedi Amit J, et al. Inferior vena cava perforation during percutaneous filter removal. Vascular, 2022; Oct 21:17085381221135268.\u003c/li\u003e\n\u003cli\u003eRamakrishnan Ganesh,Willie-Permor Daniel,Yei Kevin et al. Immediate and Delayed Complications of IVC Filters. J Vasc Surg Venous Lymphat Disord, 2022;Oct 4:S2213-333X(22)00410-3.\u003c/li\u003e\n\u003cli\u003eDesai Kush R,Pandhi Mithil B,Seedial Stephen M, et al. Retrievable IVC Filters: Comprehensive Review of Device-related Complications and Advanced Retrieval Techniques. Radiographics, 2017, 37: 1236-1245.\u003c/li\u003e\n\u003cli\u003eTeter Katherine,Schrem Ezra,Ranganath Neel, et al. Presentation and Management of Inferior Vena Cava Thrombosis. Ann Vasc Surg, 2019, 56: 17-23.\u003c/li\u003e\n\u003cli\u003eLi WD, Li CL, Qian AM, et al. Catheter-directed thrombolysis combined with manual aspiration thrombectomy for acute inferior vena cava filter thrombosis. Int Angiol. 2016; 35(6):605-612.\u003c/li\u003e\n\u003cli\u003eBaheti Aparna,Sheeran Daniel,Patrie James et al. Suprarenal Inferior Vena Cava Filter Placement and Retrieval: Safety Analysis. J Vasc Interv Radiol, 2020; 31: 231-235.\u003c/li\u003e\n\u003cli\u003ePan Y, Zhao J, Mei J, et al. Retrievable Inferior Vena Cava Filters in Trauma Patients: Prevalence and Management of Thrombus Within the Filter. Eur J Vasc Endovasc Surg. 2016; 52(6):830-837.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003eTable 3 is available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Inferior vena cava, filter, thrombosis, pulmonary angiography","lastPublishedDoi":"10.21203/rs.3.rs-2237453/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2237453/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e As the exponential increase in the number of inferior vena cava (IVC) filters in China, it has become a major predisposing factor for IVC filters-mediated thrombosis. This is an important risk factor for thrombosis recurrence.\u003c/p\u003e\n\u003cp\u003eWhat’s more, the long-term implantation of the filter will bring many uncertainties. This study is aim to summarize our experience and introduce a strategy safely in treating IVC filters-mediated thrombosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003eThe clinical data were collected and analyzed from seven patients (3 female and 4 male) who suffered IVC filters-mediated thrombosis in our center from August 2018 to June 2022. In this group, the time of IVC filters thrombosis was not exceeding two weeks. According to the location and morphology of the thrombosis in the filter, we adopt two access (Femoral vein or Jugular vein) puncture to implant the supra-renal IVC filter. Then, all steps were performed under the protecting to retrieval the double series IVC filters and thrombosis. Pulmonary Embolism(PE) assessment was taken measure by computed tomography pulmonary angiography (CTPA) .\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e In this study, Technical success rate was 100% to retrieval the double series IVC filters. The volume of IVC filters-mediated thrombosis in those patients was exceeded 1 mL.71.4% (5/7) of cases present the existing thrombosis located in the filters, 1 patient (14.3%, 1/7) has the thrombosis located both inside and floating above the filter, as well as 1 patient (14.3%, 1/7) having thrombosis located both inside and underneath the filter. Six patients removed the suprarenal IVC filters in I stage, and only one patient removed it in II stage. On removing the thrombosis, five patients were removed completely and only two were partially, including 3 patients with the help of catheter-directed thrombolysis(CDT)therapy. No procedure-related complications were observed. The median follow-up time was 22.5 months. No recurrence of thrombus symptoms was reported, B ultrasound and CTPA showed that the blood flow in the inferior vena cava and pulmonary artery were smooth.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e For the patients who suffered from IVC filters-mediated thrombosis no longer than two weeks, using double series IVC filters to protect the patients is a safe approach and could improve the retrieve rate of IVC filters at early stages.\u003c/p\u003e","manuscriptTitle":"Double series Filters in Treating Inferior Vena Cava Filter-mediated Thrombosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-11-22 19:31:13","doi":"10.21203/rs.3.rs-2237453/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dc292fb5-b51d-46f0-98fe-1541fdd1c456","owner":[],"postedDate":"November 22nd, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-02-28T09:29:29+00:00","versionOfRecord":[],"versionCreatedAt":"2022-11-22 19:31:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2237453","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2237453","identity":"rs-2237453","version":["v1"]},"buildId":"J0_U0BvcaRcwD8yVFaRlm","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}