Successful removal of a Gunther tulip vena cava filter with wall-embedded hook and migration during a retrieval attempt
Written informed consent for placement and retrieval of the vena cava filter was obtained from the patient for use of the standard procedure as well as modified procedures if difficulties were encountered.\nA 32-year-old man presented with a thrombus in the IVC. This was incidentally noticed on enhanced CT images obtained to follow-up findings from a routine chest X-ray as part of a medical check-up. The thrombus was also distributed in the proximal portion of the right common iliac vein. Pulmonary embolism was not seen. D-dimer was elevated to 1.8 μg/mL. The patient was in apparent good health and had experienced no specific episode that could have caused deep venous thrombosis. A review of the entire family tree revealed no inherited disorder, and results of blood studies suggested no genetic causative factors.\nA GTF (Cook, Bjaeverskov, Denmark) was prophylactically implanted to prevent development of a pulmonary embolism by movement of the released thrombus. Because the top of the thrombus distributed in the IVC just below the level of the renal veins, the GTF was positioned at the suprarenal IVC through the right jugular vein with the patient under local anesthesia. Anticoagulation therapy with intravenous heparin followed by warfarin sodium given by mouth was administered.\nEighteen days later, enhanced CT revealed that the venous thrombus had decreased and the risk of pulmonary embolism had lessened. Thus retrieval of the GTF was attempted.\nAt first, we used the standard method of retrieval using the GTF retrieval set supplied by the manufacturer (Cook). Details of techniques to retrieve the GTF are described elsewhere (). Devices for retrieval were inserted from the right jugular vein. However, retrieval was impossible in spite of perseverance. The filter had become slightly tilted from the position of implantation. The hook had attached to one side wall of the IVC and could not be snared. It was considered that, in implanting the GTF, more meticulous care should have been taken to orient the filter so that the hook pointed away from the contralateral IVC wall with the open side of the hook directed toward the IVC lumen. We then attempted retrieval using a modification of the standard method as described by Kuo et al. (). We inserted a 4-French angled catheter (Clinical Supply, Gifu, Japan) slowly into the retrieval catheter included in the GTF retrieval set (Cook) to enter the inside of the cone from an interstice between the filter struts and to emerge from another interstice. A 0.035-inch, 260-cm-long, hydrophilic guide wire (Terumo, Tokyo, Japan) was inserted into the previously inserted 4-French angled catheter. Then another 4-French angled catheter (Create Medics, Kanagawa, Japan) was coaxially advanced from the retrieval catheter to near the distal end of the hydrophilic guide wire. A multi-snare (10 mm in diameter, pfm, Koln, Germany) was advanced into this 4-French catheter (Create Medics) and captured the distal edge of the hydrophilic guide wire that had been advanced from the 4-French angled catheter (Clinical Supply) through the inside of the GTF'S cone (Fig. a). After access was established across and through the filter struts, both the hydrophilic guide wire that was inserted through the 4-French angled catheter (Clinical Supply) and the multi-snare that was inserted through another 4-French catheter was pulled toward the cephalad site with tension maintained at both ends. The hook of the GTF was released from the attached IVC wall and the GTF began to move. Then when we attempted to advance the vascular sheath slowly over the filter, the GTF was immediately observed to be floating up the IVC and moving into the right atrium. A strut of the GTF was quickly grasped by pulling tightly both the hydrophilic guide wire and multi-snare into the retrieval catheter and sheath. Through this maneuver, further migration of the GTF was prevented. Finally, another GTF retrieval set was inserted from the left jugular vein and the hook of the GTF was successfully grasped with the retrieval snare that was included in the GTF retrieval set (Fig. b). The GTF was then retrieved.\nDuring these actions, the patient experienced transient arrhythmias and mild back pain, but no serious complication occurred.