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Procedure Playbook — Venous Interventions

IVC Filter Placement

Percutaneous image-guided placement of inferior vena cava filters for prevention of pulmonary embolism in patients with VTE who cannot be adequately anticoagulated. All placed filters must be enrolled in a retrieval tracking program at the time of deployment and reviewed for retrieval at every clinical encounter.

IVC Filters → IVC Filter Retrieval
Sedation
Local only or minimal sedation
Bleeding Risk
Low (SIR Cat 1)
Key Risk
Filter tilt · Malposition · Caval perforation · Access site thrombosis
Antibiotics
Not routine
Follow-up
Daily anticoag reassessment; schedule retrieval at index visit; enroll in filter tracking registry
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Indications & Contraindications

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Classic (Absolute) Indications — SIR Consensus

All four require documented VTE:

  • Contraindication to anticoagulation (active major bleeding, HIT, thrombocytopenia)
  • Complication of anticoagulation necessitating cessation (life-threatening hemorrhage)
  • Failure of anticoagulation (recurrent VTE or propagating DVT despite therapeutic anticoagulation)
  • Inability to achieve or maintain therapeutic anticoagulation

Expanded (Relative) Indications

  • Iliocaval or large free-floating proximal DVT
  • Inability to maintain adequate anticoagulation (e.g., high fall risk, poor compliance)
  • Massive PE with residual DVT in patient at risk of further PE
  • Chronic VTE treated with pulmonary thromboendarterectomy
  • Iliocaval DVT undergoing catheter-directed thrombolysis
  • VTE with severely limited cardiopulmonary reserve (cannot tolerate any additional embolic burden)
  • Recurrent PE with existing IVC filter in place (filter failure)
  • High-risk complication of anticoagulation (e.g., known intracranial lesion)

Prophylactic Placement (No Documented VTE)

  • High-risk trauma patient unable to receive anticoagulation (EAST: Level 3 evidence only)
  • High-risk bariatric or oncologic surgery with VTE contraindication to anticoagulation
  • ACCP does NOT recommend prophylactic IVC filters — insufficient evidence
  • If placed prophylactically: reevaluate daily and remove as soon as anticoagulation can be started

Contraindications

  • No adequate venous access route to IVC
  • No adequate space in IVC for deployment (severely thrombosed IVC)
  • Severe uncorrectable coagulopathy (relative)
  • Bacteremia/sepsis (relative — increased risk of filter infection)
  • Known metal allergy to filter material (rare; silver allergy reported)

Evidence Basis

  • PREPIC (Décousus 1998 / 8y follow-up 2005): 400 patients with proximal DVT — filter reduced PE (3.4% vs 6.3%) but increased DVT (35.7% vs 27.5%); no effect on overall mortality
  • PREPIC II (Mismetti 2015): retrievable filter did NOT reduce symptomatic PE vs anticoagulation alone at 3 months
  • IVC filters prevent PE but increase DVT and have not demonstrated mortality benefit — retrieval is the goal whenever possible
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Pre-Procedure

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Review prior CT imaging: IVC diameter, location of renal veins, caval variants (duplicated IVC ~1–3%, left-sided IVC, circumaortic renal veins), thrombus in IVC or iliac veins. Anatomy often defines access route and filter size.
Timing classification:
  • Emergent (<12–24h): acute PE or free-floating iliofemoral DVT + contraindication to anticoagulation; severely limited cardiopulmonary reserve
  • Urgent (24–48h): proximal DVT or enlarging distal DVT + contraindication to anticoagulation
  • Elective: high VTE risk pre-operatively, chronic CTEPH before thromboendarterectomy
Filter selection: choose retrievable vs permanent based on expected duration of indication. If permanently indicated, consider permanent filter (more long-term safety data). If temporary indication (perioperative, trauma bridge): retrievable filter. Bard Recovery/G2 series had high fracture rates (39.5% at 65.7 months) — know your filter's complication profile.
IVC diameter: most filters approved for IVC ≤28 mm. Megacava (>28–30 mm) ~2.5% of population — requires Bird's Nest filter (approved up to 40 mm) or bilateral iliac vein filters.
Labs: CBC, INR (no strict threshold for placement; proceed if clinically indicated).
Consent: tilt/malposition, caval perforation, access site thrombosis, filter fracture/migration, recurrent PE (filter failure), DVT (increased by filter), inability to retrieve later.
Register in filter tracking program BEFORE procedure: SIR guidelines require institutional-level tracking. Enter patient, filter type, serial number, planned retrieval date, and responsible provider in tracking database at time of placement. Document anticoagulation plan and retrieval criteria.
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Relevant Anatomy

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IVC Anatomy & Target Zone

  • IVC formed by confluence of common iliac veins at L4–L5; runs right of midline; enters right atrium at T8–T9
  • Standard filter placement zone: infrarenal IVC with apex (cephalic end) just below the lowest renal vein — stable segment away from cardiac/respiratory motion; renal vein inflow flushes IVC and reduces IVC thrombosis risk
  • Identify left renal vein inflow on cavogram (typically at L1–L2); position filter below the most inferior renal vein

Access Routes

  • Right common femoral vein (CFV): preferred; most filters designed for inferior approach; direct caudal-to-cephalad deployment
  • Right internal jugular vein (IJV): used when femoral access is not feasible (bilateral femoral/iliac thrombus, groin wound) or filter design requires superior approach
  • Left-sided access: feasible but filter orientation may differ — confirm with manufacturer instructions

Suprarenal Placement Indications

  • Occluded infrarenal IVC (filter cannot be deployed in thrombosed segment)
  • Duplicated IVC (bilateral filters in iliac veins or single suprarenal filter)
  • Thrombus extending to or above intended infrarenal deployment zone
  • Large thrombus in renal or gonadal vein entering infrarenal IVC
  • Pregnancy (relative) — weigh risk of renal vein involvement vs PE risk
  • Suprarenal risks: greater respiratory/cardiac motion (fracture/migration), caval thrombosis may involve renal veins, perforation in suprarenal IVC more clinically significant
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Technique

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Supplies (Right CFV Approach)

Right CFV micropuncture kit 6–12 Fr delivery sheath (filter-specific) Manufacturer IVC filter deployment kit Pigtail catheter (5 Fr, 10–15 cm tip) Contrast medium Stiff guidewire (Amplatz/Rosen)
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Right CFV access

Micropuncture under US guidance → upsize to appropriate delivery sheath size. Fluoroscopy throughout.
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IVC cavogram

Advance 5 Fr pigtail catheter to infrarenal IVC (avoid entanglement with pelvic tributaries). Hand inject or power inject contrast. Identify: IVC diameter, renal vein inflow bilaterally, left renal vein (left-to-right crossing), iliac inflow, caval variants, thrombus. Measure IVC at planned deployment level in AP projection.
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Bilateral renal venogram (if needed)

Selectively catheterize left renal vein to confirm lowest renal vein level if not clearly identified on cavogram. The inferior aspect of the left renal vein defines the cephalic limit of infrarenal deployment.
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Position delivery sheath

Exchange over Amplatz/stiff guidewire to filter-specific delivery sheath. Advance to target deployment zone in infrarenal IVC. Mark position on fluoroscopy.
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Deploy filter

Follow manufacturer-specific instructions for deployment (push vs pull-back mechanism varies by filter). Release filter with apex just below lowest renal vein. Avoid rotation during deployment — filter must open symmetrically in axial plane.
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Completion cavogram

Mandatory after deployment. Confirm: filter position relative to renal veins, filter orientation (tilt <15° from IVC axis), open filter configuration, no migration. Document in fluoroscopic images.

Special Situations

  • Megacava (>28–30 mm): Bird's Nest filter (approved up to 40 mm) OR bilateral common iliac vein filters. Do NOT deploy a standard conical filter in a megacava — it will not appose the wall and will migrate.
  • Duplicated IVC: place bilateral iliac vein filters (one in each common iliac vein below the confluence) OR single suprarenal filter above the confluence. Identify on pre-procedure CT.
  • Left-sided IVC: rare; single suprarenal filter above left renal vein confluence, or filter placed from right IJV to match anatomy.
  • Thrombus on cavogram: if infrarenal IVC thrombosed, consider suprarenal placement. If thrombosis is recent, discuss systemic or catheter-directed thrombolysis vs suprarenal placement with clinical team.
  • Right IJV approach: advance delivery sheath from cranial to caudal; filter deploys with apex pointing cranially — confirm orientation is appropriate for filter design before deployment.
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Troubleshooting

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Filter Tilt After Deployment

Tilt >15° from IVC Axis

Cause: Asymmetric deployment, small delivery sheath rotation, asymmetric caval wall adhesion. SIR definition: tilt >15° = insertional complication. If filter is tilted but still infrarenal and apex is below renal veins: document and monitor. If severely tilted (>30°), struts may not appose wall adequately — re-deployment is not typically feasible. Plan retrieval with complex technique (will likely require curved sheath).

Cannot Identify Renal Vein Level

Renal Veins Not Clearly Seen on Cavogram

Selective left renal venogram (catheter directly into left renal vein) to precisely define inferior margin. Use prior CT for anatomic correlation. If circumaortic renal vein: the more inferior component defines the caudal limit of safe infrarenal placement.

IVC >28 mm (Megacava)

Standard Filter Cannot Appose Caval Wall

Do NOT deploy standard conical filter. Options: (1) Bird's Nest filter (40 mm approved) from femoral approach; (2) bilateral common iliac vein filters; (3) suprarenal placement where diameter may be smaller. Measure IVC diameter in AP projection at exact planned deployment level.

Thrombus Found in IVC on Cavogram

Infrarenal IVC Partially or Completely Thrombosed

Partial IVC thrombus: attempt infrarenal deployment if adequate space, document thrombus location relative to filter. Complete infrarenal occlusion: suprarenal filter above thrombus. Discuss with clinical team: if thrombus is acute/subacute, CDT before filter placement may clear IVC and allow infrarenal deployment.

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Complications

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Immediate / Early

  • Tilt >15° (SIR definition: insertion complication; 5–23% reported)
  • Malposition outside target zone (1–9%)
  • Access site hematoma or thrombosis (0–25%)
  • Air embolism (access site)
  • Incomplete filter opening

Delayed

  • IVC perforation: strut >3 mm outside IVC wall (0–41% depending on filter type; often asymptomatic)
  • Filter fracture with strut embolization to heart/pulmonary arteries (Bard Recovery: 39.5% at 65 months)
  • IVC thrombotic occlusion (2–30%)
  • Filter migration >2 cm (0–18%)
  • Recurrent PE despite filter (0.5–6%)
  • DVT (filter increases long-term DVT risk — PREPIC 8y: 35.7% vs 27.5%)
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Post-Procedure

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Anticoagulation & Clinical Reassessment

  • Filter placement does NOT change the anticoagulation plan — resume anticoagulation as soon as clinically safe regardless of filter presence
  • Reassess anticoagulation contraindication daily while filter is in place
  • Coordinate with referring team: once anticoagulation can be safely started, restart and immediately schedule filter retrieval
  • Patient education: filter card (manufacturer) to patient at discharge; instruct to show at any subsequent imaging

Retrieval Planning — Do This at Placement

  • Planned retrieval date entered in EMR at time of placement (SIR consensus requirement)
  • Document filter type, model, serial number, date, access route, position relative to renal veins
  • Enroll in institutional IVC filter tracking registry
  • Assign responsible provider for follow-up and retrieval
  • For prophylactic filters: retrieval as soon as high-risk period ends (≤4–6 weeks); aggressive follow-up to prevent lost to follow-up
  • Retrieval rates substantially improved with dedicated IVC filter clinic programs (Minocha JVIR 2010)
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Critical Pearls

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Plan the retrieval before you place the filter. At the moment of deployment, enter a retrieval date in the chart, assign a responsible provider, and give the patient a filter card. Filters placed without a retrieval plan become permanent by default — studies show retrieval rates dramatically improve with structured tracking programs.
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Cavogram is mandatory — every time. IVC variants are present in 3–5% of patients. Megacava, duplicated IVC, left-sided IVC, and circumaortic renal veins all change the placement plan. Prior CT does not replace intraprocedural cavogram.
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PREPIC data: filters reduce PE but increase DVT with no mortality benefit. The 8-year PREPIC data (2005) showed filters cut PE risk (3.4% vs 6.3%) but doubled DVT at 8 years (35.7% vs 27.5%), with no survival advantage. PREPIC II (2015) found retrievable filters did not reduce symptomatic PE vs anticoagulation alone. This is why anticoagulation remains primary therapy and filter retrieval is always the goal.
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Filter placement does not replace anticoagulation. Restart anticoagulation as soon as it is safe — do not use the filter as a reason to defer anticoagulation indefinitely. Once anticoagulation is therapeutic, the filter indication is usually resolved and retrieval can proceed.
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Know your filter's complication profile. Bard Recovery/G2 series: 39.5% fracture at 65 months, up to 100% IVC perforation. If a patient presents with a legacy filter and a true permanent indication, a permanent filter with better long-term data (e.g., Greenfield titanium) is preferable. Conical filters have more IVC penetration; cylindrical filters have more caval thrombosis.
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Suprarenal is safe for the right indication. Suprarenal filters are effective. The risks (greater motion, renal vein thrombosis if IVC occluded, more clinically significant perforation) are real but do not preclude placement when the infrarenal position is not suitable.
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References

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Key Guidelines

  • Kaufman JA et al. SIR Multidisciplinary Consensus Conference on Retrievable and Convertible Vena Cava Filters. J Vasc Interv Radiol. 2006;17(3):449–459
  • Caplin DM et al. SIR Quality Improvement Guidelines for IVC Filter Placement. J Vasc Interv Radiol. 2011;22(11):1499–1506
  • ACCP Antithrombotic Therapy for VTE (CHEST 2016): does not recommend prophylactic IVC filters
  • EAST VTE Guidelines 2002: Level 3 evidence for prophylactic filters in high-risk trauma
  • Dariushnia SR et al. SIR Quality Improvement Guidelines for Inferior Vena Cava Filter Placement and Management. J Vasc Interv Radiol. 2020;31(8):1234–1242. — Updated SIR QI guidelines. Key thresholds: technical success >96%; major complication rate <1%; filter tilt >15° = threshold complication; retrieval rate monitoring required institutionally. Mandates filter tracking registry and planned retrieval date at time of placement. Identifies filter fracture and IVC penetration as primary long-term safety concerns.

Primary References

  • PREPIC Study Group. Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism. Circulation. 2005;112:416–423
  • Mismetti P, et al. (PREPIC2 Study Group). Effect of a retrievable IVC filter plus anticoagulation vs anticoagulation alone on risk of recurrent PE. JAMA. 2015;313(16):1627–1635
  • Minocha J, et al. Improving IVC filter retrieval rates: impact of a dedicated IVC filter clinic. J Vasc Interv Radiol. 2010;21(12):1847–1851
  • Deso SE, Idakoji IA, Kuo WT. Evidence-based evaluation of IVC filter complications based on filter type. Semin Intervent Radiol. 2016;33(2):93–100