Retrieval of Thrombosed Inferior Vena Cava Filter and Mechanical Thrombectomy of Associated Caval Thrombosis Using FlowTriever and ClotTriever Systems With the ClotTriever as Embolic Protection

Abstract

A 55-year-old Chinese male with anti-phospholipid syndrome presented with left lower limb deep venous thrombosis (DVT) on warfarin and had an inferior vena cava filter (IVCF) implanted before a radical resection of a perineal sarcoma. The inferior vena cava (IVC) filter removal was attempted 2 weeks after the surgery, but thrombus was found at the filter. It was decided to leave the filter and to continue with anticoagulation. He presented with progressive right lower limb swelling, erythema and pain, with a CT venogram showing caval thrombosis extending from the IVC filter to the right below-knee veins. In view of worsening symptoms, endovenous mechanical thrombectomy of the IVC and iliofemoral veins, as well as caval filter removal, was performed using the ClotTriever and FlowTriever devices (Inari Medical, US). The ClotTriever itself was then placed alongside a 16Fr internal jugular vein (IJV) sheath to remove the thrombosed filter. The FlowTriever disc was next deployed from jugular access as proximal embolic protection during the thrombectomy procedure. The procedure was successful with no symptoms of pulmonary embolism (PE). This report illustrates the alternative use of the ClotTriever BOLD as an intra-operative proximal embolic protection in the absence of alternative devices like a ProTrieve sheath, during caval thrombectomy and removal for caval thrombosis secondary to an IVC filter. Clinical Impact The ClotTriever BOLD catheter, deployed alongside a large retrograde sheath may be considered as an proximal embolic protection for removing thrombosed IVCFs, where there is patient with a suitably sized IVC and when alternative and appropriate devices are unavailable.