Inferior Vena Caval Filter Placement Without Preoperative Venacavography

Despite the emergence of noninvasive studies as the gold standard of venous diagnosis, many authors still insist upon formal preoperative venacavograms prior to insertion of an inferior vena cava (IVC) filter. Conversely, the authors employed only preoperative nonin vasive venous examinations and intraoperative fluoroscopy in 123 consecutive (IVC) filter placements of either the Greenfield filter (n=66) or the LGM (Vena Tech) device (n=57) by the surgical service. They reviewed the patients' intraoperative and postop erative hospital courses to identify complications that could have been avoided by obtaining preoperative contrast venacavograms. Twenty-one intraoperative complications or untoward events occurred in 17 patients, 1 of which could definitely have been prevented by preoperative venograms. These included: unrecognized internal jugular thrombus or web (3), neck hematoma (2), partial filter opening (2), obliquely placed filters (2), requirement of multiple venous insertion sites (5) or conversion to an open procedure (2), premature filter discharge into iliac veins (2), unrecognized IVC thrombus requiring a suprarenal filter (1), placement of a Vena Tech filter inverted (1), and development of hemodynamic instability requiring inotropic support (1). Two patients (1.6%) suffered clinically apparent inferior vena caval occlusion and 4 (3.3%) had recurrent pulmonary emboli after filter placement. There were 18 deaths (14.6%), 14 of these within the thirty-day postoperative period (11.4%). None had evidence that the IVC filter or recurrent thromboembolic events led to their demise. In this retrospective review, the authors identified 1 intraoperative (unrecognized IVC thrombus) and no postoperative complications that could have been prevented by obtaining a preoperative contrast venacavogram. They conclude that noninvasive preop erative venous evaluation coupled with intraoperative fluoroscopy is adequate for the safe placement of inferior vena caval filters.