title: Retrievable inferior vena cava filters can always be removed using "fall-back" techniques.
abstract: OBJECTIVE
  Retrievable inferior vena cava filters (IVCFs) left in place for a prolonged period can lead to complications including filter migration, fracture, and caval thrombosis. "Fall-back" techniques for IVCF retrieval that can be used when standard snaring is unsuccessful have been recently described. The purpose of this study was to analyze how incorporation of these new techniques affected the outcomes of IVCF retrievals at our institution during the past 5 years.
  
  
  METHODS
  Data were collected of all patients undergoing IVCF removal by vascular surgeons at a tertiary academic medical center between 2009 and 2013, including demographics and procedural and filter characteristics. A standard technique of snaring the retrieval hook was attempted first in all cases; if this was unsuccessful, a number of fall-back techniques were employed, including the use of endoscopic graspers, 18F sheaths, and snaring a second wire below the collar of the filter to collapse it into the sheath.
  
  
  RESULTS
  IVCF retrieval was attempted in 275 patients; 3 were excluded intraoperatively because of thrombus in the filter. Most filters (97%) were Günther Tulips (Cook Medical, Bloomington, Ind); 70% had been placed prophylactically before bariatric surgery. A total of 268 filters (98.5%) were retrieved successfully, 213 (79%) by standard snaring and 55 (21%) with fall-back techniques. In patients undergoing fall-back techniques, technical success was achieved 100% of the time. The median time since insertion was significantly longer in the fall-back group (173 days vs 83 days; P < .0001). Four intraoperative complications occurred; fractured wires embolized to the right atrium or pulmonary artery and were successfully removed endovascularly. The majority of the procedures (80%) were performed under sedation in both groups.
  
  
  CONCLUSIONS
  Incorporation of fall-back techniques may allow 100% technically successful and safe removal of retrievable IVCFs and is especially useful in removing filters with prolonged dwell time.
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa. Electronic address: yana.etkin@uphs.upenn.edu.
authors.forename: Yana
authors.initials: Y
authors.lastname: Etkin
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa.
authors.forename: Julia D
authors.initials: JD
authors.lastname: Glaser
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa.
authors.forename: David A
authors.initials: DA
authors.lastname: Nation
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Foley
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa.
authors.forename: Grace J
authors.initials: GJ
authors.lastname: Wang
authors.affiliation: Department of Vascular Surgery, MedStar Washington Hospital Center, Washington, D.C.
authors.forename: Edward Y
authors.initials: EY
authors.lastname: Woo
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa.
authors.forename: Ronald M
authors.initials: RM
authors.lastname: Fairman
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa.
authors.forename: Benjamin M
authors.initials: BM
authors.lastname: Jackson
mesh_terms: D000328:Adult; D000368:Aged; D050110:Bariatric Surgery; D020878:Device Removal; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011655:Pulmonary Embolism / Q000209:etiology; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D016306:Vena Cava Filters / Q000009:adverse effects; D014682:Vena Cava, Inferior; D054556:Venous Thromboembolism / Q000517:prevention & control