Complications Associated With Inferior Vena Cava Filter Retrieval: A Systematic Review

Inferior vena cava (IVC) filters have been used successfully in high-risk patients to prevent thromboembolism. The filters are widely created as retrievable devices, but complication rates progressively increase during IVC filter retrieval. This study aims to analyze IVC filter retrieval cases and associated complications during and following the procedures regarding dwell times, specific filter types, filter positioning, and advanced retrieval techniques. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to select and analyze relevant articles. A literature search for articles was performed on September 23, 2023, through three research databases: PubMed, ProQuest, and ScienceDirect. The keywords used to identify relevant publications were “IVC Filter retrieval AND complications” and “IVC filter removal AND complications”. The articles before 2012 were excluded. Relevant articles were selected based on the inclusion and exclusion criteria. In total, 20,435 articles were found: 812 from PubMed, 15,635 from ProQuest, and 3,988 from Science Direct. Among the exclusions were 18,462 articles, which were excluded in the automatic screening process, leaving 1,973 for manual screening. The manual screening of articles was conducted based on title, abstract, article type, duplicates, and case reports, where 1,918 articles were excluded. Ultimately, 55 articles were included in this review. This study demonstrates that IVC filter retrievals have significant complication rates. Many complications have a common theme: prolonged dwell time and lost follow-up appointments. Therefore, importance should be placed on patient education and implementing strict protocols regarding the timelines of IVC filter removals.


Introduction And Background
Extensive research has been conducted on the inferior vena cava (IVC) filtration device since the 1960s.This intervention has proven to be beneficial for patients who are at a heightened risk of developing pulmonary embolism (PE) or deep vein thrombosis (DVT) [1,2].Patients with specific indications, such as a history of PE in the past, protracted immobility, or persistent risk factors (e.g., patients who are unable to take blood thinners due to an increased risk of intracranial hemorrhage, hemorrhagic stroke, or gastrointestinal bleeding), are also candidates for IVC filters [3].
IVC filters are basket-like filters designed to capture venous emboli that discharge from the lower extremities and form below the filter.This prevents the emboli from reaching the lungs, where they could otherwise cause clinically significant PE [1,4].Following the approval of IVC filters by the United States Federal Drug Administration (FDA) in the early 2000s, their use increased.Rates of IVC filter implantation have increased annually.In cases where initial anticoagulation treatments for patients with acute DVT are contraindicated or have proven to be ineffective, IVC filters have been suggested as an alternative [5,6].
Nevertheless, caval occlusions were documented in 10% of permanent filters at the one-year follow-up and increased to 30% by the nine-year follow-up [7].Thrombosis at the venous access site, migration of filters, and penetration of vessel walls are all considered serious complications [1,[8][9][10].The long-term complications associated with persistent filters have prompted the development of retrievable filters, which aim to preserve the benefits of filtration while mitigating these issues [2,11].The pursuit of developing a retrieval method that is both secure and efficient has intensified in response to the escalating rate of filter implantation since 2003 [12].The potential complication rates associated with temporary IVC filters were acknowledged by the US FDA in 2010.The agency advised that the filters be removed when the elevated risk of PE is no longer present and after a risk-benefit analysis for removal per patient had been completed [13,14].With retrievable IVC filters, complications such as small bowel perforation, abdominal complaints, and concurrent aortic and vertebral penetration have been reported during and after the procedures [15].Atrial arrhythmia and cardiac tamponade are complications that may arise from embolization of a filter fracture [16].The objective of this review is to examine and evaluate ongoing scholarly works in order to draw attention to the documented complications that are linked to transient IVC filter removal methods.

Review Methods
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to perform this systematic review.The search for articles was conducted on September 23, 2023, through the three research databases: PubMed, ProQuest, and ScienceDirect.The query used in all of the search databases includes: "IVC Filter retrieval" AND "complications," "IVC filter removal" AND "complications."Articles not written in English, duplicate articles, and articles published before 2012 were excluded during the screening process.Articles were screened based on title, abstract, and study type during the manual screening process.Our initial search from the databases resulted in 11,155 articles.We screened the selected articles according to the inclusion and exclusion criteria, and 55 were yielded.

Inclusion Criteria
The inclusion criteria consisted of studies written in English, studies conducted on humans, studies relevant to our topic and research question, and peer-reviewed full-text articles, including clinical trials and metaanalyses.

Exclusion Criteria
Exclusion criteria included duplicates of articles, case reports, animal studies, narratives, systematic reviews, and manual reviewing.Figure 1 illustrates the inclusion and exclusion process.PRISMA flowchart describing the literature screening of studies concerning the complication of IVC filter retrieval [17].
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; IVC: inferior vena cava The PRISMA statement guidelines were followed to perform the screening for this literature review [17].

Results
Three databases, including PubMed, ProQuest, and ScienceDirect, were investigated for this systematic literature review.Our initial research resulted in 20,435 articles being found: 812 from PubMed, 15,635 from ProQuest, and 3,988 from Science Direct.Using database filters, our automatic inclusion of articles consisted of peer-reviewed full-text articles, meta-analyses, clinical trials, randomized control trials, and those published between 2012-2023, which removed 18,462 articles.This left 1,973 articles for manual screening based on title, abstract, article type, duplicates, and case reports, where 1,918 articles were excluded.Two co-authors reviewed the articles for content relevance which resulted in a final inclusion of 55 articles.Of these included articles, we reviewed 42 retrospective studies, eight prospective studies, two observational reviews, two questionnaire-based studies, one randomized-control trial, and one clinical study.
In the review of these articles, studies were carefully chosen by the co-authors with significant sample sizes, which increased the power of the results.To minimize bias, studies that took place at one institution were chosen to reduce the risk of confounding results among the population studied.To further investigate the complications of IVC retrieval, a variety of filter brands, surgical removal procedures, and dwell times were studied to identify the risks and benefits.Upon exploring the articles, we were able to identify relationships contributing to IVC filter removal complications.We further categorized these findings in our discussion as filter position, dwell time, retrieval technique, and clotting.Changes in these variables play an important role in the success or failure of filter retrieval.Our hopes for this review are to establish patterns for complications that can serve as a guide for future IVC filter retrievals to minimize the complications among patients.All included studies, number of cases, significant findings, and conclusions are summarized in Table 1.The technical success (defined as the deployment of the filter such that it was judged suitable for mechanical protection from PE) of 100% was achieved in all subjects.Of all the tested subjects, eight cases resulted due to recurrent PE, three cases of symptomatic occlusion/thrombosis, and two cases of filter migration were reported in the study.There was no damage observed due to filter embolization or the filter fracture.Moreover, the clinical success of IVC retrieval was achieved in 92.3% (36 of 39 subjects) upon the mean retrieval period of 67.1 days of implantation.In addition, the study suggested that all deaths (n= 17) and deep vein thrombosis (n=18) were results of pre-existing or intercurrent illnesses and not related to the filter device.Lastly, the deaths were concluded to be unrelated to PE.

S.No Author Country
The Option IVC filter retrieval and placement were achieved safely with high clinical and technical success rates.From all of the 503 patients, ALN IVC filters were placed, only 29 patients were followed in this study as those were the only ones who had their filters for at least one year following implantation.
No history of post-thrombotic syndrome, DVT, or PE was reported in their patients since the filter implantation.The mean interval between the time of the implantation, and the time of retrieval was   The study found that the main causes for the failure of retrieval were due to filter duration and alignment.The study divided the 50 patients into two groups where Group A had 18 patients who received permanent IVC filters and 32 patients in Group B received temporary IVC filters.as their primary treatments.It was reported that there were no major complications found in either of the groups during IVC implantation, however, the mortality rate after implantation was found to be higher in Group A (35%) than in Group B (16%).
Moreover, pulmonary thromboembolism was found to have recurred and caused death in Group A patients in 18% but none of the Group B patients showed any recurrence as they received temporary IVC filters.Lastly, the study reports that 14 Group B patients were not given permanent IVC filters upon the removal of the temporary IVC filters, all of whom survived.those with plans had higher filter retrieval rates.Filter-related complications were observed in 57 patients and an additional 44 patients had long-term complications associated with filter removal.Thrombosis formation at the filter site was the most commonly observed complication (n=27), followed by filter embedment (n=10).Evidence suggests complication rates for retrievable filters to be higher than for permanent filters because of the increasing number of retrievable IVC filters being inserted combined with the lack of retrieval.Five cases (18.5%) showed tilting of the filter (≥15 degrees).
However, one of the cases showed the filter to be embedded into the right lateral wall of the IVC.Using this filter, the study showed none of the other complications of retrieval such as filter thrombosis, significant filter migration, filter fracture, and caval occlusion.
G2  Fractured IVC filter bodies can be safely removed.
Fractured filter struts can be removed when The CT imaging results showed that the specific locations showed symptomatic indications of 38.3% for the filters placed <1 cm below the lowest renal vein, 27.1% for filters placed >2 cm, and of 27.1% for filters placed 1-2 cm below the renal vein.
Further, the study showed significant differences in caval struct penetration, penetration of adjacent viscera, time to penetration, filter migration, or tilt when the filter was placed in infrarenal IVC.
None of the filters were found to be fractured.In addition, none of the complex filter retrievals showed any incidence of patients with pulmonary embolism, and only one filter retrieval failed.
The  Of these patients, five of them showed overlapping complications.
Two of them (8%) had also complained of filter-related pain.The success rate of IVC filter retrieval by double-loop technique was 14/16 (87.5%).There were no major filter retrieval-related complications.
The study concluded that the complex procedure of the double-loop technique is safe and a feasible method for complicated IVC filter retrieval.IVC filters are invaluable in the prevention of PEs in patients who are refractory or contraindicated to anticoagulation, our aim was to identify the factors that contribute to complications associated with IVC filter retrievals.Many studies have shown a strong association between IVC filter dwell times and IVCF retrieval complications.A study by Averginos et al. was included, which showed the significance of prolonged IVCF implantation time as a strong predictor of failed or challenging retrievals [28].
The striking outcome result of our research search showed that many well-referenced complications of IVCF retrieval can actually be an outcome of prolonged filter dwell times.In support of this, two studies showed that IVCF fracture rates increased as dwell durations lengthened [16,37].Other studies have documented how the increased IVCF implantation time has been correlated with IVC wall penetration, perforation, and filter migration/tilting.All of these complications lead to difficulty during standard retrievals, which lead to increased failures or the necessity for stronger force/complicated procedures.
Complicated retrieval procedures used for IVC filters that have migrated, tilted, or penetrated IVC walls include but are not limited to balloon-assisted, wire loop-and-snare, irregular bronchoscopy, and laser excimer sheath.These procedures have been documented to have led to filter leg fragment embolization to the pulmonary artery, as well as resulting IVC pseudoaneurysms, arteriovenous fistulas, and wall perforation and subsequent internal bleeding [14,26,49,51,52].These procedures are also associated with longer surgical time, and patients are exposed to a longer duration of general anesthesia, which can be a significant detriment to these patients [50].
Although standard retrievals are overall preferred due to the decreased complication rates, during the comparison of complex techniques, rigid endobronchial forceps techniques were found to be much more effective in retrievals than the balloon-assisted method or loop-and-snare techniques [52].Interestingly, studies found that using a thicker sheath of 12F is much better in retrieving the filter than the classically used 8.5F sheath due to its inability to completely encircle the filter.This technique was beneficial for the retrieval of conical, Gunther-Tulip, and Celect filters [52,53].
As discussed, filter position and minimized dwell times are crucial in the safety of IVC filter retrieval and different brands of filters have shown significant variations specifically associated with IVCF migrations/wall penetration and complication rates.The ALN filter was associated with a greater degree of filter inclination in comparison to Denali filters [2].Importantly, as we have documented dwell times to contribute to complications, the conical option and the Gunther-Tulip filter (GTF) exhibited the least complications after increased dwell times [1].
Overall, reduced dwell time was found to be beneficial in decreasing the number of complications associated with filter retrieval.Morrow et al. found 196 day median dwell time to be associated with successful retrievals [34].Studies have shown effectiveness in minimizing dwell times through proper follow-up due to successful patient education or the implementation of multidisciplinary surveillance teams (MDST).MDST cohorts had a significant increase in successful retrievals compared to the cohort that did not have an MDST implemented, as well as significant decreases in filter median dwell times [47].
Kuo et al. highlighted an important post-retrieval complication of acute partial caval thrombosis associated with patients who did not receive anticoagulation treatment prior to or during retrieval.The application of anticoagulation prior to/during is strongly recommended, one study showed that the complication was completely eliminated after the addition of anticoagulation [12].Anticoagulated patients have decreased occurrences of dislodged emboli during retrieval as well as decreased risk of new-found thrombosis [52,55,56].

Discussion
Complications associated with IVC filters were found to be influenced by a variety of factors, including filter positioning, filter dwell time, retrieval technique, and coagulation.Compared to permanent filters, retrievable IVC filters are safer and more effective at preventing the recurrence of pulmonary thromboembolism (PTE), according to the literature [18].Furthermore, temporary filters exhibited a reduced mortality rate (16%) compared to permanent filters (35%), immediately following implantation.PTE recurrence was observed in 18% of patients who underwent filter removal; conversely, retrievable filter recipients did not exhibit PTE [18].
Filter retrieval difficulties are frequently observed in patients who are contraindicated for anticoagulants, have a history of intracranial hemorrhages, increased rates of immobility, or malignancy [6,19].Filter embedment is a likely second most frequent complication, after thrombosis formation at the filter site [20].
To prevent these potentially fatal complications in patients who have chronic retrievable IVC filters, it is strongly advised that they maintain ongoing care, have an electronic communication follow-up method with their healthcare providers, and have the filters removed when clinically appropriate [21][22][23][24].Research has indicated that the probability of successful IVC filter removal rates is substantially impacted by whether or not the removal is scheduled during the placement encounter [25].

Filter Position
Embedded hooks, caval wall penetration, and filter malpositioning (tilts) are frequently linked to the requirement for sophisticated or intricate methodologies [10,26].According to one study, the location and position of IVC filter limb penetration could be determined using CT scans performed prior to retrieval procedures; 89% of those filters were subsequently retrieved successfully [10].By accurately identifying 58 out of 59 tip-embedded filters, rotational venography demonstrated its efficacy in reducing the complexities associated with retrieval methods that are complex in nature [14,27].
An additional prevalent complication observed was IVC filter inclination and angulation surpassing 15 degrees, which was linked to unsuccessful and difficult retrievals [28].ALN and Optease filters had the highest rate of IVC filter retrieval failure, according to Gotra et al. [29,30].This was because the ALN filter had the greatest mean absolute value of tilt, and the Optease filter had the greatest mean migration.In comparison to Denali filters, Option IVC filters were associated with a greater degree of filter inclination change, a greater demand for sophisticated retrieval techniques, and a higher failure rate [14,31,32].
Filter struts penetrating the right ventricle, IVC wall, extraluminal tissue adjacent to the IVC, filter fragment dislodgement, and concomitant aortic/vertebral penetration were cited as reasons for failed retrieval attempts in the reports [18,33].Greater retrieval failure rates are associated with the lateral angling and embedding of the hook/apex or collar of the filter compared to filters lacking penetration [33,34].
Although the majority of research indicates that filter position is crucial for IVC filter retrieval complications, such as dislodgement of IVC filter fragments, Puller et al. propose that in the case of asymptomatic patients, filter fragments are generally stable and can be safely monitored [35].In general, the safety of IVC filter retrieval is enhanced in the absence of migrations, penetrations, or tilts [36].

Dwell Time
Extended dwell time is associated with enhanced advanced retrieval techniques, according to Laidlaw et al. [32].Certain studies have documented a potential for significant complications during the procedure due to the use of excessive force in retracting the filter [14,23].As stated by Quencer et al., the misalignment of the retrievable IVC filters results in an extended filter retention time, which in turn contributes to the prevalent issues of filter inclination and IVC wall perforation [14].It is estimated that conventional methods are incapable of extracting 40-60% of retrievable IVC filters that have been implanted for more than a year [26].
According to the studies, fifty percent of filters that were implanted for more than two and a half million years but were not removed after twenty years did not undergo retrieval using standard techniques or failed follow-up [23].More than 1.1 million patients in the United States would receive embedded filters regardless of whether the filter is indicated [23].
The median filter dwell time for successful retrievals in Morrow et al. was 196 days, while it was 375 days for unsuccessful retrieval attempts [34].Prolonged dwell time was found to be a predictor of unsuccessful retrievals (96.9 ± 111.9 days) and challenging retrievals (51.1 ± 69.8 days), according to Averginos et al. [28].
A greater degree of IVC penetration was significantly correlated with a prolonged indwelling duration of the IVC filter.Patients with filters in place for longer than 20 days had an elevated risk of significant IVC penetration [37].Additionally, IVC filter fracture rates increase as dwell durations lengthen [16,37].In support of this claim, Kuo et al. provide evidence that the average indwell duration of fractured filters was considerably longer at 1,082 days compared to 408 days for non-fractured filters [38].Additionally, a reduced dwell time was found to be a positive predictor of successful IVC filter retrieval [30].The results of this research indicate that studies that failed to consider variations in dwell durations might have exaggerated the rates of successful IVC retrieval [36,[39][40][41].
According to Al-Hakim et al., the average filter dwell time in their study is 134 days (with a range of 0-2,475 days) [26].Furthermore, they find that extended dwell times are substantially correlated with higher rates of unsuccessful retrieval using routine techniques.A growing filter dwell duration is correlated with more complex retrieval techniques and lower retrieval success rates, according to research [10,13,42].This is because of the increased risk of strut, tilt, and caval wall penetration.Nevertheless, a 2013 study by Pellerin et al. demonstrated that an extended implantation duration does not inherently correlate with a heightened risk of filter extraction failure.Despite the detection of filter inclination and IVC penetration, none of the ALN filter retrievals experienced failure or complications during the extraction process following a dwell time of over one year [2].Approximately 25.6 months passed on average between implantation and retrieval, and every extraction was fruitful [2].Additionally, Ileascu et al. discovered a recent account in which a Lynch filter was effectively eliminated 3006 days later [10].An investigation pertaining to the percutaneous retrieval of permanent IVC filters, including Simon Nitinol and TrapEase, revealed an 8.4% rate of filter complication removal over a mean of 5.1 years (ranging from seven days to 15 years) [42,43].This research demonstrated that retrieval of IVC filters was effective, as only two instances exhibited complications despite the extended residence periods of these permanent filters.
A complicated retrieval rate of 8% was documented by Given et al. in 2008, pertaining to GTFs, following an average implantation period of 76.40 days [7].The longest retrieval occurred 309 days later.The extended dwell time and subsequent successful retrieval were corroborated by the GTF, which exceeded the manufacturer's initial suggestion of retrieval occurring no later than 14 days following filter insertion [7].The absence of complications during retrieval follow-up for the GTF was documented in the studies conducted by Anzai et al. (2011) and Kuo et al. (2013), with retrieval mean dwell times of 304 and 433 days, respectively.Furthermore, a correlation between the duration of filter implantation and extraction success rates was indicated in both investigations [8,44].Recent investigations on the GTF, on the other hand, have produced results that contradict the aforementioned conclusions.Statistical analysis revealed a significant relationship between filter strut penetration and extended dwell periods.There is a negative correlation between the duration of dwell time and the efficacy of filter retrieval.This is attributed to the heightened likelihood of tissue embedding around the filter, which can result in dense fibrosis and neointimal hyperplasia [14,42,43].
Like the GTF, the conical Option IVC filter exhibited minimal complication rates during retrieval (7.7%) following an average dwell time of 67.1 days following filter implantation [1].There were no fractures or embolizations caused by the filter.It was determined that none of the fatalities or DVTs were attributable to the filter, but rather to concurrent or preexisting conditions.Thus, 12% of the subjects exhibited clinical complications, as determined by the Options filter [1].
More than 150 instances of filter inclination associated with the risk of new PE and recurrent PE with a caval filter have been reported for the conical Celect filter [7].The study also found that Celect filters had a comparatively low convoluted retrieval rate of 7%, in contrast to the GTF's 8% [7].Following an average of 121 days of residence time and a design modification derived from the GTF, these outcomes were exceptional.In comparison to GTF, the Celect IVC filter demonstrated safety during deployment and retrieval; however, in one instance, removal was unsuccessful as a result of a thrombus in the IVC.The literature extensively covers the high incidence of IVC wall penetration of less than 3 mm by the filter legs or struts verifying PE after filter implantation (2.8% for both the G2 and conical Celect filters) [45].
The investigations conducted by Stavropoulos et al. regarding the Denali (Nitinol) IVC filter revealed that after 165 days and 200.8 days of dwell time, complicated retrieval rates of 2.7% and 2.4% of the filter, respectively [45].In both investigations, filter struts or filter hooks that are frequently encountered during filter removal and are embedded in the IVC were not observed [3,46].Nevertheless, both investigations encountered two unsuccessful filter retrievals as a result of the anterior-posterior angulation of the IVC filter.It obstructed the clinician's ability to detach the filter catch using a snare.One drawback of the cited studies is that imaging is only performed on patients with symptomatic PE for the purpose of calculating the complication rate; patients with asymptomatic PEs who may not be diagnosed are also not accounted for [3,46].
After 122 days of residence time, the G2 filter study revealed no complications and successful retrieval on all twenty-seven attempts [22].The study documented a mean filter tilt of merely 10° for the G2 conical filters.On the contrary, the venographic images of a single patient unveiled a gradual increase in filter inclination from 20° to 28°, with the apex of the filter aligned with the lateral caval wall.She was referred for filter retrieval 121 days after its insertion as the patient [22].Therefore, a recovery cone system was necessary for this patient in order to facilitate apical cone snaring and effective filter retrieval through its reinforcement [22].
Following IVC filter placements, Stevens et al. observed 453 patients, of which 181 were followed after the MDST was established and 272 were in the pre-MDST cohort.The research discovered that the rate of IVC filter retrieval was greater in the post-MDST cohort (73.5% vs. 52.6% in the pre-MDST cohort) [47].Additionally, the median latency time between IVC filter insertion and retrieval was reduced: 187 days for the pre-MDST cohort compared to 150 days for the post-MDST cohort [47].An MDST team was correlated with a reduced length of stay and an improved prognosis for the patient.

Retrieval Technique
The retrieval of IVC filters is a straightforward process that requires only a coaxial sheath and a snare [14,41,48].By administering the procedure jugularly, the standard retrieval device can easily latch onto the hook of the IVC filter, facilitating its removal.Filter mispositioning in the renal vein, filter tilt, encasement of the filter apex in the adjacent IVC wall, filter fracture, significant extracaval protrusion of filter elements, fibrin cap, or filter-associated thrombus are all potential causes of inability to engage the filter apex [49,50].When such circumstances arise, sophisticated retrieval methods are implemented [10,13,14,48].These methods consist of the suspension (wire loop-and-snare), endobronchial forceps dissection, the hangman technique, the utilization of laser excimers, balloon-assisted retrieval, and the double-snare technique.In advanced technique procedures, the incidence of complications during IVC retrieval escalated by a factor of four, from 5% to 10% for minor complications, and by a factor of 13 for significant complications, in comparison to the standard retrieval technique [14].Advanced retrieval techniques are linked to several complications, including embolization, filter fracture, an increased average fluoroscopy duration, a higher average radiation dose, and a greater utilization of general anesthesia in comparison to standard retrievals [50].
Following the failure of the initial standard technique, the segregated "low-profile" hangman technique was implemented [14].A standard 11 F Cook filter retrieval membrane is utilized for this method, which is more compact than alternative advanced removal techniques.Achieving a successful retrieval of the filter was a non-complication outcome for all 23 patients who participated in the study, both during and after the procedure.This apparatus is easily obtainable in the majority of interventional radiology practices, which confers benefits in terms of affordability and accessibility [26,49].
Irregular bronchoscopy A forceps retrieval is frequently mentioned as a sophisticated technique in cases where the IVC filter is ingrained within the caval wall.Among the most common complications is symptomatic IVC pseudoaneurysm, which necessitates balloon tamponade [14].Two filter leg fractures necessitated embolization to the pulmonary artery and an asymptomatic IVC pseudoaneurysm constituted minor complications [14].Trauma during the procedure has been identified as a drawback of this method, as evidenced by the identification of contrast extravasation in 8.3% of removals [14].Reports of arterio-venous fistulas between the renal artery and IVC, as well as embolization caused by leg fractures, have been documented subsequent to retrieval [14].
The utilization of this technique is also necessary for embedded or tilted filters, in addition to the sling (wire loop-and-snare) method.In conjunction with leg fracturing, contrast extravasation, and unintended IVC dissection are frequently observed complications.It is possible that reorientation will be required throughout this procedure, particularly when handling malleable Nitinol filters [14].Twenty consecutive patients experienced no complications as a consequence of the sling technique modification [14].After aligning the filter, the hook was loop-snared.On the contrary, several further investigations carried out by Quencer produced contradictory results regarding this modified approach, resulting in an overall incidence of complications amounting to 20% [14].
In the process of filter retrieval, a laser excimer sheath is utilized when an embedded filter is situated above adhesive tissue.A study involving 251 patients, as documented by Quencer et al., indicated that this technique was linked to a 1.6% incidence of significant complications [14].A venous pseudoaneurysm, contrast extravasation, and caval-enteric fistula accompanied by septic caval thrombophlebitis are a few potential complications [14].Furthermore, 10% of patients experienced complications, including cholecystitis, renal infarction, and coagulopathic hemorrhages, according to Cho et al.In comparison to the conventional retrieval method, this technique produced exceptional outcomes for 414 distinct categories of retrievable filters and 86% permanent filters, with the latter exhibiting the longest dwell time of 8.5 years while requiring the least amount of force.It was discovered that this method produced an average of 1.8% complications and a retrieval success rate of 99.4% [14,23,51].Therefore, this method aids in circumventing invasive open surgical procedures by safely extracting different IVC filters, irrespective of their dwell time [23].
Retrieving IVC filters that have penetrated the IVC wall requires the use of a number of complex techniques, including the balloon-assisted method and numerous loop techniques.Nevertheless, it is worth noting that the retrieval success rate for loop-snare and balloon-assisted techniques may be comparatively lower (80%) than that of rigid endobronchial forceps techniques [52].A number of interventionalists regard endobronchial forceps as an aggressive technique [52].The filter tip was rapidly secured using a modified snare-over-loop guide wire technique [52].This involved inserting the Gooseneck snare into the 12 F sheath rather than the 8.5 F inner sheath.The complex IVC filters were completely encased in hypertrophic endothelial scar tissue, which posed a retrieval challenge when employing the standard 8.5 F sheath.In contrast to the 12 F sheath, the conventional 8.5 F sheath was unable to completely encircle the filter.The modified technique demonstrated an overall success rate of 87.5% in retrieving conical, Gunther-Tulip, and Celect filters.In contrast, non-conical Optease filters failed to retrieve in 33% of patients due to their greater contact area with the caval in comparison to conical filters [52,53].

Clotting
If the patient is taking anticoagulants and has a projected survival time of at least six months, the IVC filter can be safely removed, and there are no indications that the patient will require a filter in the future, then the filter may be removed [14].Yamagami et al. determined that the mortality rate resulting from a PE subsequent to filter removal was deemed to be substantial at 2.6% [54].The presence of this complication warrants prudence when deciding whether or not to remove an IVC filter.Consequently, by diligently and consistently monitoring patients at an outpatient clinic using D-Dimer assays and ultrasounds, the risk of PE post-retrieval was reduced to 2.0% [51,54].Kuo et al. investigated the occurrence of acute partial caval thrombosis as a complication during a sequence of advanced IVC filter retrievals in all patients who did not receive anticoagulant treatment prior to or during surgery.
By administering anticoagulants to the remaining patients prior to and throughout the operation, this procedural complication was eliminated [12].A novel device was developed because prophylactic heparin has not been shown to reduce the incidence of clinically significant PE, despite the fact that it has been the primary cause of mortality in critically ill trauma patients [3].For these patients, the device integrates an IVC filter with a triple-lumen central venous catheter (CVC) for bedside administration [3].This one-of-akind administration device permits the removal of the IVC filter prior to patient discharge.Complications linked to the removal of this device consist of the development or exacerbation of acute proximal lower extremity DVT.The occurrence rate of these incidents varied over time, with 7% transpiring on day seven and 18% on day 30 [3].
Hoppe et al. support the safety of IVC retrieval in anticoagulated patients.Nevertheless, reversing anticoagulant medications from warfarin to heparin during medical procedures raises the likelihood of venous thromboembolism (VTE) in patients [11].Ho et al. observed that the insertion of IVC filters was associated with the development of DVT, VTE, and PE in the lower and upper extremities [55,56].IVC filters do not effectively inhibit thrombus formation in patients who are non-compliant or have anticoagulant medications contraindicated.Anticoagulant-treated patients have a lower risk of entrapped emboli becoming dislodged during IVC filter removal than these individuals [56].When contemplating the removal of IVC filters from these patients, extreme caution is required [52,55].

Limitations
Our review had several identifiable limitations beginning with the exclusion criteria outlined in the methods section, and specific search criteria used to identify articles pertinent to IVC filter removal/retrieval and complications.Additionally, our review did not contain a meta-analysis, to further strengthen our findings.
Our search was limited to three databases (PubMed, ScienceDirect, ProQuest) and relevant papers may have been excluded.Our inclusion of only full-text and English articles may have limited us from relevant information and significant international findings.Our systematic review is limited by the quality/bias that may have been associated with each study reviewed, including selection bias for example.Retrospective cohort studies rely on the availability of information which may have been incomplete or limited by participant recall bias.Our prospective cohort studies are limited by the possible loss of follow-up.All cohort studies are vulnerable to confounding variables and publication bias, which could have interfered with the validity of the studies included.Despite the careful manner in which our systematic review was performed, we accept that our review may not contain all relevant studies and research relevant to our topic.

Scope of future studies
Our review aimed to identify relationships associated with increased complication rates.We identified important variables such as filter position, dwell time, retrieval technique, and clotting and extracted associated outcomes from many different studies in order to find patterns.We hope that additional studies can further explore these relationships and expand on the factors contributing to increased complication rates.Future researchers can use our review as a foundation to build on the points established in this systematic review to further design and report additional studies.

Conclusions
IVC filter retrieval comes with many setbacks; our review suggests that the increased dwell time of the IVC filter is the main contributor to the complications encountered during retrievals.The retrieval technique of choice would be the standard technique, but often, chronic IVC filters lead to filter embedment, filter malpositioning, and increased thromboses at filter sites, necessitating the need for radically advanced techniques.Many factors can lead to complications during IVC filter retrieval, but timeliness is one thing that physicians can minimize.This is why we recommend proper patient education and communication and regular follow-up appointments, including IVC filter imaging or MDSTs, to ensure timely action.In conclusion, IVC filter retrieval complications can be mitigated by keeping patient relationships and thorough educational awareness.The low number of articles about IVC filter retrieval complications limited this study.Many of the articles included in our study also were based on small sample sizes of IVC filter removals.

FIGURE 1 :
FIGURE 1: PRISMA flowchart describing the literature screening of studies concerning the complication of IVC filter retrieval

25. 6
months.However, for eight of these patients, the filter extraction was upon a mean delay of 32.6 months as they had received the filter at least two years earlier.The longest dwell time of the IVC filter was 40 months.All of the filter extraction was successful without complication despite the filter's showing 15 degrees of tile in 11 patients and more than 15 degrees in two patients.Optional ALN IVC filter retrieval can be achieved with safety and feasibility for the longest dwell time of more than one year upon the primary efficacy endpoint in all 163 patients (100%) (95% CI, 97.8%-100%, P<0.01) which was to achieve freedom from the clinically significant pulmonary embolism or fatal pulmonary embolism 72 hours after filter removal.Upon the removal of the filter, the recurrence of the new or worsening acute proximal DVT was found to have occurred in the first seven days in a time-dependent manner in 11 (7%) patients.There were no (0%) catheter-related infections found in the bloodstream.Five major bleeding events occurred (3.1%), and a significant thrombus in the IVC filter occurred in 14 (8.6%) patients.Moreover, upon the admission of patients to the ICU prophylactic anticoagulation was not administered for a mean of 5with unretrieved IVC filters inserted between January 2001 and December 2013.
filters were inserted for a variety of reasons, one of them being prophylaxis of PE in perioperative patients.205 attempts were carried out in the study of which 15 failed.The retrieval rate of the GT IVC filter was found to be 92% after a dwell time of 76.95 days.The study showed three minor complications associated with the insertion of the GT filter and five related to retrieval.It also showed that the GT IVC filter's longer dwell time (76.40 days) before its retrieval is safe compared to what was suggested by the manufacturer at or before 14 days to avoid the risk of endothelialization.were assessed in 10 patients who had indicated filters due to venous thromboembolism (VTE) and contraindication to anticoagulant, VTE and inability to maintain anticoagulation therapy, pulmonary embolism while undergoing deep vein thrombosis, and a patient with a massive pulmonary embolism.Complex retrieval techniques were successful in 100% of procedures that had embedded tips.Advanced techniques included snare-over-guide-wire loop (SOGL) modified using a 10F Flexor sheath or 14 F bright-tip sheath, rigid endobronchial crocodile jaw forceps, SOGL with additional flexible endoscopic alligator jaw forceps, coaxial bi-sheath and bi-snare method, laser-assisted sheath technique with photothermal ablation, and SOGL with laser-assisted sheath technique.In conjunction with the aforementioned removal techniques, IVC recanalization, venoplasty, and/or thrombolysis were deployed when needed.Histological tissue analysis revealed all 10 patients to have neointimal hyperplasia, dense fibrosis, and scant native IVC filter removal success.
393 retrievable IVC filters were placed, with 254 of them with an indication of pre-operative PE prophylaxis.Of the 254 IVC filters inserted, attempts to remove were 168/254 (66.1%), and there was a mean dwell time of 59.5 days.On the first attempt, 143 filters were successfully removed (85.1%) and 25 cases failed or had to abort due to filter tilts and thrombus (14.9%).Seven cases were successfully removed on the second attempt, and they were failed or aborted notably due to the presence of filter thrombus.No attempt at retrieval was made in 86 patients (33.9%) because a significant proportion of them were surgical The study did not note any significant findings in filter retrieval failure due to increased dwelling time.The study concluded that preoperatively inserted filters for non-cancer surgical patients had a high retrieval rate.They noted importantly that the excellent retrieval rate was in conjunction with a plan to retrieve the filter at the 2024 Rodriguez et al.Cureus 16(2): e55052.DOI 10.7759/cureus.55052cancer patients (p<0.0107).The relationship was significant between cancer surgery and shorter survival time (p<0.0001).Overall, 150 filters were removed (59%) and (58%) of those were removed in the first three months.time of placement, and close follow-up was maintained.A large portion of non-retrieved IVC filters were due to surgical cancer patients who died with the filter still in place.made in the G2 IVC filter removal after a mean period of 122 days in 26 patients.All of the filter retrieval procedures were successful with a 100% technical success rate.
highest mean absolute value of tilt (5.6 degrees), the Optease filter had the largest mean migration (−8.0 mm) and the Bard G2 filter had the highest mean penetration (5.2 mm).The dwell time of 0-90 days or 90-180 days, net tilt of 10-15 degrees, caudal migration of -10 to 0 mm, and penetration less than 3 mm were positive predictors of successful retrievability.Higher odds of successful retrieval were obtained for the Bard G2X, Bard G2, and Cook Celect compared to the ALN and Cordis Optease filters.Shorter dwell time, lower mean tilt, caudal migration, recorded were 11.6% for Option, 5.1% for Tulip, and .9%for Denali filters (Denali vs. Option p=0.018;Denali vs. Tulip p=0.159;Tulip vs. Option p=0.045).Filter retrieval failures were notably higher for the Option filter in comparison to the Denali and Tulip filters.Median fluoroscopy time for filter retrieval was highest for Option filter at 6.75 min, 4.95 min for Tulip, and lowest for Denali at 3.2 min (Denali vs. Option p<0.01;Denali vs. Tulip p<0.01;Tulip vs. Option p=0.67).Advanced retrieval techniques were used in 21.2% of Option filters, 10.8% of Tulip filters, and 0.9% of Denali filters (Denali vs. Option p<0.01;Denali vs. Tulip p<0.01;Tulip vs. Option p<0.01).The Denali filter required the least amount of fluoroscopy time and advanced technique used compared to both Option and Tulip filters.mean IVC diameter at placement was 19.2 ± 3.3 mm.Mean filter tilts at placement and retrieval were 6.1 ± 4.9• and 5.2 ± 5.0•, respectively.The mean tilt change was 5.0 ± 5.0•.A larger IVC diameter was associated with greater filter tilt change.Greater tilt change and prolonged dwell time were associated with increased advanced retrieval technique use.Results were unchanged in a subgroup analysis of patients treated with GTFs.and December 2010, 148 IVC filters were retrieved, 15/148 filter bodies were fractured, and all were successfully retrieved.Nine of 15 fractured filters (60%) wereremoved in their entirety by using endobronchial forceps to retrieve the filter body and/or fractured struts.In three cases, forceps were used to retrieve the filter body, and the fractured strut was removed with a snare.In 6 patients (40%), only the filter body could be removed, three with the Recovery Cone and 3 with endobronchial forceps.Three failed attempts to remove fractured struts were made, with no attempt made in the remaining three.These struts were incorporated in the right ventricle, embedded in the IVC wall, or extraluminal.Minor caval defect was identified in 5/15 retrievals (33%); mild hemoptysis was noted in one case where the strut was snared from a pulmonary artery.No major complications occurred.

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Rodriguez et al.Cureus 16(2): e55052.DOI 10.7759/cureus.17patients, who had at least one strut in either the aorta or iliac artery, was 100% without any complications.Follow-up from 10 days to two years was available for 12/17 (71%) patients, and no delayed complications were reported.The retrieval techniques included standard snare retrieval in three patients, loop wire technique in eight cases, rigid endobronchial forceps in five cases, and rigid endobronchial forceps with excimer laser sheath-assisted photothermal ablation in one case.The study reports that longdwell time for the IVC filters in the 76 patients was 19.7 ± 28.6 (SD) days.The mean follow-up after filter retrieval was 39.8 ± 22.1 months.In 5 of 76 patients (6.6%), worsened VTE was seen after filter retrieval.Two patients (4.0%) had worsened or recurrence of DVT in their lower extremities, two patients (2.6%) had developed PE, and one patient had a second IVC filter placed permanently.The mortality rate during the followup period was 2.6% (n=2), both due to PE with no potential risk factor for VTE.16%) developed DVT or VTE subsequent to placement of IVC filters.27 had lower limb DVT, 8 upper limb DVT, and 4 pulmonary embolisms.A high Injury Severity Score, tibial/fibular fractures, and a delay in initiating pharmacological thromboprophylaxis after insertion of the filters (14 vs. 7 days) were significant risk factors.30 patients were lost to follow-up (13%) and their filters were not retrieved.Mechanical complications including filters adherent to the wall of IVC (4.9%), IVC thrombus (4.0%), and displaced or tilted filters (2.2%) were common when the filters were left in situ for more than 50 days.254 vena cava filters which were placed for absolute venous thromboembolism (n=65), relative venous thromboembolism (n=28), and lastly for prophylaxis of venous thromboembolism (n=161).Upon follow-up after 108.5 days with the imaging study of 96 patients, 15 of them showed complications such as filter migration, and penetration of IVC filter.The successful retrieval of 19 IVC filters was observed.The study concluded that the strict protocols for the follow-up after IVC placement need to be placed for the timely retrieval of the filter and most of the filters that were placed for prophylaxis reasons showed a low retrieval rate.
, the non-collapsible IVC filter, and the presence of procedural pain.The study found that the median dwelling time for retrieved filters was 31 days and 53 days for failed retrievals (p= .0483).92% (24/26) of the attempts were accessed through the right common femoral.vein.In the remaining two, access was through the left common femoral vein and right internal jugular Ballard et al.,   2016 [9]USA Retrospective study (n=26)There were 26 attempts at retrieval, at a mean of 42.9 days from placement.There were nine failures (34.6%) due to the inability to snare the hookwere identified, overall fracture rate=12%.The fracture rate for only filter arms and/or legs was 6%.The fracture incidence increased with longer filter dwell times.Success rates for removal of the non-fractured component (main body) and fractured components (arm or leg) were 98.4% and 53.4%, respectively.The distal embolization rate of fractured filter components was IVC filter fracture rates increase with longer dwell times.Removal of fractured filters and their components (arms and legs) can be achieved effectively and safely.Clinically significant complications of IVC filter 2024 Rodriguez et al.Cureus 16(2): e55052.DOI 10.7759/cureus.550527 of 24 13%.No immediate clinically significant complications associated with fracture component embolization or filter removal were present.One patient was encountered with symptoms related to their fractured filter.fracture are rare, and there were no immediate clinical sequelae related to the