Complex filter removal using forceps from combined transfemoral and transjugular approach unhooking the filter apex using forceps and dual access: Two case reports

Modern inferior vena cava filters (IVCFs) are intended to be retrieved once a thrombotic process or risk of pulmonary embolism has resolved independent of administration of anticoagulation. IVCF removal can be challenging with the risk of complications including venous perforation, filter migration, and device fracture. IVCF removal has been described using the nomenclature of routine versus advanced retrieval. Routine retrieval is defined as accessing the filter hook with a loop snare device before advancing a sheath over the filter. Advanced retrieval techniques are employed when routine retrieval fails and can refer to a variety of approaches, including filter realignment with loop snare, stiff wire-displacement, use of a wire and snare with dual access, angioplasty balloon advanced over a guidewire, single access sling approach, the sandwich technique, the endobronchial forceps dissection and removal, photothermic ablation with excimer laser, and the filter eversion technique among others. Successful routine retrieval of IVCF has been reported at 74% and IVCF retrieval with advanced techniques has a success rate of nearly 95%. The complication rate with advanced techniques is higher when compared with routine techniques (5.3% vs. 0.4%; p <.05) and, as expected, requires fluoroscopic time. We report two cases of advanced filter retrieval using endobronchial forceps simultaneously or sequentially through the transfemoral and trans-jugular approach.