This study demonstrated that the primary use of EF for routine IVCF retrieval procedures allows for a procedural cost reduction compared to a snare-loop retrieval technique. Additionally, given that in IVCF retrieval cases where standard snare-loop retrieval fails, EF may be needed to achieve technical success, primary use of EF would eliminate cost of using both techniques. The equipment cost reduction per retrieval is substantial and can be impactful when extrapolated over time. This cost savings becomes increasingly meaningful with the increasing number of IVCF retrievals that are being performed annually throughout the US.
Chronic indwelling IVCFs have potential complications including filter fracture, device migration, organ penetration, IVC thrombosis, and increased DVT risk [7, 10, 11]. In 2010 the FDA issued a recommendation that all IVCFs be removed as soon as medically appropriate and that physicians who place IVCF ensure appropriate management of retrieval . This recommendation has led to an increase in IVCF retrievals, including complex retrievals due to chronically indwelling and embedded IVCF. Increased IVCF dwell times have been demonstrated to increase IVCF retrieval failure [8, 12]. The large patient population with chronic indwelling IVCF requiring complex retrieval led to a need for development of new retrieval techniques, including the EF [7–9]. The EF can be advanced through a large caliber venous access sheath (figure 1: add in picture of forceps). The EF is used to grasp the filter hook, then the sheath is advanced over the EF while appropriate tension is kept on the EF which forces the IVCF to collapse into the sheath. The IVCF can then be removed through the sheath. The EF can be used for blunt dissection of embedded filter hook if needed, and the curvature of the EF can be manipulated to reach a tilted and embedded filter when necessary [6, 7]. As proceduralist have become more experienced and skilled with EF their use has expanded beyond complex IVCF retrievals. EF have potential benefits when used in routine IVCF retrieval cases. The current study demonstrated a meaningful potential equipment cost savings when primarily using EF retrievals for all routine IVCF retrievals. Although the current study demonstrated 100% technical success and no complications with the use of FR, future studies over a larger cohort are required to evaluate technical success and procedural complications rates.
The current study has multiple limitations. The single institution retrospective design of this study may limit its application. Additionally, the EF retrieval technique is user dependent. Proceduralists who perform IVCF retrievals may have less familiarity with the EF and be less proficient than those in the current study which might impact the widespread application of EF. However, as proceduralists complete greater numbers of complex IVCF retrievals the use of EF will become more ubiquitous. At the study institution the EF can be autoclaved at no direct cost to the department, however this may not be the case at other institutions which may decrease the potential cost savings. Although this study demonstrates a potential equipment cost savings from the use of a primary EF technique for all routine IVCF retrievals, further studies are needed to determine any differences in fluoroscopy time and radiation exposure (both to patient and physician) compared to standard snare-loop techniques.