V09-04: Robotic assisted transperitoneal inferior vena cava filter removal: feasibility and technique
Failure to remove an inferior vena cava filter (IVCF) in a timely manner can result in endothelialization and extrusion through the IVC wall. Although rare, failed endovascular retrieval, has traditionally resulted in an open operation. However with establishment of robotic level 1-2 renal tumor thrombectomy, the skill set learnt from this approach has allowed us the opportunity to approach IVCF removal robotically. In this video we demonstrate feasibility of robotic removal of an IVCF not amenable to endovascular retrieval.
A 57-year old experienced abdominal discomfort attributed to a permanent IVCF with radiographic evidence of IVC migration and extruded tines involving the right iliac artery and spine. After positioning and port placement, exposure of the IVC is approached in a similar technique as for IVC tumor thrombectomy. Attention must be made of extruding tines when the bowel is mobilized. Circumferential dissection of the IVC is performed above and below the IVCF, which in this case was above the iliac confluence and below the renal veins. To avoid significant blood loss(BL) during IVC occlusion, lumbar veins are ligated with bipolar cautery, vessel sealer or clips. Luminal involvement with struts required combinations of ligature techniques . Struts of the filter that have eroded through the IVC wall are either broken or straightened prior to cavotomy in order to prevent IVC tearing. IVC occlusion is accomplished with modified Rummel tourniquets. Intravascular heparin is given before tightening tourniquets. After clamping a cavotomy is performed and struts can be pulled into the lumen of the IVC and the filter can be excised. IVC reconstruction was performed with 4-0 Goretex suture. Heparinized saline is flushed through the cavotomy prior to closure and before releasing tourniquets to reestablish blood flow.
IVC occlusion and operative times were 35 & 434 minutes respectively. Estimated blood loss was 200 ml. The patient was discharged on postoperative day 2. There were no intra or post-operative complications. The patient continued on 81 mg aspirin at discharge and prophylactic enoxaparin for 3 weeks. Pain symptoms had improved at 3-month follow-up.
Transperitoneal robot assisted IVCF extraction is feasible and safe. Urologists with adequate robotic experience level I-II IVC renal tumor thrombus extraction have the necessary skills to approach robotic IVCF retrieval. Vascular surgery support, adequate preoperative cross sectional imaging, and familiarity with the IVCF design are key to a successful outcome.