Retrospective Review of 120 Celect Inferior Vena
Cava Filter Retrievals: Experience at a Single
Dayong Zhou, MD, PhD, James Spain, MD, PhD, Eunice Moon, MD,
Gordon Mclennan, MD, Mark J. Sands, MD, and Weiping Wang, MD
Purpose: To evaluate retrospectively the safety and retrievability of the Celect IVC filter.
Materials and Methods: All patients undergoing Celect filter placement and retrieval during the period 2007–2012 were assessed
for complications and retrievability.
Results: Of 620 patients who underwent Celect filter placement, 120 presented for removal. The indwelling time in these patients
was 158.1 days ? 103.0 (range, 2–518 d). There were 106 filters (88.3%) removed; 14 filters were left in situ for the following
reasons: filter embedment (n ¼ 6), caval occlusion (n ¼ 3), retained thrombus (n ¼ 2), large floating thrombus in IVC (n ¼ 2), or tilt
4151 (n ¼ 1). With filters in place, five patients developed new pulmonary embolism (PE), and two others presented with severe
abdominal pain. The available 115 pairs of placement and removal cavagrams suggested limb penetration in 99 cases (86.1%),
intracaval migration 42 cm in 5, secondary tilt 4151 in 8, filter deformity in 10, retained thrombus within filters in 12, and IVC
occlusion in 3. Among 38 available computed tomography (CT) scans, 9 scans (24%) showed asymptomatic limb penetration to the
duodenum (n ¼ 6), aortic wall (n ¼ 2), or kidney (n ¼ 1). No filter fracture was found.
Conclusions: This study showed a high penetration rate for Celect IVC filters, including penetrations that were symptomatic or
involved adjacent structures. Penetration appears to correlate with indwelling time, suggesting that the filter should be removed as
soon as PE protection is no longer indicated. Although most of the filters were removed, 5.8% of retrievals were unsuccessful because
of technical failure.
DVT = deep vein thrombosis, IVC = inferior vena cava, PE = pulmonary embolism
Retrievable inferior vena cava (IVC) filters have been
developed to provide temporary or permanent protection
from pulmonary embolism (PE). When a patient’s indication
for protection changes, the retrievable IVC filter can be
removed to reduce the risk of potential long-term complica-
tions that may result from a permanent IVC filter (1–3).
Over the past decade, several retrievable filters have been
introduced to the U.S. market (4–8). As the use of these
devices has become more widespread, various problems
have arisen, such as limb penetration resulting in adjacent
organ injury, severe tilt causing filter retrieval failure, and
most importantly, filter fracture and distant migration of
fracture fragments (9–14). After receiving many reports
related to retrievable IVC filters, the U.S. Food and Drug
Administration issued a general warning on August 9, 2010,
concerning filter fracture, filter migration, filter emboliza-
tion, and IVC perforation, in addition to the long-term risks
of lower limb deep vein thrombosis (DVT) (15).
& SIR, 2012
J Vasc Interv Radiol 2012; 23:1557–1563
G.M. has received grant support from Bard; has been a consultant for Cook
Biotech, Cook, Bard, Medtronic, Seimens, and Pneumosonics; is a member
of the Data Safety Monitoring Board/Clinical Events Committee, B. Braun;
and has a writing contract from Boehringer Ingelheim. D.Z. was a research
postdoctoral fellow at Cleveland Clinic during 2011. He was sponsored by
International Exchange Support Program of Jiangsu Province, China, and
Cleveland Clinic, Cleveland, Ohio. He is currently working at the Department
of Vascular and Interventional Radiology, Suzhou Hospital, Nanjing Medical
University, Suzhou, China. None of the other authors have identified a conflict
From the Imaging Institute, Section of Interventional Radiology, Cleveland
Clinic, Cleveland, Ohio. Received May 9, 2012; final revision received August
7, 2012; accepted August 13, 2012. Address correspondence to. W.W.,
9500 Euclid Avenue, Cleveland, OH 44195; E-mail: firstname.lastname@example.org
The Celect IVC filter (Cook, Bloomington, Indiana) is a
modification of the Gu ¨nther-Tulip filter (Cook), which was
first introduced for permanent use in April 2007 and for
optional use in March 2008 (16). We performed a
retrospective study to investigate the safety profile and to
assess retrievability of the Celect filter at a single tertiary
MATERIALS AND METHODS
This retrospective study, which included all patients who
underwent both placement and retrieval of the Celect IVC
filter between September 2007 and January 2012, was
approved by our institutional review board. Patient demo-
graphics and clinical data, including information about PE
breakthrough and symptoms or complications possibly
related to the filter placement, were retrieved from electronic
medical records and outpatient clinic visit charts. Mortality
data were obtained from the Social Security Death Index and
hospital electronic medical records. Relevant images were
collected from our imaging archiving system, including
inferior vena cavagrams obtained at filter placement and
retrieval, abdominal computed tomography (CT), chest CT,
and CT pulmonary angiography studies that imaged the filter.
Filter migration, tilt, fracture, deformity, and penetration were
recorded according to the definitions of Zhu et al (6) and the
guidelines of the Society of Interventional Radiology (SIR)
(1). The presence and size of retained thrombus at the filter
were estimated according to the visual scales of volume
method described by Wang et al (17), with estimates based
on the cavagram or a coronal reformatted CT image.
Fluoroscopic time for the filter retrieval procedure (in min)
was recorded, and the indwelling time was calculated. Factors
that could have affected the success of an attempted retrieval,
including retrieval techniques, were analyzed.
Placement and Retrieval Techniques
Celect filters, which consist of four long struts (primary
legs) and eight short struts or arms (secondary legs), were
placed via the right common femoral or right internal
jugular vein according to the manufacturer’s recommenda-
tions. Retrieval was prompted by referral from the primary
service. Routine retrieval with a Gu ¨nther-Tulip Filter
Retrieval Set (Cook) was performed using a method
described previously (18). When routine attempts failed,
one or more advanced retrieval techniques were used,
including curved catheter technique (18), loop-and-snare
technique (19), balloon-assisted technique (20), or forceps
technique (21), based on operator preference.
All images were reviewed by two interventional radiolo-
gists. The images were retrieved in digital JPEG format
and placed into Photoshop CS2 (Adobe Systems, San Jose,
California). The image pairs for placement and retrieval
were resized to match exactly and were fused together with
proper transparency (6). Distance was calibrated using
sizing catheters or the known filter length of 48 mm
SPSS 13.0 for Windows (IBM SPSS, New York, New
York) was used for data management and analysis. A two-
sample t-test was applied to compare indwelling time
between successful and unsuccessful retrievals and fluoro-
scopic time between secondary filter tilt r101 and 4101.
Pearson correlation coefficients were used to test the
relationships between penetration distance and indwelling
time, migration distance and penetration distance, and
fluoroscopic time and secondary tilt or indwelling time.
w2testing was used to determine the relationships between
retrievability and secondary tilt (r101 vs 4101), migra-
tion distance (r2 cm vs 42 cm), or deformity. Logistic
regression was used to test the relationship between
retrievability and indwelling time. A P valueo.05 indi-
cated statistical significance.
Study Population and Indications
During the study period, 620 patients had Celect filters
placed, and 120 of these patients presented for filter
retrieval. Of the patients who presented for filter retrieval,
61 were women and 59 were men with an average age of
53.2 years (range, 13–79 y) at the time of filter placement.
At retrieval, the average indwelling time of filters was
158.1 days ? 103.0 (range, 2–518 d). Indications for filter
placement included PE or DVT with contraindications to
anticoagulation (n ¼ 99), recurrent PE despite adequate
therapy (n ¼ 8), bleeding during anticoagulation (n ¼ 7),
free-floating thrombus in IVC or iliac-femoral vein
(n ¼ 5), and severe cardiopulmonary disease with DVT
(n ¼ 1).
Although attempts were made to collect placement and
retrieval images for all study patients, two placement
images and three retrieval images were unavailable for
review. Abdominal CT scans performed between filter
placement and retrieval were available for 36 patients.
Two CT scans of the chest with images of the IVC filter
were also available. Five patients underwent CT pulmonary
angiography because of newly developed clinical symp-
toms of PE while the filter was in situ.
All 120 filters in this series were placed without incident,
and 106 (88.3%) were successfully retrieved. The average
indwelling time for the 106 retrieved filters was 158.7
days ? 104.6, and the average indwelling time for the 14
unsuccessful retrievals was 154.1 days ? 93.6 (t ¼ 0.156;
P ¼ .88). Unsuccessful retrieval was the result of filter tip
embedment in six cases (5.0%), chronic IVC occlusion in
Zhou et al ’ JVIR
1558 ’ Celect IVC Filter Retrieval
three cases (2.5%), retained thrombus with volume
44 mL in two cases (1.7%), floating IVC thrombus below
the filter in two cases (1.7%), and tilt 4151 in one case
(0.8%). Retrieval failure prompted continued anticoagula-
tion in all but one case, where hematuria secondary to
bladder cancer did not allow for anticoagulation treatment.
After filter placement, five patients presented with
symptoms highly suggestive of PE, including chest pain,
dyspnea, and hypoxemia (occurring at 2, 9, 11, 27, and
86 d after filter insertion). CT pulmonary angiography was
performed in these five symptomatic patients, and new PE
was confirmed in three patients. At subsequent retrieval,
cavagrams showed no thrombus in these five patients, but
one filter had a severe tilt (17.41) and could not be retrieved
(Fig 1a, b). Two (1.7%) patients presented with severe
pain that resolved immediately after filter retrieval. The
first patient complained of intermittent mild abdominal
pain lasting 1 week that became severe 514 days after filter
placement. At retrieval, this filter was found to have
(Fig 2). The second patient had PE breakthrough after an
infrarenal G2 filter placement, with a cavagram showing a
large thrombus trapped at the G2 filter. A Celect filter was
placed at the suprarenal IVC. The patient presented with
pain associated with breathing 25 days later. On CT scan,
the suprarenal Celect filter showed penetration into the
retroperitoneum and crux of the diaphragm. In this study
cohort, seven patients ultimately died of underlying
malignancy; two of these patients eventually died with
the filter in situ after unsuccessful filter retrieval.
(16.41), and deformity
On 115 anteroposterior projection cavagrams, 99 filters
(86.1%) displayed leg penetration, including 175 primary
legs in 99 filters and 45 secondary legs in 28 filters
(Table 1). All secondary leg penetrations coexisted with
primary leg penetrations. The average penetration distance
beyond the IVC lumen was 10.3 mm ? 4.8 for primary
legs and 10.1 mm ? 4.0 for secondary legs. The primary
indwelling time (r ¼ 0.293; Pr.001).
CT scans were available for 38 patients (indwelling
time, 132.3 d ? 217.5); five of these studies were obtained
after failed retrieval procedures. In these 38 patients, 25
(65.8%) of the filters had leg penetrations, including 71
primary legs in 25 filters and 6 secondary legs in 4 filters
(Table 1). Among patients with available CT scans, nine
filters had penetrated into adjacent organs (all were single
primary leg): into the duodenum (n ¼ 6), into the aortic
wall (n ¼ 2), and into the right kidney (n ¼ 1) (Fig 3). All
of these filter penetrations were incidental findings without
clinical symptoms. From the nine proven cases of organ
penetration, seven filters were successfully removed. Of the
two that could not be removed, one penetrated the
duodenum and couldnot
embedment of the filter tip; the other had a limb
penetrating the aortic wall, and the filter could not be
removed because of a significant clot trapped in the filter.
The average filter tilt was as follows: primary tilt (occurred
at the time of placement), 4.61 (range, ?15.61 to 20.01),
with tilt 4151 in two cases; secondary tilt (occurred after
placement), 7.31 (range, ?17.41 to 40.01), with tilt 4151
in eight cases.
In the 115 paired placement and retrieval cavagrams, 89
filters (77.4%) showed intracaval migration, with a maximal
distance of 29.9 mm; 36 (40.4%; distance, 6.8 mm ? 6.7)
had migrated cranially, and 53 (59.6%; distance, 7.6
mm ? 6.3) had migrated caudally (Table 1). Five filters
(4.3%) had filter movement (defined by SIR guidelines as
change in filter position 42 cm)—two cranially and three
caudally. Caudal migration of the filter was positively
correlated with penetration distance for both primary leg
(r ¼ ?0.396; P ¼ .003) and secondary leg (r ¼ ?0.299;
P ¼ .030). However, cranial migration was not significantly
correlated withleg penetration
P ¼ .149; secondary, r ¼ 0.304; P ¼ .072). There was no
en bloc filter migration beyond the IVC and no evidence of
fracture of filter components. In 115 retrieval cavagrams, 10
filters (8.7%) showed evidence of deformity, with four
displaying leg asymmetry and six displaying mild bending
or splaying of the legs (Table 1). Trapped thrombus was
identified in 15 filters, 12 by cavagram (average volume,
2.6 mL; range, 1–4 mL) and 3 by CT scan (average volume,
2.3 mL; range, 1–4 mL) (Table 1). Thrombus identified on
CT scan all had resolved at filter retrieval.
For 20 filters (16.7%), retrieval could not be accom-
plished with the routine technique, and advanced retrieval
be removedbecause of
r ¼ 0.245;
who presented with severe shortness of breath 86 days after filter
insertion. CT pulmonary angiography confirmed new emboli at
the right lower lobar pulmonary artery. (a) The filter had good
alignment on a cavagram taken immediately after IVC deploy-
ment, with the hook at the center of the IVC. (b) At retrieval, the
filter was severely tilted (thick arrow), with the hook against the
right lateral wall. In addition, the filter displayed both primary and
secondary limb penetration (dovetail arrow) and deformity
(arrowheads). This filter could not be removed.
CT pulmonary angiography in a 71-year-old woman
Volume 23 ’ Number 12 ’ December ’ 2012 1559
techniques were required, including curved catheter tech-
nique in 3 cases, forceps technique in 8 cases, balloon-
assisted technique in 5 cases, and loop-and-snare technique
in 7 cases. Using these advanced retrieval techniques, 13
filters were removed, but 7 filters remained in situ; all of
the in situ filters had a tilt greater than 8o, with the hook
against the caval wall (probable embedment). Fluoroscopic
time was positively correlated with the degree of secondary
tilt (r ¼ 0.383; Po.001) and indwelling time (r ¼ 0.258;
P ¼ .004). Success of retrieval had no significant correla-
tion to secondary tilt (4101; w2¼ 3.021, P ¼ .221), filter
movement (migration 42 cm; w2¼ 0.735, P ¼ .692),
deformity (w2¼ 0.826; P ¼ 0.363), or indwelling time
(P ¼ .876) (Table 1).
In this study, the Celect filter was associated with a high
penetration rate, and penetration appeared to correlate with
indwelling time. Inferior vena cavagrams performed before
removal of the filter showed evidence of at least one limb
penetration in 86.1% of cases, a result significantly greater
than results seen in previously published studies compris-
ing 134 placements and retrievals (5,22,23) (Table 2) but
slightly less than the 93% rate observed by Durack et al
(24) in a prospective comparison study of Celect and
Gu ¨nther-Tulip filters. This high variation in reported
penetration rates may be the result of varying observation
methods or may be related to filter indwelling time.
Table 3 summarizes the incidence of penetration of
Gu ¨nther-Tulip filters in published studies (24–27).
There have been several previous reports of symptomatic
penetration of the Celect IVC filter. In one report, abdominal
pain appeared to be related to a primary strut lodging in the
uncinate process of the pancreas 9 days after filter insertion
(28). In a second report, acute lower abdominal and right leg
pain was seen 17 days after filter insertion as a result of the
four primary legs penetrating the IVC wall, producing a small
retroperitoneal hemorrhage (29). Pseudoaneurysms of the
infrarenal aorta and right renal artery 10 months after filter
insertion have also been reported secondary to penetration (30).
These pseudoaneurysms ultimately required autogenous aortic
reconstruction, caval repair, and subsequent right nephrectomy.
In this study, penetration resulted in severe abdominal pain in
two cases, which required early filter retrieval.
Filter penetration is a well-recognized phenomenon that
is most commonly associated with conical filters. Reported
occurrence rates have ranged from 0%–93% (6,8,25,31).
Sadaf et al (28) suggested that the stiff strut in the Celect
filter may be the reason for frequent filter penetration
beyond the caval wall. We believe that all conical filters
rely on significant radial force in the long strut (primary
leg) to secure the filter to the caval wall. The living IVC
wall accommodates the radial force of the filter, and
with severe abdominal pain 514 days after filter placement.
Cavagram showed severe tilt, with the hook embedded in the
left side of the caval wall. There were multiple legs penetrating
beyond the caval wall (arrow). The patient’s pain resolved
immediately after the filter was removed.
Cavagram in a 23-year-old woman who presented
Table 1. Celect Filter Retrieval Characteristics
On cavagram (n ¼ 115)
43 mm, r10 mm
43 mm, r10 mm
On CT (n ¼ 38)
Secondary tilt (n ¼ 115)
Migration (n ¼ 115)
40 mm, r10 mm
410 mm, r20 mm
40 mm, r10 mm
410 mm, r20 mm
Deformity (n ¼ 115)
On angiogram (n ¼ 12)
On CTn(n ¼ 25)
Caval occlusion (n ¼ 120)
Fluoroscopic time (n ¼ 120)
PE breakthrough (n ¼ 120)
PE ¼ pulmonary embolism.
n Contrast enhancement.
Zhou et al ’ JVIR
1560 ’ Celect IVC Filter Retrieval
penetration is likely to occur. Our study also showed that
the degree of penetration (distance of the strut beyond the
caval wall) correlates with filter indwelling time: The
longer the filter was in place, the further the penetration
beyond the caval wall (P ¼ .001). These findings suggest
that a Celect filter should be removed as soon as clinically
indicated to reduce the risk of symptomatic penetration.
Additionally, as with the G2 filter (Bard Peripheral
Vascular, Inc, Tempe, Arizona) (6), caudal migration of
the Celect filter was found to be positively associated with
penetration in this study.
Fracture is another serious device failure that must be
considered when retrievable IVC filters are used; such a
failure can potentially lead to fatal complications. Although
no fractures were seen in this study, the relatively short
indwelling time does not allow us to draw the conclusion that
Celect filters are not associated with a fracture risk. In a
retrospective study of 363 Bard Recovery filters (Bard
Peripheral Vascular, Inc), Tam et al (9) found that the
earliest occurrence of fracture was at 4.1 months. A review
of all published Celect filter studies involving more than 500
filters demonstrated evidence of just one fracture in a study by
Sangwaiya et al (22), but no details regarding the fracture
were provided. Distant en bloc migration of filters, another
potentially fatal complication, has been reported in several
case studies of the Gu ¨nther Tulip filter (14,32,33). However,
no such migrations occurred in this study or in previous
studies of the Celect filter, indicating that the Celect filter
probably has an improved anchoring mechanism compared
with the Gu ¨nther Tulip filter.
New PE after filter placement is another potential
complication of these devices. In this cohort, five patients
had symptoms thought to represent breakthrough PE. Three
of these five patients had new PE confirmed by CT
pulmonary angiography; the other two patients were
treated for new PE based on typical symptoms. The
incidence of PE breakthrough in this study (4.2%) was
similar to that previously reported in studies of permanent
and retrievable filters (6,8,34).
Successful retrieval in this study was achieved in 88.3% of
patients who presented for removal of the filter. This rate was
slightly lower than previously reported rates of 93.3%–96.6%
(Table 2) but comparable to the rates associated with other
retrievable filters: 90.2%–95.3% with the Gu ¨nther Tulip
(25,35,36), 84.9%–95% with the Bard Recovery G2
(37–39), 92.3% with the Option (Argon Medical Devices,
in a 61-year-old woman on CT scan 91 days after filter place-
ment. Both axial (top) and coronal (bottom) images showed a
primary limb of the Celect filter penetrating into the right kidney
(arrow). The filter was successfully retrieved 411 days after
Asymptomatic penetration was incidentally detected
Table 2. Comparison of Retrievals of Celect Filter Studies
Study Doody et al (5) Sangwaiya et al (22)Lyon et al (23)Present Study
Indwelling time (d)n
Retrieval rate (n)
Causes of failure (n)
6115 58 120
Occluded IVC, 1;
Filter clot, 1
Tilt, 1; embedment, 1
tilt 4151, 1; filter
retained thrombus, 2; floating
IVC thrombus, 2; IVC occlusion, 3
PE breakthrough (n)
Filter-related pain (n)
Tilt Z151 (n)
Local migration 42 cm (n)
Retained thrombus (n)
IVC occlusion (n)
3 (3/71, 4.1%†)
1/18 (CT, 5.6%)
1/18 (CT, 5.6%)
IVC ¼ inferior vena cava; ND ¼ not determined; PE ¼ pulmonary embolism.
n Mean value (range).
† Total placements.
Volume 23 ’ Number 12 ’ December ’ 20121561
Athens, Texas) (8), and 92.7%–99% with the ALN (ALN
Implants Chirurgicaux, Ghisonaccia, France) (31,40).
In this study, 20 filters could not be removed using the
retrieval kit provided by the manufacturer, and 7 filters could
not be removed by any means. Unsuccessful retrievals can be
the result of either technical (eg, filter tilting and incorpora-
tion of the retrieval hook into the IVC wall) or nontechnical
(eg, retained thrombus at the filter, free-floating IVC throm-
bus, lack of central venous access, or IVC occlusion with the
filter embedded entirely into the organized thrombus) causes
(6). Excluding filters unsuitable for removal, there was a 5.8%
failure rate for retrieval in this study.
Filter tilt, a common phenomenon for conical filters, is a
prime factor complicating filter retrievals. Although the
filter struts anchored at the caval wall form a relatively
stable base, the tip floats freely without support. Over time,
movement in the IVC or radial force in the filter allows the
filter to reposition itself to its most stable position. In many
cases, this places one side of the filter against the IVC wall.
In this study, eight filters had tilt 4151, but only one of
these filters could not be removed. Alternatively, in the
seven filters that could not be retrieved with advanced
techniques, only one filter had tilt 4151. However, even
moderate tilt is sufficient to embed the hook of the filter in
the caval wall, prohibiting filter capture. In a previous
study, Van Ha et al (18) used multiple advanced retrieval
techniques to successfully remove 37 of 38 filters that were
considered difficult retrievals. These cases included filters
with significant tilt and filters with the hook making
contact with the IVC wall. With the excimer laser sheath
technique, even deeply embedded filters were removed
successfully in a study by Kou et al (41). Success of
advanced filter retrievals appears to be associated with the
operator’s experience and aggressiveness and with the
availability of advanced retrieval tools.
Study limitations should be mentioned. First, only 19.3%
of patients presented for filter retrieval. In our practice, the
Celect filter was placed for both permanent and short-term
PE prophylaxis; most of the patients had permanent
indications for filter placement. The relatively low retrieval
rate was attributed to primary service–based referrals,
patient mortality (in view of the large number of patients
with cancer), and loss of follow-up because of the high
percentage of out-of-state and international patients. To
improve this retrieval rate, we have since initiated a filter
follow-up program. Our institution now has a dedicated
health care professional coordinating with the primary
service to refer patients for filter retrieval (42,43). This
program has greatly increased the number of retrievals.
However, in the context of this study, this low rate of filter
retrieval creates a selection bias, and the subset of retrieval
cases may not accurately represent all Celect filter place-
ments. Similarly, device-related complications were eval-
uated in retrieval patients only, and follow-up for this
group of patients was relatively short. Long-term follow-up
in patients not scheduled for filter retrieval may demon-
strate a higher rate of complications, such as potential
fractures. This study was also limited in that the penetra-
tion rate was likely underestimated by the catheter ante-
roposterior cavagram (24). Tilt was defined only as lateral
deviation because tilt in the anteroposterior plane could not
be determined. The actual incidence of PE breakthrough in
this study is unknown because CT pulmonary angiography
was performed only in patients who had typical PE
symptoms in the clinic. Additionally, a few images were
unavailable for review (5 of 240 cavagrams). Finally, the
best method for assessing penetration and the only method
to determine adjacent organ penetration is CT scan, but
only a limited subset of patients underwent CT scans,
possibly leading to a different selection bias.
In conclusion, the Celect IVC filter has a high rate of
penetration; some of these penetrations are also associated
with adjacent organ penetration, occasionally manifesting
as significant abdominal pain. The degree of penetration
appears to correlate with indwelling time. Close clinical
follow-up after Celect filter insertion is recommended.
Although most of the filters were removed, 5.8% of
retrievals were unsuccessful because of technical failure.
We would like to thank Matthew Tam, MD, for his advice
in manuscript preparation and Megan Griffiths for her help
with revising the manuscript.
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