Vena caval filter splaying: potential complication of use of the titanium Greenfield filter

Significant structural and mechanical differences exist between the titanium and stainless steel versions of the Greenfield filter (GF). The titanium GF has a longer leg length (49 mm vs 43 mm), a greater span (38.5 mm vs 28.0 mm), and a larger hook angle (41 degrees vs 23.5 degrees). In vitro tests demonstrated approximately sevenfold greater filter length shortening (a measure of filter splaying) for the titanium GF in response to a given applied load. These differences resulted in marked filter splaying and inferior vena cava (IVC) perforation in three patients in whom a titanium GF had been inserted. The aorta was penetrated by a filter leg in one patient, and abdominal or back pain was present in all three patients. In vitro tests involving thrombosis within a latex balloon revealed that the titanium GF, but not the stainless steel GF, remained splayed even in the face of clot retraction. Design modifications, possibly using shorter, thicker filter legs and using reduced hook angles, should be made in the titanium GF to decrease the risk of filter splaying and IVC perforation before widespread use of this device.