Operator errors during percutaneous placement of vena cava filters

Area of Science:

• Interventional Radiology
• Medical Device Safety

Background:

• Percutaneous insertion of inferior vena cava (IVC) filters is a common procedure to prevent pulmonary embolism.
• Procedural complications can arise, including those specifically related to operator actions during filter placement.
• Operator errors are distinct from device malfunctions and contribute to the overall complication rate.

Purpose of the Study:

• To review and categorize the various types of operator errors encountered during percutaneous IVC filter insertion.
• To enhance understanding of procedural risks associated with IVC filter placement.
• To provide a pictorial guide for identifying and potentially mitigating operator-related complications.

Main Methods:

• This work is a pictorial essay, reviewing common operator errors.
• It categorizes errors based on the procedural phase: preplacement imaging, filter selection, and filter deployment.
• The review synthesizes information on potential mistakes operators may make.

Main Results:

• Operator errors are specific to the procedural technique and not device defects.
• Errors can occur at multiple stages: IVC imaging, filter choice, and deployment.
• The exact frequency of operator errors remains unknown, despite technical problems occurring in 5-20% of insertions.

Conclusions:

• Operator errors represent a significant, yet often unquantified, aspect of IVC filter insertion complications.
• Recognizing these errors is crucial for improving procedural safety and patient outcomes.
• Further research may be needed to precisely determine the incidence of operator errors in IVC filter placement.