Early Experience Using Venous Sheath With Embolic Protection During Thrombectomy of Inferior Vena Cava and Complex Iliofemoral Deep Vein Thrombosis

<b>Background:</b> Percutaneous thrombectomy of the inferior vena cava (IVC) and complex iliocaval lesions may cause thromboembolism. The Inari Protrieve sheath is a device with a 33.5 mm funnel at the tip that can serve as embolic protection during thrombectomy procedures to mitigate the risk of pulmonary embolisms (PEs). <b>Methods:</b> Adult patients with acute IVC and iliocaval DVTs managed with Inari Protrieve sheath deployment followed by mechanical thrombectomy using ClotTriever or FlowTriever devices between September 2022 and September 2023 were identified. Patient characteristics were collected. The primary outcome was postoperative embolic events. Secondary outcomes included technical success, perioperative complications, and patency at 3 and 6 months. <b>Results:</b> Thirteen patients were identified. All patients had the Protrieve sheath placed via the right internal jugular vein and underwent intravascular ultrasound and venogram to confirm technical success. The median age was 55 (IQR 43-60), with 61.5% males. All patients had technical success of thrombectomy. Seven (53.8%) patients had prior IVC filters, with five (71.4%) being successfully removed. Three (23.1%) required IVC filter placement, and five (38.5%) required venous stenting. In-hospital complications included two (15.4%) patients with subsegmental PE; both patients had sheath manipulation intraoperatively. Two (15.4%) patients had recurrent DVT. Patency at 3 months was 75.0% and 71.4% at 6 months. <b>Conclusions:</b> The Inari Protrieve sheath can mitigate the risk of PE during thrombectomy. Due to the hydrophilic coating of the shaft of the sheath, periprocedural migration can occur. Repositioning the funnel results in lapses in embolic protection. We recommend securing the sheath at the skin insertion site.