Inferior vena caval filters

Utilized in patients with VTE when anticoagulation fails, when anticoagulation is associated with complications or when there is unacceptably high risk with anticoagulation.

Generally accepted that inferior vena cava filter should be inserted in patients with recurrent pulmonary embolism while on full dose anticoagulants for an existing pulmonary embolism.

Inferior vena cava (IVC) filters should be considered in patients with acute PE and absolute contraindications to anticoagulation, as well as in patients with recurrent PE despite therapeutic anticoagulation.

Routine use of IVC filters is not recommended.

Recommendations of the society of interventional radiology, American College o Cardiology, American College of Chest Physicians, American College of Surgeons Committee on Trauma, American Heart Association, Society for VascularSurgery, and Society for Vascular Medicine:

Patients taking therapeutic anticoagulation for acute venous thromboembolism, guidelines recommend against routine inferior vena cava filter placement.

For trauma patients or those undergoing major surgery without known VTE guidelines  suggest against routine IVC filter placement.

In patients with acute VTE and contraindication to anticoagulation, IVC filter placement is suggested.

In patients  with indwelling retrievable type or convertible IVC filters in whom the risk of PE has been mitigated or has resolved, routine IVC filter removal is suggested.

In a randomized controlled trial patients with proximal DVT received therapeutic anticoagulant therapy with unfractionated heparin followed by warfarin, or similar therapy with insertion of an IVC filter: there was a significant decrease in PE in the first 12 days after filter placement, however there was a significant increase in rates of recurrent DVT at two years (Decoussus H et al).

No clinical evidence has demonstrated the placement of an inferior vena cava filter improves prognosis.

Systemic reviews of clinical trials report that placement of an inferior vena cava filter is associated with an absolute risk reduction of 5% of recurrent PE, an absolute risk increase of 2% of DVT, and had no effect on mortality.

New trend is the placement for prophylactic reasons for high risk patients but without diagnosis or symptoms of VTE, and in those who cannot safely be treated with anticoagulants for prophylaxis as would be seen following pelvic or long bone fractures and have undergone surgical repair.

Frequency of recurrent pulmonary embolisms with inferior vena caval filters is 1-5.6%.

Late complications caval thrombosis, leg venous thrombosis and leg edema.

Mortality is markedly reduced in unstable PE patients who receive an IVC filter.

Despite this, the proportion of unstable patients who receive an IVC filter is decreasing.

The largest number of IVC filters continues to be inserted in stable patients, although there is no evidence of a clinically meaningful reduced mortality with IVC filters in stable patients unless age >80 years.

No evidence that insertion of an IVC filter improves survival.

Placement of IVC filter in addition to anticoagulation among patients with proximal deep vein thrombosis significantly reduced risk of recurrent PE compared with anticoagulation alone: this benefit is offset by a greater risk recurrent DVT and lack of effect on all-cause mortality.

Despite lack of randomized controlled trials demonstrating long-term safety and efficacy IVC filter insertion increases each year.

Estimated more than 259,000 IVCs were placed in 2012, and most are presently retrievable filters.

Risks associated with the use of IVC filters include: bleeding, dislodgment, incorrect positioning, local thrombosis and a twofold increase in recurrent lower extremity DVT (Decousus H et al).

Additional complications include erosion through the vena cava wall, visceral perforation, obstruction, and migration.

30 day mortality rate 17% with the highest rate in patients with neoplasms.

Median survival of patients after placement 168 days for patients with cancer and 2,064 for patients without cancer.

In a study comparing outcomes after acute venous thromboembolism in 3632 patients who had a filter place and 64,333 patients who did not receive such a filter: incidence rates of recurrent pulmonary embolus did not differ significantly between the patients (White, RH et al).

In a retrospective review, IVC filter treated patients with acute venous thromboembolism compared to patients who did not receive a filter, 1.7% of patients versus 5.3% had a PE at three years, respectively ( Spencer FA et al).

The use of IVC filters in patients with acute venous thromboembolic disease is usually the last therapeutic option utilized to prevent pulmonary embolism.

Inferior vena cava filters, previously has never been recommended for primary treatment of venous thromboembolism.

IVCFs decreases in – hospital mortality in stable patients with pulmonary embolism who received thrombolytic therapy.

The in-hospital mortality in unstable patients who do not receive an IVC filter, ranges for an 18-64% depending on age and therapy.

IVC filters reduce mortality only if inserted on the day of admission or the next day while the patients have an unstable hemodynamics and in a fragile condition from pulmonary embolism (Stein, P).

The American College of Chest Physician (ACCP) in 2008 recommendation for placement of IVC filter for patients with acute proximal lower extremity DVT in whom anticoagulant therapy is not possible, because of the risk of bleeding.

In a community-based study IVC filters were placed in 13.1% of patients with acute VTE (Spencer FA et al).

Experts suggest use of IVCF is inappropriate in 50% of cases (SpencerFA et al).

The use of IVC filters has been increasing.

The use of IVC filter placement is higher in elderly patients, with greater likelihood for recent bleeding, and the increased prevalence of co-morbid processes that increase their risk for serious bleeding with anticoagulant therapy with.

Retrievable IVC filters offer the advantages of regular IVC filters without associated risks of long-term devices.

Presently, it is urged to remove IVC devices as soon as the risk of a pulmonary embolus has subsided.

Retrievable IVC filters can be removed safely, even after prolonged indwelling times, and the American College of chest physician guidelines recommends that IVC filters be removed at six months following a pulmonary embolus.

The removal of inferior vena caval filters is successful in 94. 5% of cases.

In patients with severe PE, the use of a retrievable IVC filter plus anticoagulation alone did not reduce risk of symptomatic recurrent PE at 3 months (Mismetti P et al).

In a trial of prophylactic placement of inferior vena cava filters after major trauma, it did not result in a lower incidence of symptomatic pulmonary embolism or death at 90 days than no placement of a filter (Ho K).

Filters that are not retrieved are complicated by deep vein thrombosis in 5 to 18% of patients.

A fracture of an interior vena cava filter occurs in 2 to 10% of patients and can result in fragment embolization to the heart and lungs.

Filter struts can penetrate the bowel, arteries, and vertebral bodies.

Removing inferior vena cava filters before the occurrence of these complications is critical.

Leave a Reply

Your email address will not be published. Required fields are marked *