Current use of inferior vena cava filters

Abstract

To study possible changes in the clinical use of inferior vena cava (IVC) filters caused by the introduction of percutaneous delivery systems, we reviewed all patients who underwent placement of IVC filters at our institution from 1988 to 1991. Eighty-four patients (52 men and 32 women) ranging in age from 18 to 90 years (mean 67 years) were identified. Filters were required because of contraindications to anticoagulation in 64%, anticoagulation failure in 25%, and preoperative prophylaxis in 11% of patients. The underlying disease was lower extremity deep vein thrombosis in 50% and pulmonary embolism in 45% of patients. Five percent of patients received prophylactic filters without documented thromboembolism. All filters were placed percutaneously by interventional radiologists, 77 through the common femoral vein and 7 through the internal jugular vein. Three types of filters were used. One procedure-related death occurred because of acute IVC occlusion. Fatal pulmonary embolism within 48 hours after filter placement was documented in one patient and suspected in one late death. No other clinically apparent pulmonary embolism or leg swelling occurred after filter placement. Minor complications related to filter placement occurred in 13 patients, but none required operative intervention. Analysis of complication rates of the three filter types was precluded by the small sample size. After a mean follow-up of 11 months, 42 patients (50%) had died of malignancy (n = 25), multisystem organ failure (MSOF; n = 7), cardiovascular events (n = 4), recurrent pulmonary embolism (n = 2), cerebrovascular events (n = 4), or an unknown cause (n = 1). Twenty-three patients (27%) died before hospital discharge. Of these patients, 16 died as a direct result of disseminated cancer or MSOF. Among the subgroup of 48 patients with a history of advanced cancer or MSOF, 20 (43%) died before hospital discharge and an additional 12 died within 6 months of filter placement. Percutaneous placement of IVC filters has not changed the indications for filter placement, nor has this new technique significantly reduced the charge for percutaneous placement ($5300) compared with operative placement ($5800). Filter placement in patients with advanced malignancy or MSOF was associated with such poor survival that the benefit of IVC filtration in these patients was questionable. Careful patient selection is required to avoid nonbeneficial filter placement in as many as 25% of patients in whom IVC filter placement initially appears indicated.