Requiem for Liberalizing Indications for Vena Caval Filters?

Abstract

Use of inferior vena caval (IVC) filters has proliferated. In 1979, ≈2000 vena caval filters were inserted. In 1999, the number of IVC filters inserted annually had increased ≈25-fold to 49 000. Retrievable IVC filters were first approved in 2003 and gained popularity rapidly. By 2006, retrievable IVC filters accounted for about half of all IVC filters that were inserted. The largest proportional increase in IVC filter use was subsequently in patients at risk for pulmonary embolism (PE) but who had had neither PE nor deep vein thrombosis (DVT).1 Article, see p 2018 Appropriate use of IVC filters is a hot topic. On the one hand, filters hold the promise of reducing PE rates by trapping moderate and large DVT that have detached from the deep veins of the legs and pelvis and that are hurtling toward the heart. On the other hand, we do not have clear-cut definitions of which patients with PE and DVT will benefit most from this technology. Aside from the expense and possible futility, an array of complications can ensue, including caval perforation,2 caval thrombosis, fracture, fragment embolization, intracardiac migration,3 cardiac perforation, and cardiac tamponade.4 In a systematic review of retrievable IVC filters, only 34% were retrieved, and the majority remained in place permanently. Most of the complications from retrievable filters occurred with long-term use.5 In Medicare fee-for-service beneficiaries ≥65 years of age, ≈17% of PE patients undergo IVC filter placement. The IVC filter use rate in PE patients has remained stable since year 2000. However, the frequency of hospitalization for PE has increased in this population by ≈70%, resulting in a sharp rise in the absolute number of filters inserted. Use appears especially high in blacks, in men, and in octogenarians, but overall use varies markedly across the United States. …