Filter Placement In Patients Research Articles

The Role of Short-term IVC Filter Placement in Patients With High-risk DVT

The Role of Short-term IVC Filter Placement in Patients With High-risk DVT

Increased incidence of venous thromboembolism associated with inferior vena cava filter placement in patients diagnosed with isolated calf deep vein thrombosis after intracranial hemorrhage or intracranial operation.

In this study, we sought to investigate the effectiveness of inferior vena cava (IVC) filter placement in reducing the incidence of venous thromboembolism (VTE) in patients diagnosed with isolated calf deep vein thrombosis (DVT) after an intracranial hemorrhage or intracranial operation. A retrospective chart review (January 2000-December 2019) was performed to identify patients diagnosed with calf DVT after intracranial hemorrhage or intracranial operation. A total of 100 patients met the study criteria and were divided into groups based on treatment: IVC filter placement (n = 22), prophylactic anticoagulation (n = 42), or imaging surveillance (n = 36). Treatment-related complications were identified, and differences between groups in the primary endpoint (VTE occurrence after DVT diagnosis) were assessed using logistic regression. VTE occurred in 15 patients after calf DVT diagnosis. The rate of VTE was higher in the IVC filter group (9/22; 41%) than in the anticoagulation (2/42; 5%; p = 0.002) and surveillance (4/36; 11%; p = 0.013) groups. These treatment effects remained significant after adjustments were made for baseline characteristics (IVC filter vs anticoagulation, p = 0.009; IVC filter vs surveillance, p = 0.019). There was a single occurrence of pulmonary embolism in the surveillance group (3%). A single case of IVC filter thrombus was identified; no anticoagulation-related complications were reported. The findings of this study do not support IVC filter placement as a primary and solitary treatment for isolated calf DVT occurring after intracranial hemorrhage or intracranial operation.

Prophylactic IVC filter placement in patients with severe intracranial, spinal cord, and orthopedic injuries at high thromboembolic event risk: A utilization and outcomes analysis of the National Trauma Data Bank

PurposeTo determine relationships between prophylactic inferior vena cava filter (IVCF) insertion and pulmonary embolism (PE), deep venous thrombosis (DVT), and in-hospital mortality outcomes in patients with severe traumatic pelvic/lower extremity, intracranial, and spinal cord injuries. MethodsAdult patients with severe traumatic pelvic/lower extremity, intracranial, and spinal cord injuries admitted to level I-IV trauma centers were selected from the National Trauma Data Bank (NTDB). IVCFs that were inserted both ≤48 h after admission and before a lower extremity venous ultrasound were defined as prophylactic. Associations between prophylactic IVCF insertion and PE, DVT, and overall mortality outcomes during admission were estimated using logistic regression models after propensity score matching. Additionally, factors predictive of prophylactic IVCF insertion were estimated using multivariate logistic regression. ResultsOf 462,838 patients, 11,938 (2.6%) underwent prophylactic IVCF insertion. Prophylactic IVCF utilization decreased over time (6.3% in 2008 to 1.8% in 2015). Factors associated with prophylactic IVCF placement were injury pattern, trauma center level/region, Injury Severity Score, and race. Prophylactic IVCF placement was positively associated with PE (Odds Ratio (OR): 5.25, p < 0.01) and DVT (OR: 5.55, p < 0.01), but negatively associated with in-hospital mortality compared to the propensity score-matched control group (OR: 0.46, p < 0.01). ConclusionProphylactic IVCF insertion in adult patients with severe pelvic/lower extremity fractures, intracranial injuries, and spinal cord injuries was negatively associated with in-hospital mortality, but positively associated with VTE. Further research evaluating the use of prophylactic IVCF placement in trauma patients with these specific severe injury types may be warranted.

Thrombotic Risk Associated with Inferior Vena Cava Filter Placement in Patients with Heparin-Induced Thrombocytopenia

PurposeThis study sought to define thromboembolic risk and mortality in patients with heparin-induced thrombocytopenia (HIT) undergoing inferior vena cava filter (IVCF) placement, in light of the American Society of Hematology’s 2018 guidelines against routine use of IVCFs in this population. MethodsA total of 26 patients with HIT who received IVCFs were retrospectively reviewed, and the outcomes of this group were compared with those of 4,707 controls with either HIT or IVCFs alone and with reported outcomes in prior studies. ResultsThe patient group demonstrated 6- and 12-month mortality rates of 26.9% and 30.8%, respectively, which did not differ significantly from those of the control groups and were in line with published mortality rates in the literature. The measured thromboembolic risk of 19.2% in the patient group was also within the range of published rates for patients with HIT or IVCF alone. ConclusionsIVCF placement did not significantly increase the risk of thromboembolism or death in patients with HIT and may be a viable option in the subset of these patients who are not candidates for anticoagulation.

IVC filter placement in patients undergoing surgical treatment of bone or soft‐tissue tumors

Patients with cancer to bone or soft tissues undergoing orthopedic procedures may be unable to receive pharmacologic prophylaxis for venous thromboembolism (VTE). Inferior vena cava (IVC) filters may be an effective method to prevent fatal pulmonary embolism (PE) in these patients. Retrospective chart review performed for patients surgically treated for malignant disease of bone or soft tissue who had IVC filter placement. Type of surgery, anatomic region, and development of wound complications requiring repeat surgery were analyzed. From 2007 to 2018, 286 patients received IVC filters. Ten (3.5%) patients suffered deep vein thrombus (DVT) postoperatively. There was no acute fatal PE. Two patients suffered PE at 2 and 99 days postoperatively. Risk of DVT was comparable following surgery with endoprosthesis versus open reduction and internal fixation (p = 0.056) and with soft tissue versus bone involvement (p = 0.620). Three filter-related complications occurred. Patients disease at the femur had the highest rate of DVT. Following treatment of malignant disease of bone or soft-tissues, two patients with IVC filter placement experienced nonfatal PE and three patients experienced filter-related complications. No patients in this series experienced a fatal PE.

Abstract No. 665 Association of inferior vena cava filter placement and mortality among in-patients with pulmonary embolism after adjusting for immortal time bias

Several large observational studies have suggested short-term mortality benefit with IVC filter placement in patients admitted with acute PE. However, these studies have failed to adjust for immortal time bias, i.e., the time between admission and filter placement during which death can only occur in the non-filter group. We assessed the association between IVC filter placement and inpatient mortality in patients admitted with pulmonary embolism, while adjusting for immortal time bias. Patients admitted with pulmonary embolism and undergoing IVC filter placement were retrospectively identified using ICD-9 diagnosis and procedure codes in the 2014 National Inpatient Sample. The association between IVC filter placement and inpatient mortality was assessed using survey-weighted Cox proportional hazard regression models and adjusted for baseline disease severity. Two regression models were fitted to assess the impact of immortal time bias: (1) IVC filter placement as a binary yes/no variable (implicit immortal time bias) and (2) IVC filter placement as a time-dependent variable (accounting for immortal time bias). There were 179,235 national admissions (52.64% females, mean age 62.1 years) for acute pulmonary embolism in 2014. Among these, 16,390 (9.15%) received IVC filters and 5299 (2.96%) patients died before discharge. All-cause mortality among patients who received IVC filters was 605/16,390 (3.69%), compared with 4694/162,815 (2.88%) without a filter. Naïve regression modelling indicated a protective benefit for IVC filter placement (hazard ratio:0.64, 95% CI: 0.53- 0.77). However, this apparent benefit was mitigated with inclusion of IVC filter placement as time-dependent variable (hazard ratio 0.86, 95% CI: 0.70-1.04). IVC filter placement does not protect against inpatient mortality in patients admitted with acute pulmonary embolism after accounting for immortal time bias. Future observational studies should adjust for immortal time bias when reporting association of mortality with IVC filter placement.

Impact of IVC Filter Guidelines, Registry, and Clinic on Filter Retrieval.

Background and hypothesis: Deep vein thrombosis (DVT) and pulmonary embolism (PE), collectively referred to as venous thromboembolism (VTE), are serious medical conditions that affect up to 900,000 Americans yearly, accounting for up to 100,000 deaths. The first line treatment for VTE is anticoagulation; however, in patients who experience a contraindication to, or failure of anticoagulation, an IVCF may be used. There are two types of IVCFs, permanent and retrievable. Retrievable filters are indicated when the contraindication to anticoagulation is transient, and they may be removed once the contraindication has passed. Retrievable filters have become associated with serious complications such as filter fracture, migration, and IVC perforation. Subsequently, they have become the subject of litigation. As such, strategies should be undertaken to reduce filter dwell time and improve filter retrieval rates. We hypothesize that implementation of IVCF guidelines, registry, and clinic will reduce dwell time while increasing retrieval rate.&#x0D; Methods: This study was a mixed retrospective and prospective chart review of patients who received an IVCF before and after implementation of IVCF guidelines, registry, and clinic. The guidelines, registry, and clinic were established in July 2017. Cases were analyzed during the years 2014-2015 (n=191) and 2017-2018 (n=103) beginning in July 2017. Data was obtained on filter retrieval rate, dwell time, filter-associated complications, and indication for placement.&#x0D; Results: There was a significant decrease in dwell time (p&lt;.001) and a significant increase in retrieval rate (p&lt;.001). There was no difference in complication rate, and there was a decrease in filter placement in patients with ‘soft’ indications, though this difference was not statistically significant (p=.109).&#x0D; Conclusion and potential impact: Implementation of dedicated efforts to increase patient follow-up and filter retrieval were effective in reducing dwell time and retrieval rate. Although there was no significant difference in complication rate, these efforts may be protective against litigation for patients who experience a filter-associated complication.

Association of Inferior Vena Cava Filter Placement for Venous Thromboembolic Disease and a Contraindication to Anticoagulation With 30-Day Mortality

Despite the absence of data from randomized clinical trials, professional societies recommend inferior vena cava (IVC) filters for patients with venous thromboembolic disease (VTE) and a contraindication to anticoagulation therapy. Prior observational studies of IVC filters have suggested a mortality benefit associated with IVC filter insertion but have often failed to adjust for immortal time bias, which is the time before IVC filter insertion, during which death can only occur in the control group. To determine the association of IVC filter placement with 30-day mortality after adjustment for immortal time bias. This comparative effectiveness, retrospective cohort study used a population-based sample of hospitalized patients with VTE and a contraindication to anticoagulation using the State Inpatient Database and the State Emergency Department Database, part of the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality, from hospitals in California (January 1, 2005, to December 31, 2011), Florida (January 1, 2005, to December 31, 2013), and New York (January 1, 2005, to December 31, 2012). Data analysis was conducted from September 15, 2015, to March 14, 2018. Inferior vena cava filter placement. Multivariable Cox proportional hazard models were constructed with IVC filters as a time-dependent variable that adjusts for immortal time bias. The Cox model was further adjusted using the propensity score as an adjustment variable. Of 126 030 patients with VTE, 61 281 (48.6%) were male and the mean (SD) age was 66.9 (16.6) years. In this cohort, 45 771 (36.3%) were treated with an IVC filter, whereas 80 259 (63.7%) did not receive a filter. In the Cox model with IVC filter status analyzed as a time-dependent variable to account for immortal time bias, IVC filter placement was associated with a significantly increased hazard ratio of 30-day mortality (1.18; 95% CI, 1.13-1.22; P < .001). When the propensity score was included in the Cox model, IVC filter placement remained associated with an increased hazard ratio of 30-day mortality (1.18; 95% CI, 1.13-1.22; P < .001). After adjustment for immortal time bias, IVC filter placement was associated with increased 30-day mortality in patients with VTE and a contraindication to anticoagulation. Randomized clinical trials are needed to determine the efficacy of IVC filter placement in patients with VTE and a contraindication to anticoagulation.

Contemporary Trends and Comparative Outcomes With Adjunctive Inferior Vena Cava Filter Placement in Patients Undergoing Catheter-Directed Thrombolysis for Deep Vein Thrombosis in the United States: Insights From the National Inpatient Sample

ObjectivesThe aim of this study was to investigate the contemporary trends and comparative effectiveness of adjunctive inferior vena cava filter (IVCF) placement in patients undergoing catheter-directed thrombolysis (CDT) for treatment of proximal lower extremity or caval deep vein thrombosis. BackgroundCDT is being increasingly used in the management of proximal deep vein thrombosis. Although a significant number of patients treated with CDT undergo adjunctive IVCF placement, the benefit of this practice remains unknown. MethodsThe National Inpatient Sample database was used to identify all patients with proximal or caval deep vein thrombosis who underwent CDT (with and without adjunctive IVCF placement) in the United States between January 2005 and December 2013. A propensity score–matching algorithm was then used to derive 2 matched groups of patients (IVCF and no IVCF) for comparative outcomes (mortality and major and minor bleeding) and resource use analysis. ResultsOf the 7,119 patients treated with CDT, 2,421 (34%) received IVCFs. There was no significant difference in in-hospital mortality (0.7% vs 1.0%; p = 0.20), procedure-related hemorrhage (1.4% vs. 1.0%; p = 0.23), or intracranial hemorrhage (0.7% vs. 0.6%; p = 0.70) between the IVCF (n = 2,259) and no-IVCF (n = 2,259) groups, respectively. Patients undergoing IVCF placement had higher rates of hematoma (3.4% vs 2.1%; p = 0.009), higher in-hospital charges ($104,049 ± 75,572 vs. $92,881 ± 80,194; p < 0.001) and increased length of stay (7.3 ± 5.6 days vs. 6.9 ± 6.9 days; p = 0.046) compared with the no-IVCF group. ConclusionsThis nationwide observational study suggests that one-third of all patients undergoing CDT receive IVCFs. IVCF use was not associated with a decrease in in-hospital mortality but was associated with higher inpatient charges and longer length of stay.

Abstract No. 566 - Clinical implication and safety of inferior vena cava (IVC) filter placement in patients with bacteremia or systemic inflammatory response syndrome (SIRS) with unknown source of infection

Abstract No. 566 - Clinical implication and safety of inferior vena cava (IVC) filter placement in patients with bacteremia or systemic inflammatory response syndrome (SIRS) with unknown source of infection

Evaluation of nonpermanent inferior vena cava filter placement in patients with deep venous thrombosis after lower extremity fracture: A single-center retrospective study.

To investigate nonpermanent inferior vena cava (IVC) filter in the prevention of perioperative pulmonary embolism (PE) in patients of lower extremity and/or pelvic bone fracture with deep vein thrombosis (DVT). Lower extremity or pelvic bone fracture patients with lower extremity DVT hospitalized in our hospital from January 2003 to October 2014 were retrospectively analyzed. Data was analyzed for age, gender, position of fracture, position of proximal of thrombosis, indications of placement, complications, retrieval rate, and rate of entrapped filter clot. Patients who underwent IVC filter placement were selected as the filter group. The patients who did not perform IVC filter placement after 2008 and the cases between January 2003 and December 2007 were selected as control group 1 and control group 2, respectively. The incidence of perioperative symptomatic PE and mortality were analyzed. A total of 2763 cases complicated with DVT underwent orthopedic surgery between January 2003 and October 2014. 823 nonpermanent filters were inserted. All filters were successfully deployed with no major complications. After a mean 14.2 days indwelling time, all of temporary filters were removed. Retrieval was attempted in 556 patients with retrievable filters and was successful in 545 (98%); mean indwelling time was 16.3 days. The total retrieval rate was 90%. The incidence of PE in the filter group was significantly lower compared with the two control groups. Among the patients who received chemical anticoagulant therapy, the incidence of PE in filter group, control group 1 and control group 2 were 0.14%, 1.60% and 2.10%, respectively. The incidence of PE in filter group was also significant lower compared with control groups. Nonpermanent IVC filter placement seems like to be a safe and effective method for preventing perioperative symptomatic and fatal PE in bone fracture patients with DVT in the present retrospective study.

Utility of Inferior Vena Cava Filters in Severe Pulmonary Embolism, Catheter-directed Therapy in Massive and Submassive Pulmonary Embolism, and HAS-BLED Score to Determine Risk of Major Hemorrhage in Pulmonary Embolism.

The American College of Chest Physicians and the American Society of Hematology advocate use of an inferior vena cava (IVC) filter only when anticoagulation is contraindicated, whereas the Society of Interventional Radiology has a list of absolute, relative, and prophylactic indications (2–4). To clarify this issue further, Mismetti and colleagues performed a prospective, randomized, open-label study evaluating the efficacy and safety of retrievable IVC filters for preventing pulmonary embolism (PE) recurrence in patients presenting with acute severe PE and superficial venous thrombosis or deep venous thrombosis (DVT) (1). A total of 399 patients from 17 French centers were openly randomized to either a retrievable IVC filter plus anticoagulation group (n = 200) or an anticoagulation-only group (n = 199). Approximately 65% of patients in each group had evidence of right ventricular dysfunction. Primary outcome was recurrence of fatal or symptomatic nonfatal PE at 3 months. Secondary outcomes were fatal or nonfatal symptomatic PE at 6 months and new or recurrent symptomatic DVT at 3 and 6 months. By 3 months, PE had recurred in six patients in the filter group and three patients in the control group (relative risk with filter, 2.00; 95% confidence interval [CI], 0.51–7.89; P = 0.50). One additional PE recurrence was observed in each group between 3 and 6 months. No difference was observed between the two treatment groups with respect to DVT, major bleeding, or death from any cause at 3 and 6 months. This is a landmark clinical trial as it sheds light on outcomes after IVC filter placement in patients with non–high-risk PE and superficial venous thrombosis or DVT who are also anticoagulated. An earlier study performed by the same investigators determined that in patients with proximal DVT on anticoagulation, IVC filters reduced the risk of PE but increased that of DVT and did not affect survival (5). The strengths of this study are in its originality, the clinical relevance of the subject matter, and the multicenter and prospective nature. A major limitation is that the patient characteristics selected to determine PE severity are not the ones in current use. Standardized criteria for PE severity, such as the Pulmonary Embolism Severity Index score or the classification of patients with acute PE on the basis of early mortality risk proposed by the European Society of Cardiology, were not available while this study was being undertaken (6, 7). Thus, this study may not represent the population that best benefits from an IVC filter placement. An exceptionally high filter retrieval rate seen in this study (79%) will be very difficult to duplicate in the community, leading to increased complications such as DVT, filter migration, and IVC stenosis (8). Another minor limitation was the time (7 yr) needed to complete this study. Studies with inclusion criteria that are better validated to measure PE severity are needed to define the specific role of IVC filters. n

Abstract No. 377 - Outcomes of inferior vena cava filter placement in patients with chronic pulmonary thromboembolic disease undergoing pulmonary thromboendarterectomy surgery

Abstract No. 377 - Outcomes of inferior vena cava filter placement in patients with chronic pulmonary thromboembolic disease undergoing pulmonary thromboendarterectomy surgery

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Introduction: Pulmonary Embolism (PE) is a common and potentially life-threatening condition. Overall mortality ranges between 5–15% and varies substantially depending upon comorbidities and severity of presentation. Epidemiologic studies have shown an increase of inferior vena cava (IVC) filter placement in patients with acute PE and observational data suggest that IVC filter use, irrespective of anticoagulation, may improve outcomes. Therefore, we assessed the incidence and impact on outcomes of IVC filter use in patients admitted with acute PE in a large integrated health care system. Methods: We performed a retrospective cohort study of all adult patients admitted to either of two tertiary-care teaching hospitals in the Geisinger Health System from Jan 2006 through Dec 2012. Eligible patients had both an admission and discharge diagnosis of acute PE; chart review was performed in a subset of patients to confirm accuracy of administrative codes. Relevant clinical information was extracted and the Pulmonary Embolism Severity Index (PESI) score was assigned to each patient. The primary outcome was in-hospital and 30 day mortality. Results: Of a total of 1052 patients, 13.4% (n=141) received an IVC filter. The use of IVC filters did not show a clear trend over time, ranging from 6.8% to 20.4% per year during the study period. Patients who received IVC filters, compared to those who did not, were older (median 65 years, interquartile range (IQR) 54.7–78.0 vs 62 years, IQR 49.0–73.7, p=0.009), had significantly higher PESI scores (median 88, IQR 67–110 vs 79, IQR 61–98, p=0.0002), and had longer length of stay (median 5 days, IQR 3.1–7.7 vs 3 days, IQR 1.9–4.9, p<0.0001). There was a trend toward higher in-hospital mortality (6.4% vs 3.4%, OR=1.94, 95%CI 0.90–4.16, p=0.09), but no difference in 30 day mortality (7.8% vs 7.0%, OR=1.12, 95%CI 0.58–2.18, p=0.74) in those who received IVC filters compared to those who did not, respectively. When controlling for severity of presentation using PESI score, the mortality difference between the two groups decreased compared to uncontrolled analysis; however, neither outcome was statistically significant (in-hospital mortality OR=1.59, 95%CI 0.69–3.65, p=0.27 and 30 day mortality OR=0.71, 95%CI=0.33–1.52, p=0.38). Conclusions: Patients with acute PE who received IVC filters in this study were older, had longer length of stay, and had greater severity of illness compared to those patients who did not receive IVC filters. We found that IVC filter use did not impact either in-hospital or 30 day mortality, even when controlling for severity of presentation. While epidemiologic studies report that IVC filter use in those with acute PE has increased over the past few decades, we found that in our health care system the use of IVC filters was variable over time and no clear temporal trend was observed. Although multiple observational studies suggest that IVC filters reduce mortality in acute PE patients, we did not observe a benefit in our patient population. Practice guidelines currently recommend that IVC filter use be limited to those with contraindications to, or failure of, anticoagulation. The lack of prospective study evidence that IVC filters improve outcomes in acute PE patients at least partially explains the inconsistent use of IVC filters in our study. Based on observational data that suggest improved outcomes and uncertainty at the patient care level, prospective randomized trials in acute PE patients are needed to define which patients, if any, benefit from IVC filter use to reduce the risk of adverse outcomes.

Clinical Outcomes of Inferior Vena Cava Filter Placement in Patients with Renal Vein Anomalies

To investigate the clinical outcomes in patients with renal vein anomalies who undergo inferior vena cava (IVC) filter placement. Contrast-enhanced computed tomography images of 410 patients who underwent IVC filter placement were retrospectively reviewed to detect renal vein anomalies. Clinical outcomes involving de novo pulmonary embolism and worsening of renal function were compared between patients with the location of filters placed in relation to the anomalous renal veins versus not in relation to any renal veins. A total of 97 (23.7%) renal vein anomalies were identified: 62 (15.1%) multiple right renal veins, 23 (5.6%) circumaortic left renal veins, 10 (2.4%) retroaortic left renal veins, and 2 (0.5%) accessory left renal veins. Frequency of de novo pulmonary embolism in patients with circumaortic left renal veins who had filters placed at or in between the 2 left renal veins was not significantly different from patients who underwent infra- or suprarenal filter placement (5.9% [1/17] vs. 3.1% [12/387]; P = 0.433). The frequency of patients who had a >25% decrease in estimated glomerular filtration rate after IVC filter placement was not significantly different whether the filter was placed in an infrarenal location or at or above the level of the anomalous renal veins (11.0% [37/335] vs. 17.6% [6/34]; P = 0.261). Clinical outcomes involving the frequency of de novo pulmonary embolism and worsening of renal function are not dependent on location of IVC filter placement in patients with renal vein anomalies.

8:56 AM Abstract No. 182 - Clinical outcomes of IVC filter placement in patients with renal vein anomalies

Purpose To investigate the clinical outcomes in patients with renal vein anomalies who undergo inferior vena cava (IVC) filter placement. Materials and Methods Contrast enhanced computed tomography images of 410 patients who underwent IVC filter placement were retrospectively reviewed to detect renal vein anomalies. Clinical outcomes involving de novo pulmonary embolism and worsening of renal function were compared between patients with the location of filters placed in relation to the anomalous renal veins versus not in relation to any renal veins. Results A total of 97 (23.7%) renal vein anomalies were identified: 62 (15.1%) multiple right renal veins, 23 (5.6%) circumaortic left renal veins, 10 (2.4%) retroaortic left renal veins, and 2 (0.5%) accessory left renal veins. Frequency of de novo pulmonary embolism in patients with circumaortic left renal veins who had filters placed at or in between the two left renal veins was not significantly different from patients who underwent infra- or supra-renal filter placement (5.9% [1 of 17] vs. 3.1% [12 of 387], p = .433). Frequency of patients who demonstrated a greater than 25% decrease in estimated glomerular filtration rate (eGFR) following IVC filter placement was not significantly different whether filter was placed in an infrarenal location, versus at or above the level of the anomalous renal veins (11.0% [37 of 335] vs. 17.6% [6 of 34], p = .261). Conclusion Clinical outcomes involving frequency of de novo pulmonary embolism and worsening of renal function are not dependent on location of IVC filter placement in patients with renal vein anomalies.

Long-Term Outcome of Inferior Vena Cava Filter Placement in Patients Undergoing Gastric Bypass

It has been well established that inferior vena cava (IVC) filter placement at the time of open gastric bypass (OGB) surgery in patients with a body mass index of more than 55 kg/m(2) reduces both the pulmonary embolism rate and the perioperative mortality. However, little is known about the long-term effects of IVC filter placement in this particular group of patients. Over an 8-year period, a total of 571 morbid obese patients underwent OGB procedures, and 58 (10%) of them required placement of an IVC filter before their procedure. All IVC filters were placed percutaneously through a femoral vein approach using a portable OEC fluoroscope. Types of IVC filters used in our study included the TrapEase (n = 35), Simon-Nitinol (n = 9), Greenfield (n = 2), and Bard Recovery (n = 12). Of the 58 patients who required an IVC placement, 56 remained free of any thromboembolic phenomena over the 8-year period (range, 1-8 years). The remaining two patients developed deep venous thrombosis. One patient was successfully treated with intravenous heparin and a 6-month course of Coumadin. She had complete resolution of her deep venous thrombosis and was incidentally noted to have a prothrombin 20210 gene mutation. The other patient, who had multiple gastric bypass complications, could not be successfully treated with intravenous heparin and thus progressed on to complete IVC thrombosis. She developed phlegmasia cerulea dolens and required bilateral above-the-knee amputations. She subsequently died 3 months after her procedures. It appears that IVC filter placement at the time of OGB surgery is a relatively benign intervention with a maximal benefit. A note of caution should be exerted for those obese patients who have a hypercoagulable disorder and for those who have complications related to the gastric bypass. An aggressive posture, which may consist of immediate anticoagulation after their procedures (only when it is deemed safe), should be advocated in this small sub-group of morbid obese patients.

Clinical outcome of perioperative nonpermanent vena cava filter placement in patients with deep venous thrombosis or blood stasis of the vein

To evaluate the recent clinical experience with nonpermanent inferior vena cava (IVC) filter placement preoperatively, especially with regard to patients who had deep venous thrombosis (DVT) due to compression by a tumor or an aneurysm. Preoperative prophylactic IVC filter placement was performed between October 2002 and March 2008 in 48 of 83 patients who underwent IVC filter placement. IVC filter placement was performed preoperatively in 35 of the 48 patients due to DVT located distally in an iliac vein or due to IVC compression by a tumor or aneurysm. This study examined the early and mid-term outcomes resulting from nonpermanent IVC filter placement. The mean implantation period was 11.1 +/- 9.3 days (range, 3-56 days). Three patients (8.6%) experienced minor complications during the IVC filter placement. A thrombus was captured in the filter in 4 patients (8.8%). One patient in whom the filter was left as a permanent filter died during the follow-up period. No patient experienced any pulmonary embolus during the follow-up period. Nonpermanent IVC filter insertion is perioperatively useful in surgical procedures that eliminate the compression of the vein by an excision of either the tumor or aneurysm compressing the vein.

Experience with inferior vena cava filter placement in patients undergoing open gastric bypass procedures

Patients undergoing open gastric bypass (OGB) for morbid obesity are at significant risk for pulmonary embolism (PE) despite the use of subcutaneous heparin injections and sequential compression devices. Prophylactic preoperative inferior vena cava (IVC) filter placement may reduce this risk. We report our experience with simultaneous IVC filter placement and OGB in an operating room setting. From July 1999 to April 2001, 193 patients (group 1) underwent OGB. Eight patients had prophylactic intraoperative IVC filters placed for deep vein thrombosis, PE, or pulmonary hypertension. From May 2001 to January 2003, 181 patients (group 2) underwent OGB. There were 33 IVC filters placed for body mass index (BMI) greater than 55 kg/m2 in addition to the above-mentioned criteria. To confirm observations made in group 1 and 2 patients, from July 2003 to May 2005, 197 patients (group 3) underwent OGB, and patients with a BMI greater than 55 kg/m2 (n = 35) were offered IVC filter placement. Group 3A (n = 17) consented to IVC filter placement, and group 3B (n = 18) did not. Fifty-eight IVC filters were placed (100% technical success rate) with an increase in operating room time of 20 +/- 5 minutes. In group 1, the eight patients with IVC filters had a BMI greater than 55 kg/m2. There were four PEs (3 fatal and 1 nonfatal) in the other 185 patients, all which occurred in patients with BMIs greater than 55 kg/m2. In group 2, there were no PEs. The perioperative PE rate in these patients was reduced from 13% (4/31; 95% confidence interval [CI], 1.1%-25.7%) to 0% (0/33; 95% CI, 0%-8.7%). Perioperative mortality was reduced from 10% (3/31; 95% CI, 0%-20.0%) to 0% (0/33; 95% CI, 0%-8.7%). There were no pulmonary emboli or deaths related to PE in group 3A patients. Group 3B patients had a 28% PE rate (two fatal and three nonfatal) and an 11% PE-related death rate. None of the remaining patients in group 3 had a PE. Intraoperative IVC filter placement for the prevention of PE in morbidly obese patients undergoing OGB is feasible. We observed a significant reduction in the perioperative PE rate when a BMI greater than 55 kg/m2 was used as an indication for IVC filter placement despite the use of subcutaneous heparin injections and sequential compression devices.

Experience with the Recovery Filter as a Retrievable Inferior Vena Cava Filter

This study evaluates clinical experience with the Recovery filter as a retrievable inferior vena cava (IVC) filter. One hundred seven Recovery filters were placed in 106 patients with an initial clinical indication for temporary caval filtration. Patients were followed up to assess filter efficacy, complications, eventual need for filter removal, time to retrieval, and ability to remove the filter. The patient cohort consisted of 62 men and 44 women with a mean age of 48 years (range, 18-90 y). Mean implantation time was 165 days. Indications for filter placement in patients with deep vein thrombosis (DVT) and/or pulmonary embolism (PE) included contraindication to anticoagulation (n = 33), complications of anticoagulation (n = 8), poor cardiopulmonary reserve (n = 6), large clot burden (n = 3), and PE while receiving anticoagulation (n = 1). Indications for filter placement in patients without proven PE or DVT included immobility after trauma (n = 35); recent intracranial hemorrhage, neurosurgery, or brain tumor (n = 18); and other surgical or invasive procedure (n = 3). Three patients (2.8%) had symptomatic PE after placement of the Recovery filter. No caval thromboses were detected. No symptomatic filter migrations occurred. Recovery filter removal was attempted in 15 of 106 patients (14%) at a mean of 150 days after placement. The Recovery filter was successfully retrieved in 14 of 15 patients (93%); one removal was unsuccessful at 210 days after placement. Ninety-two filters (87%) currently remain in place. Although all the filters were placed with the intention of being removed, a large percentage of filters were not retrieved. The Recovery filter was safe and effective in preventing PE when used as a retrievable IVC filter.