Filter Placement Research Articles

Lateral tilt during IVC filter placement does not predict the need for advanced filter retrieval techniques.

We aimed to determine if lateral inferior vena cava (IVC) filter tilt at placement predicts the need for subsequent advanced retrieval techniques. A retrospective chart review was performed of all Gunther Tulip IVC filter placements with subsequent retrievals between February 2015 and October 2017. Chart and imaging review was performed for patient, filter placement, and filter retrieval demographics/characteristics. Degree of agreement between two measurement sets was evaluated with the intraclass correlation (ICC) analysis. Categorical variables were compared with chi-square or Fisher exact test, as appropriate. Kendall rank correlation was used to measure correlation between categorical variables. There was poor agreement between filter tilt angle at the time of placement and retrieval (ICC coefficient, 0.54). Mean difference ± standard deviation between tilt angle at the time of placement and retrieval was 4.6°±4.3° (p = 0.35). Among patient- or procedure-related factors, a common femoral vein access on placement (regression coefficient, -2.90; p = 0.039) was associated with a lower difference between placement and retrieval filter tilt angles compared to internal jugular vein access. Higher filter tilt angle measured at the time of retrieval (OR: 1.19, p = 0.025), hook embedment (OR: 77.3, p < 0.001), and a longer dwell time (OR: 1.25, p = 0.002) were associated with the need for advanced retrieval techniques. However, in univariate and multivariate analysis filter tilt angle at the time of placement was not associated with the subsequent need for advanced retrieval technique (p = 0.16). Lateral tilt at the time of placement is poorly associated with lateral tilt at the time of retrieval and does not correlate with the need for advanced retrieval technique.

Argatroban and ultrasound-facilitated thrombolysis with alteplase in a patient with bilateral pulmonary embolism and history of heparin-induced thrombocytopenia: A case report

A 58-year-old female was admitted to the hospital with bilateral pulmonary embolism (PE) with right heart strain. Her medical history included a previous PE resulting in thrombolysis and inferior vena cava filter placement, heparin-induced thrombocytopenia, morbid obesity, and chronic pain that was treated with an epidural injection 2 weeks prior to admission. This case is unusual due to the need for alternative anticoagulation management during thrombolysis in a patient with a heparin allergy who was at increased risk for bleeding. She was initiated on argatroban to achieve therapeutic aPTTs before receiving both mechanical thrombectomy and alteplase through ultrasound-facilitated catheter-directed thrombolysis. The argatroban was reduced to a flat rate of 0.5 mcg/kg/ min during thrombolysis and was subsequently increased to achieve therapeutic aPTTs upon completion of thrombolysis. The patient was transitioned from argatroban to apixaban for lifelong anticoagulation.

Impact of Access Site Choice on Outcomes of Inferior Vena Cava Filter Placement

Limited studies have evaluated optimal access site choice during placement of inferior vena cava (IVC) filters. In this study, we aim to compare the outcomes of IVC filter placement between femoral and internal jugular vein access sites.

Digital radiograph (DR) guided bedside IVC filter placements in patients with intracranial pressure monitors

PurposeThe purpose of this study is to report a single center experience with portable digital radiographically (DR) guided bedside IVC filters placed in intensive care unit (ICU) patients with high ICP and elevated head of bed (HOB). Materials and methodsA retrospective chart review was conducted on all bedside IVC filters placed from January 1, 2010 to September 16, 2020. Patients with high ICP and elevated head of bed requirements were included. Charts were reviewed for filter type, common femoral vein (CFV) access, filter location, pre procedure imaging, pre and post filter ICPs, glascow coma scale, number of radiographs taken, and filter removal. ICPs were obtained 1 ​h prior to procedure and 2 ​h post procedure and analyzed with a paired T test.Filters were placed by reviewing prior CT scan for IVC size, caval variants, renal and iliac veins and vertebral body landmarks. Then, CFV access was obtained and a Bentson wire was advanced 30–40 ​cm. A radiograph was used to confirm adequate position of the of the wire. The filter sheath was advanced and serial radiographs were used to position the filter sheath at the final predetermined position below the renal veins and above the iliac bifurcation. The filter was deployed, and a radiograph was obtained to confirm filter positioning. ResultsA total of 9 DR guided bedside IVC filters were placed (4 Denali, 3 Option Elite, 2 Celect). Indications included prophylactic placement (n ​= ​8) and acute DVT (n ​= ​1). The average patient age was 35.8 years (range: 18–56 years) CT abdomen and pelvis was used to assess for the level of renal veins in all patients (n ​= ​9). No caval variants were encountered on pre-procedural planning. The average pre, intraprocedural, and post procedure intracranial pressure was 16 ​mmHg, 13 ​mmHg, and 16 ​mmHg, respectively. Confirmation of placement after final placement was available in 7 patients (4 DR, 2 CT and one fluoroscopic examination). Two non-procedural related deaths occurred.Technical success, defined as successful placement of IVC filter at the predetermined level, was achieved in 100% of patients (n ​= ​9). The right CFV was used in most patients (n ​= ​7). The left CFV was used for access in two patients due to right CFV thrombus (n ​= ​1) and existing right femoral venous central line (n ​= ​1). The average number of radiographs taken was 5.8 (range 4–9). In all cases, filters were placed below the level of the lowest renal vein (n ​= ​9). A comparison of pre, during and post intervention ICP pressures is shown in table, 2. No differences between pre and post filter ICP was noted (p ​= ​0.77). Three filters were later removed. One minor complication was reported, which was filter tilt (23%) in an Option filter. ConclusionBedside IVC filters can be safely placed in patients with head trauma and high ICP who are unable to lay supine using portable DR guidance with a high rate of technical success and minimal complications.

Successful IVC thrombus extraction with the AngioVac device following five vessel coronary artery bypass graft: a case report

BackgroundInferior vena cava thrombosis is cited to be a complication of inferior vena cava filter placement and post coronary artery bypass surgery. Often only mild symptoms arise from these thrombi; however, due to the chronic nature of some thrombi and the recanalization process, more serious complications can arise. Although anticoagulation remains the gold standard of treatment, some patients are unable to be anticoagulated. In this case, we present a 65-year-old male who underwent IVC filter placement and open-heart surgery who later developed extensive femoral and iliocaval thrombosis leading to right heart failure, which required thrombus extraction with an AngioVac suction device.Case presentationWe present a 65-year-old male who presented with bilateral pulmonary emboli with extensive right lower extremity deep vein thrombosis. Upon investigation he had ischemic heart disease and underwent a five-vessel coronary artery bypass for which he had an IVC filter placed preoperatively. On post operative day 3 to 4, he was decompensated and was diagnosed with an IVC thrombus. He progressed to right heart failure and worsening cardiogenic shock despite therapeutic anticoagulation and was taken for a suction thrombectomy using the AngioVac (AngioDynamics, Latham, NY) aspiration thrombectomy device. The thrombectomy was successful and he was able to recover and was discharged from the hospital.ConclusionDespite being a rare complication, IVC thrombosis can have detrimental effects. This case is an example of how IVC thrombus in the post-operative setting can lead to mortality. The gold standard is therapeutic anticoagulation but despite that, this patient continued to have worsening cardiogenic shock. Other therapies have been described but because of its rarity, they are only described in case reports. This case shows that the AngioVac device is a successful treatment option for IVC thrombus and can have the possibility of future use.

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.

Inferior vena cava filter tilting between placement and retrieval is associated with caval diameter and need for complex retrieval techniques

PurposeInferior vena cava (IVC) filter tilt may lead to apex embedment and need for advanced retrieval techniques. This study assesses factors associated with filter tilt change over time and need for complex retrieval procedures. Materials and methods252 consecutive patients underwent retrievable IVC filter placement and removal at a single academic institution over 58 months. 182 (72.2%) patients met inclusion criteria. IVC filters included 168 (92.3%) Gunther Tulip and 14 (7.7%) Option filters. The primary outcome was medial-to-lateral IVC filter tilt change between placement and retrieval. Secondary outcomes included advanced retrieval technique use and multiple retrieval attempts. Independent variables included demographics, IVC diameter, filter hook position relative to the renal veins, and dwell time. Associations were determined using student's t-tests, ANOVA, and linear and logistic regressions. ResultsMean IVC diameter at placement was 19.2 ± 3.3 mm. Mean filter tilts at placement and retrieval were 6.1 ± 4.9° and 5.2 ± 5.0°, respectively. Mean tilt change was 5.0 ± 5.0°. Larger IVC diameter was associated with greater filter tilt change (p = 0.0004). While IVC diameter did not independently predict retrieval difficulty, greater tilt change and prolonged dwell time were associated with increased advanced retrieval technique use (p = 0.01 and 0.002, respectively). Results were unchanged in a subgroup analysis of patients treated with Gunther Tulip filters. ConclusionLarger IVC diameter predicts increased filter tilt change, which in turn is associated with challenging retrievals. Attention to IVC diameter during filter placement may anticipate tilt-related complications.

Comparison of Retrievability and Indwelling Complications of Celect and Denali Infrarenal Vena Cava Filters: A Randomized, Controlled Trial.

To compare the Celect and Denali filters in terms of complex filter retrieval and indwelling complications after a 2-month indwelling time. In this prospective, randomized trial, 153 subjects were assessed for eligibility between May 2016 and July 2018. A total of 136 participants were randomly assigned to receive either Celect (n = 68) or Denali (n = 68) filter placement in the infrarenal inferior vena cava. Tilt angles at placement and retrieval and rates of overall filter retrieval, indwelling complication, and complex retrieval were compared. Of 136 participants (mean age, 62 ± 12.8years, 55 male), 24 (17.6%) were lost to follow-up. The mean indwelling time of filter was 60.4 ± 7days and there was no significant difference in the baseline characteristics between the two groups. Filter retrieval was successful in all participants (112/112, 100%). Significantly higher rates of filter tilt >15° (n = 8) and strut penetration (n = 14) were found with the Celect filter than with the Denali filter (1 significant tilt and 1 penetration) (P = 0.033 and 0.001, respectively). No filter fractures were observed and there was no significant difference in tip embedment, filter fracture, filter migration, or mean fluoroscopy times. There were 3 cases of complex retrieval (1 for Denali vs. 2 for Celect, P = 0.500), for which the loop-snare technique was used. Denali filters demonstrated significantly lower rates of tilt angle >15° and strut penetration. However, there was no significant difference in the complex filter retrieval rate between the Celect and Denali filters.

Penerapan Metode WASPAS Dalam Penempatan Hawker Branded Dunhill Filter

The location placement is an explanation related to the spatial layout of an economic activity, and this is always linked to the geographical allocation of limited resources which in turn will have an effect on and have an impact on both economic and social locations. Placement of location is a strategic activity that aims to maximize profits for the company. Placement of location greatly influences costs and determines income, location completely has the power to make or break a company's business strategy. To determine the recommendation for the placement of hawker brended dunhill filters at PT. Bentoel Group Asmo Medan can use the weight aggregated sum product assessment (WASPAS) method. The Waspas method can be used to rank the Hawkwer Dunhill Filter location with predetermined criteria.

Efficacy of Uterine Artery Embolization for Treatment of Anticoagulant-Associated Abnormal Uterine Bleeding

Data regarding uterine artery embolization (UAE) to specifically treat anticoagulant-associated iatrogenic abnormal uterine bleeding (AUB-I) are sparse. This manuscript aimed to quantify the effectiveness of UAE in treating this subset of patients. Retrospective case series. Academic hospital serving a large minority-majority population. Twenty-four patients with AUB-I that was provoked or aggravated by the initiation of anticoagulation therapy. Treatment of anticoagulant-associated AUB-I that failed medical management or was acute with UAE rather than inferior vena cava filter placement and hysterectomy. An imaging database search was performed to identify patients who underwent UAE for anticoagulant-associated AUB-I from May 2011 to July 2020. Medical and radiologic records were reviewed. Short- and long-term outcomes were obtained to date, ranging from 10 months to 10 years after the procedure. In total, 24 patients were identified, ranging in age from 35 to 54 (mean 44.9) years. Venous thromboembolic disease was the most common (92%) indication for anticoagulation. At presentation, 14 patients (58%) were anticipated to require lifelong anticoagulation. Most UAE procedures (54%) occurred within 10 days of anticoagulation initiation. Before UAE, 17 patients (71%) attempted and failed medical management, myomectomy, or endometrial ablation to control bleeding. After UAE, 21 patients (88%) experienced substantial improvement or resolution of AUB and continued anticoagulation therapy. Three patients (14%) did not experience improvement and were treated with hysterectomy. Amenorrhea immediately after UAE occurred in 1 patient at age 45. UAE was an effective tool in the management of anticoagulant associated AUB-I in this cohort, resulting in decreased bleeding while allowing the continuation of anticoagulation therapy, with high rates of uterine preservation and preserved menses.

Making Invaluable Changes: Assessing Appropriateness for IVC Filter Insertion and Reasons for Non-Retrieval

Background:Inferior vena cava (IVC) filters are commonly placed in patients with contraindications to anticoagulation including bleeding concurrent with venous thromboembolism (VTE). Retrievable IVC filters have been preferred over permanent filters for their flexibility to be removed once anticoagulation can be resumed. Published reports show that the retrieval rate of the filters is around 34%. Non-retrieved filters can result in significant complications such as filter migration, embolization, filter fracture, vena cava thrombosis, and IVC perforation.Objective:The primary objective of this study is to assess IVC filter insertion indications, retrieval rate and factors prohibiting timely retrieval.Methods:A retrospective chart review was conducted on patients with a history of IVC filter placement and/or removal between January 2012 and January 2017. Data collected included demographics, indications for filter placement, referring and placement services and the reasons for non-retrieval.Results:A total of 573 patients were identified of which 343 patients had IVC filters inserted without retrieval, 200 patients had placement followed by retrieval and 30 patients who had retrieval alone. Reasons for placement included VTE with active bleed in 29.48%, trauma, surgery, or immobilization in 22.01%, VTE with planned surgery in 19.22%, history of VTE with planned surgery in 11.94%, and extensive clot burden in 9.33%, VTE with elevated bleeding risk in 3.92%, PE with thrombolysis therapy in 0.19%, and other in 3.92% of patients. Internal medicine had ordered IVC filters in 44.44% of patients compared to 27.16% in surgical services with (p-value of 0.0028). This indicates that a significantly greater proportion of IVC filters were placed due to VTE with active bleeding in internal medicine as opposed to all other departments. In addition, Internal medicine ordered IVC filters for immobilization from trauma in 4.23% of patients compared to 24.73% by other departments (p-value <0.0001), indicating that other departments order IVC filters for immobilization or bleeding from trauma at a significantly higher rate than does internal medicine.For those 343 patients who had IVC filters placed but not retrieved, reasons for non retrieval by Interventional radiology(IR) included lost to follow up in 39.80% compared to 58.97% in vascular surgery, decided to use as permanent IVC filter in 20.72% in IR compared to 12.82% in vascular surgery, ongoing thrombosis in 4.93% in IR compared to 7.69% in vascular surgery, trapped clots in 1.32% in IR compared to 0% in vascular surgery, died within 3 months in 31.58% in IR compared to 15.38% in vascular surgery, filter removed locally in 0.99% in IR compared to 5.13% in vascular surgery, and scheduled to be removed in 0.66% in IR compared to 0% vascular surgery.To further investigate the rates of patients that were “lost to follow up” we dichotomized the reasons into “lost to follow up” in comparison to all other reasons. This showed that the reason for non-retrieval was lost to follow up in 39.80% compared to 58.97% of patients in vascular surgery (p-value 0.0224). This indicates that the proportion of patients that were “lost to follow up” in vascular surgery is significantly higher than in interventional radiology.Conclusion:Only one-third of IVC filters were ordered in compliance to current evidence based guidelines. There was also a significantly greater proportion of “lost to follow up” patients in vascular surgery compared to interventional radiology, indicating room for improvement regarding patient follow up. To improve the appropriateness of IVC filter insertion and overall retrieval rate, we plan to implement best practice alerts and institutional guidelines along with hematology referral upon patient discharge to aid in timely retrieval. We plan to reevaluate our practice in 6 months following the implementation of these guidelines. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Venous Thromboembolism (VTE) Increases the Healthcare Burden in Patients with Malignant Glioma (MG)

Background: The cumulative incidence of symptomatic venous thromboembolism (VTE) among patients with malignant glioma (MG) is high, with estimates ranging from 20-35% during the course of therapy. VTE is the second leading cause of death among ambulatory patients receiving cancer chemotherapy, with a 2-fold or greater increase in mortality compared to those without VTE, even after adjusting for stage. Specific to MG patients, Semrad et al. reported a higher likelihood of death at 2-year follow up (hazard ratio 1.3). The development of VTE is associated with increased mortality, an increased risk of hospitalization, delays in cancer treatment and an increased risk of complications including pain, bleeding, and bruising from high dose therapeutic anticoagulation. As a result, the economic burden of VTE in cancer patients is substantial and is associated with a nearly 2 fold increase in cost. Data regarding VTE burden encompasses all cancer types and additional data is needed to characterize VTE burden in specific cancer types, particularly rarer cancers. The aim of this study was to assess the healthcare burden associated with the development of VTE in MG patients.Methods: A retrospective chart review of patients with MG at an academic medical center was conducted from 2009-2016. Patients 18 years and older with a histologic diagnosis of malignant glioma, WHO grade 3-4 were assessed. A total of 31 patients were identified and information was collected with respect to their healthcare consumption as related to their oncologic care. Specifically, the number of office visits, emergency room visits, inpatient hospitalizations with the associated costs of VTE management and it's complications were collected. Using SPSS, linear regression models and descriptive statistics were used to determine the relationship between the development of VTE and healthcare consumption.Results: Of the 31 patients in the study, 10 developed VTE (32%). All patients who developed a VTE were placed on therapeutic anticoagulation as part of VTE management. Fifty percent of patients developed complications related to anticoagulation, including gastrointestinal, retroperitoneal and intracranial bleeding events. One patient required placement of an IVC filter after experiencing a bleeding complication. Patients that developed VTE had an increase in inpatients days (21.3 inpatients days) as compared to their non-VTE counterparts (10 inpatient days), (p=.04). There was a trend towards increased utilization of the emergency room with an average of 5.1 visits in those patients with VTE as compared to those without (2.89), (p=0.244). A limited cost analysis found that anticoagulation management alone generated an additional $84,335 in healthcare costs with an average of $8,433 per patient. A full cost analysis is currently underway.Discussion: The development of VTE in patients with malignant glioma increases inpatient admissions days and pharmaceutical costs related to anticoagulation. While limited in patient number, this represents the first assessment of health care burden associated with VTE specific to this cancer patient population. Given the significant number of MG patients who develop VTE (approximately 1/3 in this study), increases in health care burden are magnified in this patient population and studies are needed to prevent VTE in this particular group of patients. DisclosuresNo relevant conflicts of interest to declare.

Incidence of Venous Thromboembolism in Korea from 2009 to 2013

Incidence of venous thromboembolism (VTE) in Asian population is known to be significantly lower than that in Western population. However, Recent studies from Asia have indicated that the incidence rate of VTE is as high as that in Western population under certain circumstances such as surgery, suggesting that VTE has become a disease of major concern in Asian population. Therefore, data regarding the incidence of VTE and annual change in its incidence are of a crucial importance to understand the influence of VTE on social and medical aspects of Asian population at present and in the future.The objective of the present study was to evaluate annual age- and sex- adjusted incidence rate (ASR) of VTE from 2009 to 2013 in South Korea. In addition, annual change in pattern of VTE treatment over the study period was estimated.South Korea has a compulsory public health insurance coverage system and the National Health Insurance (NHI) service basically covers the whole population living in Korea. Health Insurance Review and Assessment Service (HIRA) is a government-operated organization that builds review and quality assessment system for claims for NHI. All claims data that healthcare service providers submit to HIRA to be reimbursed for a service provided to patient are collected by HIRA, making a nationwide population study feasible. Using the HIRA database, VTE cases from 2009 to 2013 were identified. A VTE case was defined if both diagnostic and medication codes were identified simultaneously in a patient. Coexisting medication codes for unfractionated heparin, low-molecular-weight heparin (LMWH), or direct oral anticoagulant (DOAC; rivaroxaban) were mandatory to verify accurate detection of the VTE. To analyze pattern of VTE treatment, all medical codes of anticoagulants approved for VTE treatment in Korea prescribed within 6 months after the time of VTE diagnosis were collected. In addition, codes of procedures including thrombectomy, thromboplasty, thrombolysis, and placement of inferior vena cava filter recorded from -1 to +6 months of the time of VTE diagnosis were searched. The proportion of cancer-associated VTE, who had diagnostic codes of both cancer and VTE was analyzed.Among 63,184 annual index cases of VTE from 2009 January to 2013 December, incidence rate of VTE was increased yearly. It was significantly higher in older population compared to that in younger population and higher in females compared to that in males. In 2009, ASRs of VTE, deep vein thrombosis (DVT), and pulmonary embolism (PE) were from 21.3, 8.1, and 13.2 per 100,000, respectively. They were increased to 29.2, 12.7, and 16.6 per 100,000, respectively, in 2013 (Table).Prescription rates of warfarin and LMWH were significantly decreased with the introduction of DOAC between 2012 and 2013 (Figure). It might be influenced by benefits of lower cost of rivaroxaban reimbursed by NHI service for 6 months of treatment duration. Although ASR itself was increased, proportions of subjects who received mechanical procedures were decreased annually. Cancer associated VTE accounted for 33.1% of all VTE and they had higher relapse rate compared to those who did not have a diagnostic code of cancer (7.08% vs. 6.54%; p < 0.013).Our near a whole nationwide epidemiologic study shows that ASR of VTE in Korea has continuously increased from 2009 to 2013. The result reflects a rapid aging society, improved awareness of VTE, and improved survival of patients with cancer and other morbidities that complicate VTE. The introduction and reimbursement of DOAC resulted in significant change in the pattern of anticoagulant prescription within a short period of time. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Evaluation of Clinical and Radiological Factors Associated with Thrombosis Recurrence in Cancer Associated Subsegmental Pulmonary Embolism

Background: Acute pulmonary embolism (PE) is a leading cause of morbidity in the cancer population. The availability of computed tomographic (CT) scans and CT-pulmonary angiography (CT-PA) has allowed for better visualization of the peripheral pulmonary arteries and assessment of PE, resulting in greater detection of subsegmental pulmonary embolism (SSPE). The clinical outcomes and the factors determining PE recurrence are not clear in the cancer related-SSPE population.Our objectives were to evaluate the incidence of recurrent PE within 12 months of SSPE in cancer patients and to identify factors influencing PE recurrence and overall survival (OS).Methods: A retrospective analysis (2014-2015) of adult cancer patients followed at The University of Texas MD Anderson Cancer Center who were diagnosed with SSPE. The primary outcome was the rate of PE recurrence within 12 months of SSPE diagnosis and to identify clinical and/or radiological factors associated with PE recurrence and overall survival. The study was approved by IRB with consent waiver.Results: Among 158 patients, 62% were male, 73.9% with stage IV disease, and 58.9% were on chemotherapy at time of SSPE diagnosis. Most of the patients had an ECOG performance status of 0 to1 (74.1%) and had no prior history of venous thromboembolism (VTE) (89.9%). The majority of SSPE (75.3%) were diagnosed incidentally by staging CT versus 24.7% by CT-PA. Amongst clinical factors, active chemotherapy and prior history of VTE at the time of SSPE diagnosis seemed to influence the probability of PE recurrence on the univariate analysis, however there was no statistical significance on logistic regression analysis. The radiological features of SSPE did not impact the rate of PE recurrence (Table 1). A total of 120 patients (75.9%) were treated with anticoagulation alone, 8 patients (5.1%) had IVC filter placement, 14 patients (8.9%) received both anticoagulation and IVC filter, and 16 patients (10.1%) had no therapy. At 12-month follow-up, 15 of 158 patients (9.5%) had PE recurrence. There was no significant effect of anticoagulation in OS, after adjustment for performance status (PS) and tumor stage (TS) (P=0.3971), or by PE recurrence status (P=0.4).Conclusion: The study showed a clinical significant rate of PE recurrence among cancer patients with SSPE, which is comparable to rates of PE recurrence from data of cancer-specific VTE clinical trials. Specific clinical or radiological predictors for PE recurrence were not identified. The PS and TS were found to be the main predictors of survival in this population, regardless of the secondary prevention strategy used. [Display omitted] DisclosuresRojas Hernandez:Daichii Sankyo: Research Funding.

Aspirin May be Inadequate Thromboprophylaxis in Multiple Myeloma

BackgroundMultiple myeloma (MM) is associated with a 9-fold increased risk of venous thromboembolism (VTE). Current guidelines support routine thromboprophylaxis in select patients (ASCO, IMWG). The 2015 ASCO guidelines recommend low-molecular-weight heparin or low-dose aspirin in patients receiving immunomodulatory drugs (IMIDs) in combination with chemotherapy and/or dexamethasone. The IMWG guidelines recommend low-dose aspirin for MM patients with one or no VTE risk factors including those on lenalidomide in combination with low-dose dexamethasone, melphalan, or doxorubicin. Two randomized trials support thromboprophylaxis in patients receiving lenalidomide and thalidomide; however, patients with a prior history of VTE were excluded from participation (Palumbo 2011, Larocca 2012). We assessed the association between aspirin use and VTE in a large cohort of patients with MM.MethodsPatients diagnosed with MM within the Veterans Health Administration between September 1, 1999 and December 31, 2013 were identified in the Veterans Administration Central Cancer Registry (VACCR) using International Classification of Diseases (ICD)-O3 codes 9732/3. We retrospectively followed the cohort through December 2014. We excluded patients who did not receive MM-directed therapy within 6-months of diagnosis. We collected baseline information on demographics, comorbidities, laboratory data, MM-directed therapy, and use of aspirin, warfarin, and statins. All drug therapy was analyzed as time-varying. Using a previously validated algorithm, (Sanfilippo, 2015), we identified patients diagnosed with VTE after MM diagnosis by a combination of ICD-9 code for VTE plus pharmacologic treatment for VTE or IVC filter placement. We used competing risk analysis to assess the association between aspirin use and incident VTE while adjusting for known VTE risk factors and for death as a competing event.ResultsWe identified a cohort of 4,892 patients of whom 586 developed VTE. A total of 1,888 patients received aspirin therapy after MM diagnosis while 862 received warfarin therapy. After adjusting for known potential VTE risk factors, including history of VTE and use of IMIDs, aspirin was not associated with a decreased risk of VTE (adjusted Hazard Ratio (aHR) 1.18; 95% Confidence Interval (CI) 0.92-1.52). Warfarin use was associated with a trend towards reduction in risk of VTE (aHR 0.77; 95% CI 0.53-1.12). Risk factors for VTE after MM diagnosis included: history of prior VTE (aHR 3.83; 95% CI: 2.68-5.48), lenalidomide (aHR 2.36; 95% CI 1.82-3.05), and thalidomide (aHR 2.60; 95% CI: 2.09-3.24). The figure shows the high probability of developing VTE after MM diagnosis, especially among patients with a history of VTE.ConclusionsLenalidomide, thalidomide, and a prior VTE increased the risk of VTE after MM diagnosis. Patients with such history should be considered high risk for VTE. In this high-risk population, aspirin may not provide adequate thromboprophylaxis. [Display omitted] DisclosuresSanfilippo:Bristol Myers Squibb: Speakers Bureau. Carson:Seattle Genetics: Honoraria.

Placement of Simultaneous Inferior Vena Cava Filter During Emergent Open Pulmonary Thromboembolectomy

Background: This study retrospectively reviewed results of simultaneous (SIM) inferior vena cava (IVC) filter and separate (SEP) IVC filter placement with open pulmonary thromboembolectomy (PTE) in pulmonary embolism and its clinical outcomes. Materials and Methods: From November 2006 to May 2014, 23 patients (14 females and 9 males; median age 58 years; range, 21–88 years) underwent emergent PTE for submassive (12) or massive (11) pulmonary embolism (PE). All had a preoperative computed tomography (CT) scan and echocardiography consistent with right ventricular (RV) strain. Mean cardiopulmonary bypass times and temperatures; chest tube outputs; length of stay; perioperative complications; and survival were compared between groups. Results: There were 13 patients in the SIM group and 10 in the SEP group. PE consisted of 14 acute (60.9%) and nine acute on chronic (39.1%). There were seven deaths (30.4%). Median follow up was 44 days (range, 2–2204 days). Follow up was 81% complete in surviving patients. Actuarial survival at one and three years was 83% for the SIM group and 43% for the SEP group, respectively. There were no differences in cardiopulmonary bypass (CPB) times and temperatures, chest tube outputs, or length of stay between groups. Using multivariable logistic regression, we found SIM was associated with increased survival (p=0.09). Further analysis showed patients &gt;55 years in the SEP group were at significantly higher risk of death (hazard ratio [HR]=7.1:1; 95% confidence interval [CI]: 1.55, 32.5, p=0.011). Conclusion: IVC filter placement can be performed simultaneously and safely at PTE. Age &gt;55 years and PTE with IVC filter placed separately were at significantly higher risk of death. A larger cohort is needed to evaluate efficacy of simultaneous IVC filter placement and PTE.

Correlation of exhaled propofol with Narcotrend index and calculated propofol plasma levels in children undergoing surgery under total intravenous anesthesia -\xa0an observational study

BackgroundExhaled propofol concentrations correlate with propofol concentrations in adult human blood and the brain tissue of rats, as well as with electroencephalography (EEG) based indices of anesthetic depth. The pharmacokinetics of propofol are however different in children compared to adults. The value of exhaled propofol measurements in pediatric anesthesia has not yet been investigated. Breathing system filters and breathing circuits can also interfere with the measurements. In this study, we investigated correlations between exhaled propofol (exP) concentrations and the Narkotrend Index (NI) as well as calculated propofol plasma concentrations.MethodsA multi-capillary-column (MCC) combined with ion mobility spectrometry (IMS) was used to determine exP. Optimal positioning of breathing system filters (near-patient or patient-distant) and sample line (proximal or distal to filter) were investigated. Measurements were taken during induction (I), maintenance (M) and emergence (E) of children under total intravenous anesthesia (TIVA). Correlations between ExP concentrations and NI and predicted plasma propofol concentrations (using pediatric pharmacokinetic models Kataria and Paedfusor) were assessed using Pearson correlation and regression analysis.ResultsNear-patient positioning of breathing system filters led to continuously rising exP values when exP was measured proximal to the filters, and lower concentrations when exP was measured distal to the filters. The breathing system filters were therefore subsequently attached between the breathing system tubes and the inspiratory and expiratory limbs of the anesthetic machine. ExP concentrations significantly correlated with NI and propofol concentrations predicted by pharmacokinetic models during induction and maintenance of anesthesia. During emergence, exP significantly correlated with predicted propofol concentrations, but not with NI.ConclusionIn this study, we demonstrated that exP correlates with calculated propofol concentrations and NI during induction and maintenance in pediatric patients. However, the correlations are highly variable and there are substantial obstacles: Without patient proximal placement of filters, the breathing circuit tubing must be changed after each patient, and furthermore, during ventilation, a considerable additional loss of heat and moisture can occur. Adhesion of propofol to plastic parts (endotracheal tube, breathing circle) may especially be problematic during emergence.Trial RegistrationThe study was registered in the German registry of clinical studies (DRKS-ID: DRKS00015795).

AB0786 HUGHES–STOVIN SYNDROME: A PECULIAR AUTOIMMUNE ORIGIN OF PULMONARY ANEURYSMS

Background:Hughes-Stovin Syndrome (HSS) is a rare potentially fatal vasculitis supposedly belonging to the spectrum of Behçet disease without ocular involvement. HSS tends to play by a temporal pattern, starting with thrombosis and followed by formation of pulmonary aneurysms. Since its mortality can reach 25% of cases, the early recognition and the appropriate therapy represent the major challenges.Objectives:In this report, we aimed at describing a rare case of HSS successfully treated in accordance with a prompt combined management with endovascular approach and immunosuppressive treatments.Methods:We described a Caucasian 33-year-old man presented to the Emergency Room of our Hospital with hemoptysis associated with dyspnea and chest pain, without fever and hypotension, with a 2-year history of painful genital and oral ulcers. Blood test revealed anemia, elevated white cell count with increased C-reactive protein (77 mg/L) and D-dimer (2740 ng/mL). Doppler ultrasonography of legs showed thrombosis of the left femoral vein, while CT-angiography reported multiple aneurysms of the pulmonary arteries. An early and extensive work-up for infections and autoimmunity did not document relevant abnormalities. An appropriate genetic assessment revealed the HLA-B51 positivity. The patient immediately underwent endovascular embolization with coils and plugs of the largest pulmonary aneurysm, and inferior vena cava filter placement. Then, he started methylprednisolone (1 mg/kg/day) IV for three days in association with LMWH (6000 IU/day). Prednisone (1 mg/kg/day) in combination with cyclophosphamide (100 mg daily) were started orally, with tapering of steroids within a month. At the tight follow up (1 month and 3 months later), no genital and oral ulcers nor vascular thrombosis occurred, and acute phase reactants were in normal range. The 3-month-CT angiography showed a complete resolution of the aneurysms and no new changes.Results:The peculiar diagnosis of HLAB51 positive HSS with multiple pulmonary aneurysms was made. The appropriate imaging followed by a prompt endovascular embolization of aneurysms with LMWH treatment were successfully performed. Interestingly, the oral combination therapy with corticosteroid and cyclophosphamide showed a rapid efficacy with a relevant safety profile. At the tight follow up, the young man improved significantly with clinical signs and pulmonary changes (Figure 1 next page).Conclusion:This case is of interest because of the early recognition of such a rare disease that allowed an adequate combined radiological, vascular, and rheumatologic approach. In our case, LMWH resulted useful in preventing the pulmonary embolism, despite the use of anticoagulants is still debated in HSS. Moreover, the endovascular embolization let a less invasive approach to surgery without the need for multiple surgical procedures. For the first time, we documented that oral cyclophosphamide showed an early efficacy as a first line therapy of a HLA-B51 HSS.

Comparative outcomes of Inferior Vena Cava filters placed at bedside using digital radiography versus conventional fluoroscopy

PurposeTo retrospectively assess the outcomes of Inferior Vena Cava (IVC) filters placed in critically ill patients in the ICU at bedside using digital radiograph (DR) guidance with previous cross-sectional imaging for planning, compared to IVC filters placed by conventional fluoroscopy (CF). Method and materialsThe cohort consisted of 129 IVC filter placements; 48 placed at bedside and 81 placed conventionally from July 2015 to September 2016. Patient demographics, indication, radiation exposures, access site, procedural duration, dwell time, and complications were identified by the EMR. IVC Filter positioning with measurements of tip to renal vein distance and lateral filter tilt were performed when cavograms or post placement CTs were available for review. Statistical analysis was performed using Stata IC 11.2. ResultsTechnical success of the procedure was 100% in both groups. Procedural duration was longer at the bedside lasting 14.5 +/- 10.2 versus 6.7 +/- 6.0 ​min (p<0.0001). The bedside DR group had a median radiation exposure of 25 ​mGy (15–35) and the CF group had mean radiation exposure of 256.94 ​mGy +/- 158.6. There was no significant difference in distance of IVC tip to renal vein (p=0.31), mispositioning (p=0.59), degree of filter tilt (p=0.33), or rate of complications (p=0.65) between the two groups. ConclusionIVCF placement at the bedside using DR is comparable to CF with no statistical difference in outcomes based on IVCF positioning, degree of lateral tilt or removal issues. It decreased radiation dose, but with overall increased procedural time.

Association of Vena Cava Filters and Catheter-Directed Thrombolysis for Deep Vein Thrombosis With Hospital Readmissions

OBJECTIVES: The objective was to evaluate all-cause 30 days readmission rate and its association with inferior vena cava filters (IVCF) placement and catheter-directed thrombolysis (CDT) in patients with proximal and caval DVT. BACKGROUND: The rehospitalization rates and its predictors in acute proximal DVT have not been well characterized, including the impact of IVCF placement and CDT.METHODS: Patients with index hospitalization for acute proximal lower extremity DVT were evaluated for unplanned readmission rates at 30 days using Nationwide Readmission Database from 2016 to 2017. We used Cox proportional hazard model to determine the predictors of 30-days readmissions and its association with IVCF and CDT use. RESULTS: 58,306 adult patients were identified with an index hospitalization for acute proximal DVT. 533 patients died during the index admission or within 30 day from initial discharge. The unplanned 30-day rehospitalization rate among survivors of initial hospitalization was 14.7% (95% confidence interval [CI]: 14.5-15.0%). In multivariable analysis, only CDT was associated with a lower hazard for rehospitalization (HR 0.77, 0.71-0.84), whereas IVCF placement (HR 1.26, P<0.001, 95% CI 1.19-1.34), malignancy (HR 1.45, P<0.001, 95% CI 1.34-1.57), and length of stay more than 5 days (HR 1.39, P<0.001, 95% CI 1.33-1.46) were associated with higher readmission rates. CONCLUSIONS: The 30-day unplanned rehospitalization rate continues to be high in patients with acute proximal DVT. CDT was associated with lower rehospitalization rates, while IVCF placement was associated with increased rehospitalization rates. FUNDING STATEMENT: This research was funded by the Division of Cardiovascular Disease, Temple University Hospital. DECLARATION OF INTERESTS: Dr Bashir has equity interest in Thrombolex Inc. Dr. Bikdeli reports that he is a consulting expert, on behalf of the plaintiff, for litigation related to specific brand models of IVC filters. Dr. Anthony J. Comerota is an unpaid member of the Scientific Advisory Board of Thrombolex, Inc. No other disclosures are reported. ETHICS APPROVAL STATEMENT: NRD is publicly available and contains deidentified patient information, hence, the study was exempted from institutional review board assessment.