Inferior Vena Cava Filter Placement In Patients Research Articles

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.

Meta-Analysis of the Usefulness of Inferior Vena Cava Filters in Massive and Submassive Pulmonary Embolism

To conduct a systematic review and meta-analysis evaluating the safety and effectiveness of inferior vena cava filter (IVCF) placement in the setting of massive and submassive pulmonary embolism (PE), Pubmed and Cochrane Library were queried to identify all clinical studies evaluating IVCF placement in patients with massive and submassive PE from database establishment to December 2019. The rate of recurrent PE, PE-related mortality, adverse events, IVCF type, additional treatment intervention, DVT status, and follow-up length were retrieved. Recurrent PE, mortality, and complication rates were pooled. Meta-analysis was performed to compare mortality rates between groups with and without IVCF placement. Subgroup analysis was performed based on whether catheter-directed therapy was used for PE intervention. Fifteen observational studies with a total of 232 patients who received IVCF for submassive or massive PE were included. The pooled overall recurrent symptomatic PE and mortality rates were 1.4% and 5.5%, respectively. A lower mortality rate among patients with IVCF was observed than those without (6.8% vs 26.3%; odds ratio [OR] 0.275 [95% confidence interval] 0.090 to 0.839], I2 = 30.6%, p = 0.023). Patients who received concurrent catheter-directed therapy demonstrated a lower recurrent PE (0% vs 2.8%) and mortality rate (3.4% vs 7.8%) than those who did not. The cumulative IVCF-related complication rate was 0.63%. In conclusion, based on a limited amount of low-quality evidence, IVCF placement is associated with low recurrent PE and PE-related mortality rates among patients with massive and submassive PE, suggestive of a potential clinical benefit in this scenario. Prospectively designed studies are warranted to confirm these findings.

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.

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

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.

The Prophylactic Use of Inferior Vena Cava Filters in Patients Undergoing High-Risk Spinal Surgery

Prophylactic inferior vena cava filter (IVCF) placement is advocated in some high-risk groups. We sought data regarding safety and efficacy for prophylactic IVCF placement in patients at high risk for venous thromboembolism (VTE) following major spinal reconstruction. Seventy-four spine surgery patients with contraindication to anticoagulation (44 females, 30 males; mean age 56.2) received prophylactic IVCFs. Criteria were (1) history of thromboembolism, (2) diagnosed thrombophilia, (3) malignancy, (4) bedridden >2 weeks prior to surgery, (5) staged procedures or multiple levels, (6) combined anterior/posterior approaches, (7) expected need for significant iliocaval manipulation during exposure, and (8) single-stage anesthetic time >8 hr. Seventy patients had at least two risk factors. All received IVCFs prior to the first stage of spine reconstruction. Patients were evaluated for filter complications, deep vein thrombosis (DVT), and pulmonary embolism (PE). Patients' lower extremity veins from groin to ankle were imaged weekly until discharge using duplex ultrasound (DUS). One-third also underwent thoracic and pelvic computed tomography scans, and the pelvic veins, IVC, and pulmonary vasculature were evaluated for VTE. Multiple DUS (n = 198, mean 2.6 studies per patient) were performed in 68 patients. At a mean follow-up of 11 months, one of the patients developed PE. Twenty-seven limbs in 23 patients developed DVT. Five limbs had isolated calf DVT, and 22 had proximal vein involvement. Insertion site DVT accounted for nearly one-third of the DVTs. Six patients died from unrelated complications. There was one technical error with an IVCF deployed in the iliac vein. Despite a high incidence of DVT following high-risk spinal surgery, prophylactic IVCF placement appears to protect patients from PE.