Inferior Vena Cava Filter Placement Research Articles

Clinical Correlates of In-Hospital Mortality in Patients Undergoing Inferior Vena Cava Filter Placement for Acute Deep Vein Thrombosis

Background: It is reasonable to place an Inferior Vena Cava Filter (IVCF) when an acute deep vein thrombosis (DVT) of the lower limbs occurs in a patient with absolute contraindication to therapeutic anticoagulation. An additional potential reason for placing an IVCF is the need to stop therapeutic anticoagulation in a patient with acute DVT who must undergo urgent non-deferrable surgery. However, IVCFs are often used outside of such established indications and many authors argue about their actual utility, especially in terms of survival. In this retrospective study, we looked for clinical correlates of in-hospital mortality among patients who underwent IVCF placement, limiting our analysis to the cases for which a correct indication to IVCF placement existed. Methods: We retrospectively analyzed the electronic database of our University Hospital, searching for consecutive hospitalized patients who had acute DVT and underwent IVCF placement because of an established contraindication to therapeutic anticoagulation and/or because it was necessary to stop anticoagulation due to urgent surgery. The search covered the period between 1 January 2010 and 31 December 2020. Results: The search resulted in the identification of 168 individuals. An established contraindication to therapeutic anticoagulation was present in 116 patients (69.0%), while urgent non-deferrable surgery was the reason for IVCF placement in 52 patients (31.0%). A total of 24 patients (14.3%) died during the same hospital stay in which the IVCF was placed. Mortality rate was significantly higher in patients with a contraindication to anticoagulation than in patients who underwent IVCF placement because of urgent surgery (19.0% vs. 3.8%, OD 5.85 vs. 0.17). In-hospital mortality was also significantly higher among patients with chronic kidney disease and those who needed blood cell transfusion during hospitalization. Conclusions: This study provides novel information on clinical correlates of in-hospital mortality among patients with acute DVT who undergo IVCF. Prospective observational studies are needed to substantiate these findings.

Independent association between IVC filter placement and VTE risk in patients with upper gastrointestinal bleeding and isolated distal DVT: A retrospective cohort study.

The placement of inferior vena cava (IVC) filters often emerges as an alternative preventative measure against pulmonary embolism in patients with upper gastrointestinal (GI) bleeding and isolated distal deep vein thrombosis (DVT). We aimed to investigate the association of IVC filter placement and the incidence of venous thromboembolism (VTE) recurrence in this patient population. We performed a retrospective cohort study including 450 patients with upper GI bleeding and isolated distal DVT. Propensity score matching using logistic regression was conducted to mitigate potential selection bias. Logistic regression models and additional sensitivity analyses were conducted to estimate the association between IVC filter implantation and VTE recurrence. Interaction and stratified analyses were also performed according to the background covariates. Patients who underwent IVC filter placement were significantly younger than patients in the surveillance group (55.8 ± 9.0 vs 58.4 ± 11.2 years, p = 0.034). Patients in the IVC filter group demonstrated a higher distal thrombus burden. The VTE recurrence composite was significantly higher in patients who underwent IVC filter placement (44.1% [45/102] vs 25% [87/348], p < 0.001). Unmatched crude logistic regression analysis identified a significant association between IVC filter placement and VTE recurrence composite (OR = 2.37; 95% CI, 1.50-3.75). Sensitivity analyses yielded congruent outcomes. This study revealed an increased risk of VTE recurrence among patients receiving IVC filter placement, suggesting that IVC filter placement may not be suitable as a primary treatment for patients with upper GI bleeding and isolated distal DVT.

Urological complications caused by inferior vena cava filters: a systematic review.

Inferior vena cava (IVC) filters act in preventing pulmonary embolisms (PE). Various complications have been reported with their use. However, a credible urological complication rate, filter characteristics, and clinical presentation has yet to be summarized. Thus, we reported these complications in the form of a systematic review. A search strategy was designed using PubMed, MEDLINE, and EMBASE on February 10th, 2022. The design of this search strategy did not include any language restrictions. The key words (and wildcard terms) used in the search strategy were urolog*, ureter*, bladder, kidney coupled with filter, inferior vena cava, and cava*. Inclusion criteria were: patients older than 18, with previous IVC filter placement, and urologic complication reported. Exclusion criteria were: patients younger than 18, no IVC filter placement, and no urologic complication reported. Other case series and reviews were excluded to avoid patient duplication. Thirty-five articles were selected for full-text screening. Thirty-seven patient cases were reviewed, and the median age was 53 (range: 21-92 years old). Abdominal and or flank pain was reported in 16 (43%) patients, hematuria was seen in eight (22%) and two (5%) patients died due to acute renal failure resulting from the urologic complications of the IVC filter. Indications for IVC filter placement were recurrent pulmonary embolism (PE), contraindication to or noncompliance with anticoagulant therapy. The IVC filters were infrarenal in 29 (78.4%) patients, suprarenal in five (13.5%) patients, not reported in two patients, and misplaced into the right ovarian vein in one patient. Three or more imaging modalities were obtained in 19 patients (51%) for planning. IVC filter removal was not performed in 17 (45.9%) patients, endovascular retrieval occurred in nine (24.3%) patients, and open removal was performed in seven (18.9%) patients, and tissue interposition was performed in two (5.4%) patients. One patient did not have the management reported. Urological complications caused by IVC filters although rare, are likely underreported, require extensive workup, and pose surgical challenges. Due to their complex management, filter retrieval should be planned for as soon as feasible, and plans should be made as early as during the IVC filter implant. For those that do develop complications, clinical judgement must be exercised in management, and open surgical, endovascular or even conservative management strategies can be viable options and should be discussed in a multidisciplinary setting.

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

466 Development of Machine Learning Algorithms to Predict Symptomatic VTE at Time of Admission and Time of Discharge after Severe Traumatic Injury

OBJECTIVES/GOALS: Clinical indicators predictive of venous thromboembolism (VTE) in trauma patients at multiple time points are not well outlined, particularly at time of discharge. We aimed to describe and predict inpatient and post-discharge risk factors of VTE after trauma using a multi-variate regression model and best of class machine learning (ML) models. METHODS/STUDY POPULATION: In a prospective, case-cohort study, all trauma patients (pts) who arrived as level 1 or 2 trauma activations, from June 2018 to February 2020 were considered for study inclusion. A subset of pts who developed incident, first time, VTE and those who did not develop VTE within 90 days of discharge were identified. VTE were confirmed either by imaging or at autopsy during inpatient stay or post-discharge. Outcomes were defined as the development of symptomatic VTE (DVT and/or PE) within 90 days of discharge.A multi-variate Cox regression model and a best in class of a set of 5 different ML models (support-vector machine, random-forest, naives Bayes, logistic regression, neural network]) were used to predict VTE using models applied a) at 24 hours of injury date or b) on day of patient discharge. RESULTS/ANTICIPATED RESULTS: Among 393 trauma pts (ISS=12.0, hospital LOS=4.0 days, age=48 years, 71% male, 96% with blunt mechanism, mortality 2.8%), 36 developed inpatient VTE and 36 developed VTE after discharge. In a weighted, multivariate Cox model, any type of surgery by day 1, increased age per 10 years, and BMI per 5 points were predictors of overall symptomatic VTE (C-stat 0.738). Prophylactic IVC filter placement (4.40), increased patient age per 10 years, and BMI per 5 points were predictors of post-discharge symptomatic VTE (C-stat= 0.698). A neural network ML model predicted VTE by day 1 with accuracy and AUC of 0.82 and 0.76, with performance exceeding those of a Cox model. A naīve Bayesian ML model predicted VTE at discharge, with accuracy and AUC of 0.81 and 0.77 at time of discharge, with performance exceeding those of a Cox model. DISCUSSION/SIGNIFICANCE: The rate of inpatient and post-discharge VTEs remain high. Limitations: single institution study, limited number of patients, internal validation only, with the use of limited number of ML models. We developed and internally validated a ML based tool.Future work will focus on external validation and expansion of ML techniques.

Role of Vena Cava Filter in the Prophylaxis and Treatment of Venous Thromboembolism in Injured Adult Patients: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma.

Injured patients are at an increased risk of developing deep vein thrombosis (DVT) and pulmonary embolism (PE). Inferior vena cava (IVC) filters have been used in injured patients to prevent venous thromboembolism (VTE), but current evidence-based guidelines are lacking. Questions regarding IVC filter use in injured patients with clearly defined Population(s), Intervention(s), Comparison(s), and appropriately selected Outcomes (PICO) were formulated. The study sought to understand the evidence behind use of ultra short term IVC filters and use of IVC filters in injured patients with and without known VTE who are unable to receive therapeutic anticoagulation and chemoprophylaxis, respectively. A literature search and review was conducted, followed by meta-analysis. The quality of evidence was assessed per Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. There were twenty-one studies that were analyzed. Three studies were randomized controlled trials (RCTs), three were observational studies, and fifteen studies were retrospective studies. In injured patients without known acute VTE who cannot receive chemoprophylaxis, we recommend against placement of an IVC filter due to associated higher rate of mortality, DVT, PE, and length of stay. The quality of evidence was assessed to be low. In injured patients with known DVT who cannot receive chemoprophylaxis we conditionally recommend against placement of an IVC filter. The quality of evidence was assessed to be very low. No recommendations can be made with respect to placement of ultra short term IVC filters based upon available data. IVC filters should not be placed routinely for prophylaxis in injured adult patients without known VTE who cannot receive chemoprophylaxis. The taskforce conditionally recommends against the placement of IVC filter in injured adult patients with known DVT who cannot receive chemoprophylaxis. Guideline; Systematic review/meta-analysis, level IV.

The Role of IVC Filters in the Management of Acute Pulmonary Embolism.

Venous thromboembolism (VTE), comprising deep venous thrombosis (DVT) and pulmonary embolism (PE), is a prevalent cardiovascular condition, ranking third globally after myocardial infarction and stroke. The risk of VTE rises with age, posing a growing concern in aging populations. Acute PE, with its high morbidity and mortality, emphasizes the need for early diagnosis and intervention. This review explores prognostic factors for acute PE, categorizing it into low-risk, intermediate-risk, and high-risk based on hemodynamic stability and right ventricular strain. Timely classification is crucial for triage and treatment decisions. In the contemporary landscape, low-risk PE patients are often treated with Direct Oral Anticoagulants (DOACS) and rapidly discharged for outpatient follow-up. Intermediate- and high-risk patients may require advanced therapies, such as systemic thrombolysis, catheter-directed thrombolysis, mechanical thrombectomy, and IVC filter placement. The latter, particularly IVC filters, has witnessed increased usage, with evolving types like retrievable and convertible filters. However, concerns arise regarding complications and the need for timely retrieval. This review delves into the role of IVC filters in acute PE management, addressing their indications, types, complications, and retrieval considerations. The ongoing debate surrounding IVC filter use, especially in patients with less conventional indications, reflects the need for further research and data. Despite complications, recent studies suggest that clinically significant issues are rare, sparking discussions on the appropriate and safe utilization of IVC filters in select PE cases. The review concludes by highlighting current trends, gaps in knowledge, and potential avenues for advancing the role of IVC filters in future acute PE management.

Comparison of inferior vena cava filter use and outcomes between cancer and non-cancer patients in a tertiary hospital

BackgroundWhile accepted indications for the use of inferior vena cava filter (IVCF) in patients with a venous thromboembolism (VTE) have remained stable, their use continues to be frequent. Retrieval rates are still low, being particularly notable in the population with cancer. This study aims to review the rate of adherence to guidelines recommendation and to compare retrieval rates and complications in both cancer and non-cancer patients. MethodsA retrospective study was performed including 185 patients in whom an IVCF was placed in Hospital Clinic of Barcelona. Baseline characteristics, clinical outcomes, and IVCF-related outcomes were analyzed. A strongly recommended indication (SRI) was considered if it was included in all the revised clinical guidelines and non-strongly if it was included in only some. ResultsOverall, 47 % of the patients had a SRI, without differences between groups. IVCF placement after 29 days from the VTE event was more frequent in the cancer group (46.1 vs. 17.7 %). Patients with cancer (48.1 % of the cohort) were older, with higher co-morbidity and bleeding risk. Anticoagulation resumption (75.3 % vs. 92.7 %) and IVCF retrieval (50.6 % vs. 66.7 %) were significantly less frequent in cancer patients. No significant differences were found regarding IVCF-related complications, hemorrhagic events and VTE recurrence. ConclusionsSRI of IVCF placement was found in less than half of the patients. Cancer patients had higher rates of IVCF placement without indication and lower anticoagulation resumption and IVCF retrieval ratios, despite complications were similar in both groups.

How should the liver be approached in patients with severe abdominal wall varices?

AbstractAlthough liver resection in patients with abdominal wall varices (AWV) is rare, we should have a special surgical strategy for the liver in such cases. We report our experience of approaching the liver in a patient with severe AWV. The patient was a 77‐year‐old man who had undergone inferior vena cava (IVC) filter placement for a pulmonary embolism 10 years prior. Severe AWV due to complete IVC obstruction appeared 3 years ago. The patient was diagnosed with intraductal papillary neoplasm of the bile duct and referred to our hospital. Although it was difficult to see the small AWV, it was necessary to avoid bleeding due to AWV injury. The ports were inserted while confirming the AWV with indocyanine green (ICG) imaging, and laparoscopic left hepatectomy was performed. Our approach to the liver using abdominal wall ICG imaging might be a standard strategy to avoid severe AWV injury.

Acute caval thrombosis leading to obstructive shock in the early post insertion period of an inferior vena cava filter: a case report and literature review

BackgroundObstructive shock is extremely rare in clinical practice and is caused by acute blood flow obstruction in the central vessels of either the systemic or pulmonary circulation. Utilizing inferior vena cava filters (IVCFs) to prevent pulmonary embolism (PE) is associated with some potential complications, such as inferior vena cava thrombosis (IVCT). Shock as a direct result of IVCT is rare. We present a case of obstructive shock secondary to extensive IVCT caused by inadequate anticoagulant therapy after the placement of an IVCF.Case presentationA 63-year-old male patient with a traffic accident injury presented orthopaedic trauma and lower limb deep vein thrombosis (DVT). He experienced sudden and severe abdominal pain with hypotension, tachycardia, tachypnea, oliguria and peripheral oedema 5 days after IVCF placement and 3 days after cessation of anticoagulant therapy. Considering that empirical anti-shock treatment lasted for a while and the curative effect was poor, we finally recognized the affected vessels and focused on the reason for obstructive shock through imaging findings—inferior vena cava thrombosis and occlusion. The shock state immediately resolved after thrombus aspiration. The same type of shock occurred again 6 days later during transfer from the ICU to general wards and the same treatment was administered. The patient recovered smoothly in the later stage, and the postoperative follow-up at 1, 3, and 12 months showed good results.ConclusionThis case alerts clinicians that it is crucial to ensure adequate anticoagulation therapy after IVCF placement, and when a patient presents with symptoms such as hypotension, tachycardia, and lower limb and scrotal oedema postoperatively, immediate consideration should be given to the possibility of obstructive shock, and prompt intervention should be based on the underlying cause.

Inferior Vena Cava Filter Long Term Complications and Retrieval Techniques: A Case Series and Literature Review.

Long-term mechanical complications after inferior vena cava (IVC) filter placement include embedded or tilted filters, erosion of the vena cava, filter thrombosis. In the setting of caval thrombosis, patients may subsequently develop venous hypertension and post-thrombotic syndrome (PTS). Here we present three unique cases of IVC filter complications and surgical management. A 30-year-old female presented with acute abdominal pain, revealing a duodenal perforation caused by an IVC filter eroding into her duodenum. A 42-year-old female with an IVC filter in place for 20years due to a prior pulmonary embolism underwent laser-assisted retrieval of the filter due to concerns of caval adherence. A 48-year-old male with a history of DVT, venous stasis ulcer, and an IVC filter presented for filter retrieval. The surgical techniques described in this report include complicated IVC filter retrieval, performed in cases of filter complications including migration, fracture, duodenal perforation and IVC thrombosis resulting in PTS. One case, requiring open retrieval, is explained and the surgical technique is provided. There are images and videos of these procedures to enrich the learning experience. The surgical techniques described in this report include complicated inferior vena cava filter retrieval, performed in cases of filter complications including migration, fracture, duodenal perforation and IVC thrombosis. One case, requiring open retrieval, is explained and the surgical technique is provided. There are images and videos of these procedures to enrich the learning experience. Endovascular retrieval of long-term complicated IVC filters is challenging, but it can be a safely performed in many patients. However, open surgery may be necessary in selected patients.

Racial and gender disparities in the management of acute pulmonary embolism

ObjectiveThe aim of this study was to assess race and sex disparities in use and outcomes of various interventions in patient with acute pulmonary embolism (PE). MethodsWe included 129,445 patients with acute PE from the NIS from January 2016 to December 2019. Rates of inferior vena cava (IVC) filter placement, catheter-directed thrombolysis (CDT), CDT with ultrasound, systemic thrombolysis, surgical embolectomy, percutaneous thrombectomy, extracorporeal membrane oxygenation, and mechanical ventilation were compared between race and sex subgroups, along with length of hospital stay, major bleeding events, mortality, and other adverse events. Multivariate linear regression analysis was used to adjust for variables that were significantly different between race and sex, including demographic factors, comorbidities, socioeconomic factors, and hospital characteristics. ResultsCompared with White male patients, all subgroups had significantly higher odds of in-hospital mortality highest in Hispanic male patients (odds ratio [OR], 1.34; 95% confidence interval [CI], 1.090-1.640; P < .01). All subgroups also had a higher odds of major bleeding events and increased length of stay. All subgroups also had lower odds of receiving CDT, lowest in Black female patients (OR, 0.740; 95% CI, 0.660-0.820; P < .001) and Hispanic female patients (0.780; 95% CI, 0.650-0.940; P < .001) compared with White male patients. There was no significant difference in the use of systemic thrombolysis among subgroups. ConclusionsBlack and Hispanic patients and female patients are less likely to undergo CDT compared with White male patients, in addition to having higher odds of mortality, major bleeding, and increased length of stay after management of PE. Further efforts are needed to mitigate disparate outcomes of PE management at not only an institutional, but at a national, level to promote health care equality.

Statin Use and the Risk of Venous Thromboembolism in Women Taking Hormone Therapy

Although hormone therapy (HT) in perimenopausal women is associated with increased risk for venous thromboembolism (VTE), it is unclear to what extent statins may mitigate this HT-associated risk. To estimate VTE risk in women aged 50 to 64 years taking HT with or without statins. This nested case-control study analyzed data from a commercially insured claims database in the US. Eligible participants included women aged 50 to 64 years with at least 1 year of continuous enrollment between 2008 and 2019. Data analysis occurred from January 2022 to August 2023. Filled prescriptions for estrogens, progestogens, and statins were recorded in the 12 months prior to index. Recent HT was defined as any estrogen or progestogen exposure within 60 days before the index date. Current statin exposure was defined as 90 or more days of continuous exposure prior to and including the index date. Statin intensity was defined by the statin exposure 30 days prior to index. Cases were identified with VTE diagnoses (diagnostic codes) preceded by at least 12 months without VTE and followed within 30 days by anticoagulation, an inferior vena cava filter placement, or death. Controls were matched to cases (10:1) on date and age. Conditional logistic regression models estimated risk for HT and statin exposures with odds ratios (OR), adjusted for comorbidities. Conditional logistic regression models were used to estimate VTE risk for HT and statin exposures with odds ratios (ORs), adjusted for comorbidities. Intensity of statin therapy was measured as a subgroup analysis. The total sample of 223 949 individuals (mean [SD] age, 57.5 [4.4] years) included 20 359 cases and 203 590 matched controls. Of the entire sample, 19 558 individuals (8.73%) had recent HT exposure and 36 238 individuals (16.18%) had current statin exposure. In adjusted models, individuals with any recent HT exposure had greater odds of VTE compared with those with no recent HT exposure (OR, 1.51; 95% CI, 1.43-1.60). Individuals receiving current statin therapy had lower odds of VTE compared with those with no current statin exposure (OR, 0.88; 95% CI, 0.84-0.93). When compared with those not recently taking HT or statins, the odds of VTE were greater for those taking HT without statins (OR, 1.53; 95% CI, 1.44-1.63) and for those taking HT with statins (OR, 1.25; 95% CI, 1.10-1.43), but were lower for those taking statins without HT (OR, 0.89; 95% CI, 0.85-0.94). Individuals taking HT with statin therapy had 18% lower odds of VTE than those taking HT without statins (OR, 0.82; 95% CI, 0.71-0.94) and there was greater risk reduction with higher intensity statins. In this case-control study, statin therapy was associated with reduced risk of VTE in women taking HT, with greater risk reduction with high-intensity statins. These findings suggest that statins may reduce risk of VTE in women exposed to HT and that HT may not be contraindicated in women taking statins.

Incidence and risk factors for inferior vena cava filter thrombosis detected at time of filter retrieval in patients with lower extremity deep vein thrombosis: a multicenter retrospective cohort study.

Inferior vena cava filter (IVCF) thrombosis is an uncommon complication of IVCF utilization. The aims of this study were to investigate inferior vena cava (IVC) venography before filter retrieval to determine the incidence relative to filter dwell time and risk factors of IVCF thrombosis based on the clinical data and imaging findings in patients with lower extremity deep vein thrombosis (LEDVT). The clinical data from a multicenter randomized trial conducted between October 2017 and March 2019 were reviewed to determine the incidence of IVCF thrombosis in preretrieval venography and the associated risk factors. The correlation between filter dwell times (within 90 days) and incidence was assessed. Baseline demographics, LEDVT presentation, laboratory examination, thrombus characteristics, concurrent pulmonary embolism (PE), comorbidities and risk factors for LEDVT, and IVCF-relevant information were analyzed using the independent samples t-test, chi-squared test, Fisher exact test, and regression analysis to determine the univariable and multivariable associations in assessing the risk factors of IVCF thrombosis. A total of 178 eligible patients were included, of whom 58 were in the IVCF thrombosis group and 120 were in the IVCF nonthrombosis group, and the mean filter dwell time was 22.07±27.91 days (range, 4-190 days). The overall incidence of IVCF thrombosis in patients with LEDVT who received IVCFs was 32.58% (58/178). The incidence of IVCF thrombosis was 35.25% (49/139) in the first 30 days after the IVCF placement and decreased to 22.73% (5/22) between 30 to 60 days of dwell time and to 18.18% (2/11) between 60 and 90 days of dwell time, indicating a decreasing trend within the first 90 days. The risk factors for the occurrence of IVCF thrombosis were concurrent PE [odds ratio (OR) =2.59; 95% confidence interval (CI): 1.27-5.28; P=0.01], rheumatic diseases of the immune system (OR =14.42; 95% CI: 1.52-136.41; P=0.02), IVC:filter radial ratio >0.587 (OR =0.25; 95% CI: 0.10-0.65; P<0.01), and percutaneous angioplasty (PTA) (OR =2.50; 95% CI: 1.09-5.70; P=0.03). The incidence of IVCF thrombosis at the time of filter retrieval appears to decrease with dwell time within 90 days. Concurrent PE, rheumatic diseases of the immune system, and PTA were taken into account as risk factors. An IVC:filter radial ratio of 0.587 was a protective factor against developing IVCF thrombosis. These findings require further validation in a well-designed study since the present study lacked a close follow-up.

Safety and Efficacy of Inferior Vena Cava Filters in the Peri-Partum Period: Experiences at a Tertiary Care Facility

Background: Guidelines recommend placement of inferior vena cava (IVC) filters in patients with acute thrombotic episodes and a concurrent contraindication to anticoagulation, however filter placement during or immediately postpartum presents significant technical challenges. The use and complications of IVC filters in the peripartum period is poorly documented in current literature. Objective(s): To evaluate the use of and outcomes related to IVC filters in an obstetric population at a large tertiary care center. Study Design: Retrospective review of all patients at a tertiary academic medical center from 2001-2016 who either conceived with an IVC filter in place or underwent IVC filter placement during the antepartum or postpartum interval. Manual abstraction of each chart was performed, with data stored in a RedCap database. Results: A total of 24 patients were included in the final analysis: 5 with IVC filter placement prior to pregnancy, 7 with antepartum placement, and 12 with postpartum placement. One patient had multiple pregnancies during our study timeframe and was therefore included twice. The cohort of postpartum placement were the youngest mean age (23.7 years), had a higher number of IVC filters placed for polytrauma (n=4), and had the shortest time to removal (135.9 days). The vast majority (91.3%) of IVC filters placed during pregnancy were retrievable filters in the suprarenal position, while most deployed in an infrarenal position (83.3%) when placed prior to conception. Complications encountered included multiple attempts to remove IVC filter, severe angulation, embedded struts, fracture, and one case of cardiac tamponade during filter placement requiring emergent sternotomy and evacuation. Of the filters requiring multiple attempts for removal, in 1 patient (4%) it was unable to be removed despite multiple attempts and the filter was ultimately left in situ. Complications were more common when placement was performed prior to pregnancy or antepartum (40% and 57.1% respectively) versus postpartum (16.7%). From an obstetrical perspective, 1 patient (4%) required early preterm delivery due to preeclampsia; 1 maternal death occurred in a postpartum patient who experienced a massive pulmonary embolism and subsequently died despite emergent thrombectomy and IVC filter placement, and 1 neonatal death occurred due to congenital heart disease following periviable preterm delivery. Conclusion(s): In our study across 16 years at a large academic medical center we identified 23 patients who had an IVC filter placed prior to pregnancy or placed during the antepartum or postpartum periods. Data from our experience suggested a higher incidence of complications with preconceptual and antepartum placement, although the majority of these did not impact clinical outcomes. While not frequently needed, IVC filters remain an option for clinicians treating pregnant and postpartum patients but should be considered a last resource as they can lead to various complications.

Recurrent Leg Deep Vein Thrombosis in a Female with Atypical Right-Sided Variant of May Thurner Syndrome and Factor V Leiden Mutation

I ntroduction: May-Thurner syndrome (MTS) is a condition in which the right common iliac artery presses on the left common iliac vein, causing it to narrow over time. Right-sided MTS is a rare event. We present this unique case of recurrent right leg deep vein thrombosis in a female with atypical right sided variant of MTS and Factor V Leiden mutation. Case Presentation: A 34-year-old lady with with no signficiant past medical history presented to the hospital with right lower leg edema, tingling, and discolouration. She was taking oral contraceptive pills. Vitals were unremarkable. Doppler studies revealed right lower extremity deep vein thrombosis in the right external iliac vein, common iliac vein and common femoral vein. She was started on an intravenous heparin drip and subsequently had a thrombectomy procedure. She was subsequently discharged home on apixaban anticoagulation. We opted to request a hypercoagulable and vasculitis workup in light of the extensive thrombosis, despite the OCP risk factor, and discovered a heterozygous Factor V Leiden mutation. She returned to the hospital 2 days later with worsening right leg pain. Repeat Doppler studies demonstrated acute right femoral and popliteal deep vein thrombosis. CT angiography of abdomen and pelvis revealed significant right femoral vein DVT that extends into the External iliac vein, common iliac vein, and IVC to at least slightly below renal vein level. Invasive Radiology was consulted and she had a venogram and intravascular ultrasound (IVUS) which showed high-grade right common iliac vein and IVC stenosis (&amp;gt;90%) at L4 superior endplate. Iliac stenting and angioplasty improved iliac and inferior IVC diameters. Patient also underwent thrombectomy &amp; IVC filter placement. The diagnostic venography revealed a popliteal-to-proximal femoral vein rethrombosis. This was treated with tissue plasminogen activator (TPA) by 8 French power pulse AngioJet and a mechanical thrombectomy. This resulted in partial clearing of the common femoral vein with persistent narrowing and thrombosis of the popliteal vein. TPA was infused at 1 mg/hour with a 5 French McNamara lysis catheter over the popliteal region.Patient transferred to ICU for overnight intravenous thrombolysis. The patient was then re-initiated on the heparin drip and then bridged to therapeutic warfarin. Discussion: MTS is a phenomenon commonly described as an acquired stenosis of the left common iliac vein secondary to compression by the right common iliac artery 1. It has been associated with genetic clotting factor abnormalities, repeated pregnancies, postpartum, contraceptive pills, prolonged immobilization, scoliosis, anti-phospholipid syndrome, COVID-19, and recurrent DVT 2. In patients with left lower-limb DVT, the incidence of MTS is about 20-50%. Right lower limb DVT in patients with right sided variant of MTS is rare. Right lower limb DVT with right sided variant of MTS with co-existing Factor V Leiden mutation is even rarer. Ultrasound imaging typically cannot detect the high pelvic abnormalities seen in MTS. Contrast venography, MRI, or IVUS are needed to diagnose MTS 4. As was the case in our patient, venography should be done to evaluate stenosis and iliac vein compression hemodynamics after thrombus removal. Treatment of MTS depends on the presentation, severity of symptoms, and whether the patient has developed DVT. Conservative treatment such as compression stockings can be used for patients who are asymptomatic or have mild symptoms. For patients with moderate symptoms or DVT, endovascular treatment with stenting is recommended 5. Conclusion: This is a very atypical presentation of MTS variation affecting the right lower extremity with limited description in the literature. To our knowledge, this is the first case presentation of right sided MTS resulting in a DVT in a patient with factor V Leiden mutation. MTS is a potentially treatable and often-overlooked pathology. In the era of expanded endovascular management of MTS, recognition of this disease entity is essential for early diagnosis and treatment.

Bleeding and Thrombosis in Patients with Cancer and Acute Venous Thromboembolism Requiring Urgent Procedures

BACKGROUND There are limited data of outcomes in patients who require anticoagulation interruption for a surgical procedure shortly after an acute VTE, especially in patients with cancer who are at higher risk for both hemorrhage and recurrent thrombosis. Our goal was to assess the incidence of recurrent thrombosis or major hemorrhage at 60-days following an urgent surgical procedure in patients with acute VTE (within one month prior to surgery). METHODS We performed a retrospective cohort study of patients with cancer at Memorial Sloan Kettering Cancer Center (from January 1 st 2021 to December 31 st 2022). Patients were eligible for inclusion if they were diagnosed with a new acute deep vein thrombosis or pulmonary embolism and underwent surgical procedure within 30-days following the acute VTE diagnosis. Recurrent VTE was defined as symptomatic new deep-vein thrombosis or pulmonary embolism, incidental new deep-vein thrombosis or pulmonary embolism involving segmental or more proximal pulmonary arteries, or fatal pulmonary embolism or unexplained death for which pulmonary embolism could not be ruled out as the cause. Major hemorrhage was characterized according to ISTH definition. Competing risk framework was used to estimate cumulative incidences of major hemorrhage, VTE and death at 30 and 60-days. RESULTS A total of 90 patients were included in this analysis. The median age was 73 years and 62% were female (Table 1). Surgical procedures were classified by their risk of bleeding with 64 patients undergoing lower bleeding risk procedures and 26 high-risk procedures (Table 1). There were 10 recurrent or new VTE within 60-days of surgery (60-day cumulative incidence of 8.9%, 95% CI 4.1-16%). The recurrent sites were deep venous (N=7) and new PE (N=3). There were 12 major hemorrhagic events within 60 days (cumulative incidence of 12%, 95% CI 6.5-20%). The most common sites of hemorrhage were the lower gastrointestinal tract and genitourinary system. The competing risk framework is shown graphically in Figure 1. Among patients who received IVC filters the incidence of recurrent VTE was 1.1% and major hemorrhage was 2.2%. The 60-day cumulative incidence of death following surgical procedure was 19% (95% 12-28%). There were no fatal VTE and 3 fatal hemorrhagic events. CONCLUSION Among patients with cancer undergoing surgical procedures within 30-days of an acute VTE, the rates of recurrent VTE and major hemorrhage are substantively higher than reported in non-surgical acute VTE cohorts. Placement of temporary IVC filters may improve short-term bleeding and thrombotic outcomes.

The Choice of Anticoagulant at First Recurrence Does Not Alter the Risk for the Second Recurrence

Introduction : Venous thromboembolism (VTE), encompassing deep venous thrombosis (DVT) and pulmonary embolism (PE), is a major public health hazard, with up to 30-50% of patients with unprovoked VTE experiencing a recurrent VTE event. These recurrent VTE events are associated with significant morbidity and mortality. However, transition strategies to second-line anticoagulation regimens following the first recurrence on anticoagulation have not been well studied. We sought to examine whether rates of the second VTE recurrence were different in those patients who changed their anticoagulation regimen from those who did not . Methods: With an IRB approval for the study, we created a database of all patients 18 years and older diagnosed with the first recurrent VTE at a large tertiary academic hospital between January 1, 2010, and December 31, 2019. The collected data was de-identified and compiled in a secure, standardized institutional database. We assessed the anticoagulation status at the time of and immediately following the first VTE recurrence, and identified patients who were switched to a different anticoagulant regimen. We used Fisher's exact test to evaluate proportions. Statistical significance was set at p&amp;lt;0.05. Results:We identified 138 patients with the first VTE recurrence. Of these patients, 114 (83%) developed DVT, 7 (5%) PE, and 17 (12%) both DVT and PE. Mean age was 63 years at the time of first VTE; 70 (51%) were female. Racial/ethnic representation was 84 (61%) White, 46 (33%) Black, and 133 (96%) non-Hispanic. The majority of patients had cardiovascular risk factors, including hypertension 80 (58%), hyperlipidemia 44 (32%), ordiabetes 40 (29%). Among 138 patients, 32 (23%) had active cancer, May-Thurner syndrome or inferior vena cava (IVC) atresia were reported in 13 (9%) of cases, and 21 (17%) underwent IVC filter placement at the time of the first VTE recurrence. The median follow-up time after diagnosis of a second VTE was 5 years. Following the first VTE recurrence, 19 (14%) of patients switched to a different anticoagulant agent, 7 (5%) had the dose of the anticoagulant adjusted, 1 (0.7%) was given a different INR target, and one had a change in the frequency of administration. The second VTE occurred in 49 (46%) patients who remained on the same anticoagulation regimen and in 3 (16%) who had the agent changed, in 5 who had dose of anticoagulant changed, in 1 (100%) each who had frequency or INR target changed. The association between unprovoked first VTE and the development of the second VTE was not significant (p= 0.85, Fisher's exact test). 49 (36%) of patients had at least one bleeding episode requiring the interruption of anticoagulation or hospitalization. Of those, 43 (88%) occurred while on an anticoagulant. Conclusion: The choice of an anticoagulant regimen after the first VTE recurrence does not impact the rate of the second recurrence.

Analysis of Inferior Vena Cava Filter Indications and Retrieval Rates at an Academic Medical Center in Appalachia

Introduction: Inferior vena cava (IVC) filters are placed for prevention of pulmonary embolism in patients with venous thromboembolism (VTE) and a contraindication to anticoagulation. Additional clinical indications for IVC filters, such as pre-operative prophylaxis for VTE and extensive VTE, are controversial and vary across clinical guidelines. Current guidelines recommend that IVC filters be retrieved after resolution of their clinical indication. A common problem is failure to retrieve IVC filters when indicated, resulting in prolonged or indefinite placement of these devices. Failure to remove IVC filters contributes to an increased risk of filter-associated complications such as device migration, embolization to the cardiopulmonary circulation, perforation and increased risk of deep vein thrombosis (DVT). The goal of this study is to identify IVC filter indications and retrieval statistics at our academic medical center in Appalachia. We seek to compare our performance to national averages, identify the reasons for failure of retrieval in our patient population and develop quality improvement initiatives to improve our performance. Methods: An IRB-approved, single-institution, retrospective chart review was conducted for all patients who had an IVC filter placed between January 2020 and December 2022 at West Virginia University Hospital. Patient demographics, comorbidities, placement indications, retrieval statistics and filter-associated complications were obtained from the electronic medical record (EMR). Patients who had a permanent IVC filter placed were excluded from the final analysis. Statistical analysis was performed using Mann-Whitney U and Chi squared tests where appropriate to compare the retrieval and failure of retrieval groups. Results: The study sample (n=450) had a mean age of 65.3±15.4 years and was comprised of 54.2% males and 45.8% females. West Virginia residents comprised 82.4% of the study sample. The most common reported clinical indications for placement included VTE with a contraindication to anticoagulation (62.4%), preoperative prophylaxis for VTE (15.8%), extensive VTE (15.3%), pharmacomechanical thrombectomy (15.0%) or other (3.1%). The rate of IVC filter retrieval was 25.4% (n=114). The most common reasons for failure of retrieval were loss to follow-up (31.8%), other reasons including provider or patient preference (31.5%), patient death (28.3%), clinical indication remains present (5.7%) and unsuccessful retrieval (2.7%). Patients in the failure of retrieval group (n=114) were significantly older (69 vs 61 years, p&amp;lt;0.001) and had a higher frequency of clinical indications for history of VTE with a contraindication to anticoagulation (231 vs 50 patients, p&amp;lt;0.0001) and extensive VTE (49 vs 20 patients, p&amp;lt;0.0001) compared to retrieval group (n=336). There was a nonsignificant trend toward greater frequency of chronic conditions in the failure of retrieval group including cancer history (101 vs 26 patients, p=0.15), heart failure (44 vs 11, p=0.41) and hypercoagulable disease (16 vs 2 patients, p=0.26). Conclusions: Our institution had a lower IVC filter retrieval rate than the estimated average of 34% reported in a systematic review by Angel et al. Patients with comorbid conditions tended to not undergo retrieval, predisposing them to a higher risk of filter-associated complications. A history of VTE with a contraindication to anticoagulation was the most common clinical indication for placement, but the other most common indications are not universally guideline recommended which identified an area of opportunity for multidisciplinary provider education. Patient loss to follow-up is the predominant reason for failure of retrieval at our institution, which is consistent with the healthcare disparity faced by our predominantly rural, Appalachian patient population of travelling long distances to our tertiary center to obtain specialty care. Quality improvement strategies to mitigate this limitation in the context of IVC filter placement through close local follow-up for timely reassessment, retrieval evaluation and removal will be developed.

Survival Outcomes after Placement of Inferior Vena Cava Filters in Cancer Patients: Insights from a Comprehensive Cancer Center’s Experience

Background: Inferior vena cava (IVC) filters serve as a vital intervention when systemic anticoagulation proves ineffective or contraindicated, particularly in the context of cancer patients. This study aimed to provide real-world insights into the outcomes of cancer patients following IVC filter placement. Patients and methods: Cancer patients with IVC filters were retrospectively reviewed. The indications and survival outcomes following IVC filter insertion have been reported. Results: A total of 176 cancer patients with IVC filters were included in the study. The median patient age was 56 years (range: 18–88 years). Solid tumors were the most common primary cancers (n = 125, 71.0%), and the majority (n = 99, 79.2%) had the advanced-stage disease at the time of IVC insertion. The filters were inserted because of contraindications to anticoagulation (n = 99, 56.3%) or the failure of anticoagulation (n = 56, 31.8%). The median survival (range) following filter placement was only 2 (1.45–2.55) months for patients with advanced-stage solid tumors, 5 (0.62–9.38) months for patients with brain tumors, and 44 (8.59–79.41) months for those with early-stage solid tumors, p &lt; 0.001. Conclusions: Our findings suggest that IVC filter placement offers limited benefits to patients with advanced-stage disease. The underlying tumor, stage, and life expectancy are crucial factors in the decision-making process before IVC filter insertion.