Inferior Vena Cava Filter Placement Research Articles

A case of catheter-directed thrombolysis for deep vein thrombosis worsened after inferior vena cava filter placement

A case of catheter-directed thrombolysis for deep vein thrombosis worsened after inferior vena cava filter placement

P845 Deep vein thrombosis, pulmonary embolism and patent foramen ovale: a lethal mix

Abstract A 50-year-old woman without remarkable medical history was admitted at the Emergency Department for acute dyspnoea. The patient had been recently submitted to C5-C6 microdiscectomy. She was tachypneic and oxygen saturation was 88%. CT angiography showed bilateral pulmonary embolism (PE) (Figure 1A, yellow arrowheads) with signs of right ventricle overload. Bilateral deep vein thrombosis was also confirmed. The patient was admitted at the Intensive Care Unit, clinically stable. Few hours later, she presented sudden hemodynamic and respiratory deterioration, requiring invasive mechanical ventilation and vasopressors. Due to recent cervical surgery, systemic fibrinolysis was ruled out. Decision for percutaneous thrombectomy and inferior vena cava filter placement was made. Nevertheless, percutaneous thrombectomy was unsuccessful due to the impossibility to catheterize pulmonary artery. Contrast injection demonstrated that the guiding catheter was located in the left atrium (Figure 1B), suggesting a patent foramen ovale (PFO). Transoesophageal echocardiogram confirmed the presence of a 5x6 mm PFO with right-to-left shunt (Figures 1C – yellow arrows, and 1D). In addition, a 4 cm mobile mass attached to the aortic valve and protruding throughout the left ventricle outflow tract was visualized, suggesting paradoxical embolism (Figure 1E – white arrows). Accordingly, open surgical approach with pulmonary thrombectomy, PFO closure and removal of the left-sided thrombus was decided. Unfortunately, despite careful cannulation, thrombus was not found when aortic valve was inspected. Worst suspicions were confirmed, when the patient presented non-reactive mydriatic pupils. A brain CT showed signs of an extensive bihemisferic ischemic stroke (Figure 1F) presumably related to cerebral embolization of aortic thrombus. The patient finally died. Autopsy study was not consented. PFO has been associated with paradoxical embolisms and risk of stroke in PE. This case strikingly illustrates that treatment of these patients may be challenging in spite of an adequate diagnosis and management. Abstract P845 Figure.

Inferior vena cava filter thrombosis: An overview

The leading long term and undervalued impediment associated with inferior vena cava (IVC) filter placement is said to be increased risk of venous thrombosis within and below the IVC. Anticoagulation remains the mainstay treatment preference for the management of deep-vein thrombosis (DVT) and pulmonary embolism (PE). Now and then, it is not viable due to bleeding complications or, occasionally, breakthrough PE associated with this treatment method. In these patients, the development of vena cava filters was a significant advancement in their management. Patients with IVC filters predominantly the ones placed with permanent filters are considered to be at a greater risk for the development of recurrent DVT. Cautious applications of IVC filters, along with retrieval of temporary IVC filters in good time, significantly diminishe the risk of IVC thrombosis. The proof of connection of IVC thrombosis with each of the following factors is known: Population demographics, history of or preexisting hypercoagulable states/anticoagulation, the manner in which the thrombus is assessed, and the duration since the filter employment. Most cases of IVC filter thrombosis are asymptomatic. Contrast-enhanced computed tomography is a preferred imaging modality compared to Doppler sonography. Here in this article, we attempt to discuss briefly the present ideas concerned with the indications of IVC filters along with the prevalence, risks, and management of IVC filter thrombosis.

Permanent Inferior Vena Cava Filters Offer Greater Expected Patient Utility at Lower Predicted Cost

Retrievable inferior vena cava (IVC) filters were first approved for use in the United States in 2003 to address long-term complications of migration, thrombosis, fracture, and perforation observed with permanent IVC filter implantation. Although approval of retrievable IVC filters includes permanent implantation, the incidence of complications appears to be greater from long-term implantation than from existing permanent IVC filters, and only a small fraction of such retrievable IVC filters are ever retrieved. The purpose of this study was to determine the threshold retrieval rate at which the use of retrievable IVC filters can be justified. A Markov decision tree was constructed comparing retrievable and permanent IVC filters. Review of the literature provided probabilities, and the Tufts Cost-Effectiveness Analysis Registry was the source of the utility values for the various potential outcomes. Medicare reimbursement rates were used as a proxy for costs. Sensitivity analysis was performed for various parameters, primarily to determine the retrieval rate threshold at which use of retrievable IVC filters outperformed permanent IVC filters. Base case analysis demonstrated a greater predicted utility for permanent over retrievable IVC filter implantation (4.68 vs 4.49) at a lower cost ($1080 vs $4160) with a greater net monetary benefit for willingness to pay of $65,000 ($303,000 vs $288,000). Monte Carlo simulation at 10,000 iterations confirmed expected utility (4.65 ± 3.03 vs 4.48 ± 3.02; P < .00001), cost ($1040 ± $4640 vs $4320 ± 8140; P = .00007), and net monetary benefit ($301,000 ± $197,000 vs $287,000 ± $196,000; P < .00001) to be statistically superior. Sensitivity analysis for filter retrieval rate demonstrated that the strategy of use of a retrievable IVC filter is never preferable for any of the three outcomes. The superiority of permanent IVC filter placement for all three outcomes persists regardless of anticipated patient predicted annual mortality. Two-way sensitivity analysis for both IVC filter removal rate and annual mortality confirmed superiority of permanent IVC filter placement at all levels. The predicted utility of permanent over retrievable IVC filters is higher and the predicted cost is lower regardless of rate of ICV filter retrieval. This implies that unless the long-term complication rate of retrievable IVC filters can be significantly improved, regardless of retrieval rate, their use should be abandoned in favor of currently available permanent IVC filters.

In-hospital outcomes of catheter-directed thrombolysis versus anticoagulation in cancer patients with proximal deep venous thrombosis

ObjectiveThe objective of this study was to determine the rate of complications of catheter-directed thrombolysis (CDT) in cancer patients with deep venous thrombosis (DVT) compared with anticoagulation therapy alone. MethodsThis observational study used the National Inpatient Sample database to screen for any cancer patients who were admitted with a principal discharge diagnosis of proximal lower extremity or caval DVT between January 2005 and December 2013. Patients treated with CDT plus anticoagulation were compared with those treated with anticoagulation alone using propensity score matching for comorbidities and demographic characteristics. The primary end point was in-hospital mortality. Secondary end points were acute intracranial hemorrhage, inferior vena cava filter placement, acute renal failure, blood transfusion rates, length of stay, and hospital charges. ResultsWe identified 31,124 cancer patients with lower extremity proximal or caval DVT, and 1290 (4%) patients were treated with CDT. Comparative outcomes as assessed in the two matched groups of 1297 patients showed that there was no significant difference in in-hospital mortality of patients undergoing CDT plus anticoagulation compared with those treated with anticoagulation alone (2.6% vs 1.9%; P = .23). However, CDT was associated with increased risk of intracranial hemorrhage (1.3% vs 0.4%; P = .017), greater blood transfusion rates (18.6% vs 13.1 %; P < .001), and higher rates of procedure-related hematoma (2.4% vs 0.4%; P < .001). The length of stay (6.0 [4.0-10.0] days vs 4.0 [2.0-7.0] days; P < .001) and hospital charges ($81,535 [$50,968-$127,045] vs $22,320 [$11,482-$41,005]; P < .001) were also higher in the CDT group compared with the control group. ConclusionsThere was no significant difference in in-hospital mortality of cancer patients who underwent CDT plus anticoagulation compared with anticoagulation alone. CDT was associated with increased in-hospital morbidity and resource utilization compared with anticoagulation alone. Further studies are needed to examine the effect of CDT on the development of PTS in this population.

Impact of ligation versus repair of isolated popliteal vein injuries on in-hospital outcomes in trauma patients

BackgroundPopliteal vascular injuries are common and frequently associated with limb loss. Although many studies have evaluated the treatment and outcomes of popliteal artery injuries (PAI), there is little available evidence regarding popliteal venous injuries (PVI). As such, substantial debate remains regarding the benefit of repair over ligation of PVI. The objectives of this study were to compare in-hospital outcomes of repair versus ligation of isolated PVI, as well as to determine nonvascular factors associated with worse outcomes. MethodsPatients in the National Trauma Databank from 2007 to 2014 with at least one PVI were evaluated. First, patients with concomitant PVI and PAI were compared with patients with isolated PVI. Second, outcomes were compared between ligation and repair of isolated PVI. To limit the impact of concomitant injuries and focus on the impact of venous injury management, we defined isolated PVI as cases without concomitant PAI and with Abbreviated Injury Scale severity score of less than 3 for all body regions other than lower extremity. Patients dead on arrival and those with less than 18 years of age were excluded. The primary outcomes were in-hospital mortality, amputation, and in-hospital amputation-free survival (AFS). Secondary outcomes included lower extremity compartment syndrome, fasciotomy, acute kidney injury, pulmonary embolism, deep venous thrombosis, and inferior vena cava filter placement. ResultsOverall, 1819 patients (0.03%) had a PVI and after exclusion 1213 met the criteria for initial analysis. Of those, 308 had isolated PVI, and 905 had combined PVI and PAI. Patients with combined PVI and PAI had higher rates of amputation (15.2% vs 6.8%; P < .001), fasciotomy (64.5% vs 30.8%; P < .001), compartment syndrome (14.8% vs 8.8%; P = .006), and a lower AFS (82.9% vs 91.8%; P < .001) than patients with isolated PVI. There was no difference in in-hospital mortality, amputation, or in-hospital AFS between ligation and repair of isolated PVI. On multivariable logistic regression of isolated PVI, ligation was not independently associated with in-hospital AFS, amputation, or mortality. ConclusionsLigation of isolated PVI was not an independent predictor of in-hospital mortality, lower extremity amputation, or in-hospital AFS. Ligation also did not result in higher rates of fasciotomy, acute kidney injury, or pulmonary embolism.

Outcomes and Prognosis Factors in Patients With Vena Cava Filters in a Quaternary Medical Center: A 5-Year Retrospective Analysis.

Indications for inferior vena cava filter (IVCF) placement are controversial. This study assesses the proportion of different indications for IVCF placement and the associated 30-day event rates and predictors for all-cause mortality, deep vein thrombosis (DVT), pulmonary embolism, and bleeding after IVCF placement. In this 5-year retrospective cohort observational study in a quaternary care center, consecutive patients with IVCF placement were identified through cross-matching of 3 database sets and classified into 3 indication groups defined as "standard" in patients with venous thromboembolism (VTE) and contraindication to anticoagulants, "extended" in patients with VTE but no contraindication to anticoagulants, and "prophylactic" in patients without VTE. We identified 1248 IVCF placements, that is, 238 (19.1%) IVCF placements for standard indications, 583 (46.7%) IVCF placements for extended indications, and 427 (34.2%) IVCF placements for prophylactic indications. Deep vein thrombosis rates [95% confidence interval] were higher in the extended (8.06% [5.98-10.58]) and prophylactic (7.73% [5.38-10.68]) groups than in the standard group (3.36% [1.46-6.52]). Mortality rates were higher in the standard group (12.18% [8.31-17.03]) than in the extended group (7.55% [5.54-9.99]) and the prophylactic (5.85% [3.82-8.52]) group. Bleeding rates were higher in the standard group (4.62% [2.33-8.12]) than in the prophylactic group (2.11% [0.97-3.96]). Best predictors for VTE were acute medical conditions; best predictors for mortality were age, acute medical conditions, cancer, and Medicare health insurance. Prophylactic and extended indications account for the majority of IVCF placements. The standard indication is associated with the lowest VTE rate that may be explained by the competing risk of mortality higher in this group and related to the underlying medical conditions and bleeding risk. In the prophylactic group (no VTE at baseline), the exceedingly high DVT rate may be related to the IVCF placement.

Characteristics of Inferior Vena Cava Filter Placement, Management, and Retrieval at a Multi-Center Institution

Background: Retrievable inferior vena cava filters (IVCF) were developed to address the adverse events associated with permanent IVCF. However, this benefit cannot be fully appreciated if filters are not removed in a timely manner and when appropriate. Although there are clinical scenarios when permanent placement is desired, studies show that these situations are far outweighed by scenarios of medically inappropriate non-retrieval. There is substantial evidence describing adverse events related to IVCF such as filter thrombosis, DVT, fracture, perforation, and migration. Furthermore, evidence supporting the benefit of IVCF to prevent the development or progression of pulmonary embolism remains controversial. Therefore, indications for IVCF placement are not standardized at most centers. Specialty societies, such as radiology and cardiology, have differing recommendations for filter placement. IVCF placement is not uncommon (of 130,643 patients hospitalized at 263 hospitals with acute venous thromboembolism [VTE], 15% had IVCF placed) and retrieval rates of non-permanent filters remain low (18-41%). Methods: This study assesses IVCF indications, removal rate, complications, and practice patterns at a multi-center institution via retrospective chart review. Procedure codes and associated diagnosis codes were used to identify 626 adult patients who had IVCF placed over a span of 5 years by either interventional radiology, vascular surgery, or interventional cardiology. Of note, patients were excluded from analysis if they had a documented death within 60 days of filter placement. Descriptive statistics, chi-squared tests, and Wilcoxon rank-sum tests were used for statistical analysis. All IVCF evaluated were retrievable filters. Results: Most IVCF were placed by interventional radiology (77%) as expected. Retrieval rate was 27%. No significant difference was found in retrieval rates among the procedural specialties. Also, retrieval rate was not significantly different between specialty groups that followed the patient after filter placement, including radiology, vascular surgery, or hematology (p value: 0.5382). Overall, 58% of IVCF were unmanaged after placement and, as expected, this was associated with a higher rate of non-retrieval (p value: 0.0001). There was no significant difference in retrieval rate among inpatient or outpatient procedures (p value: 0.2067). Patients in the retrieval group had a lower Charlson Comorbidity Index score than those in the non-retrieval group (p value: 0.0001). The most common indications for placement were acute VTE with contraindication to anticoagulation (40%) and anticoagulation failure (21%). The most common filter complication was filter thrombus (2%). Primary care providers were the most common ordering provider group that requested filter placement (51% of filter placement requests). Interestingly, patients with Medicare/Medicaid had a lower rate of retrieval than patients with any other coverage, including no coverage (20% versus 35%, p value &lt;0.0001). Recurrent VTE occurred in 44 patients (not including filter thrombus) and 9 of those events occurred after filter removal. 62% of patients received anticoagulation therapy during or after filter placement. Conclusion: Lack of follow-up and filter non-removal continues to remain a problem since the emergence and use of IVCF. Surprisingly, our study didn't show that retrieval rates were different based on inpatient or outpatient status, or by follow-up specialty. We did not expect to find that retrieval rates would be lowest in patients with Medicare/Medicaid, or that the most frequently ordering provider group would be primary care providers (over pulmonologists or hematologists, for example). Even after excluding patient deaths within 60 days of filter placement, we still found retrieval rates to be low. As a retrospective study, we can only show association and there may be unique characteristics of our centers that affect external validity. Also, in some clinical scenarios permanent filter placement may be indicated. Regardless, this analysis challenges assumptions regarding the factors involved with filter placement and persistently low rates of retrieval. It also proposes new targetable areas for collaboration and improvement. Disclosures No relevant conflicts of interest to declare.

Inferior Vena Cava Filter Retrieval Trends: A Single Center Experience

Background: Inferior vena cava (IVC) filters are indicated in patients with deep vein thrombosis (DVT) or pulmonary embolism (PE) who either have contraindications to or have failed anticoagulation (AC). Given rising concerns about their safety and efficacy, the FDA has issued a communication urging clinicians to remove filters (optimally, within 90 days post-implantation). According to national data retrieval rates remain low. Our study aimed to assess IVC filter retrieval rates and factors that influence retrieval. Methods: This is a single center, retrospective cohort study of patients who had IVC filter placement between December 2015 and December 2018. Subjects were identified using procedural codes for IVC filter insertion; data regarding demographics, comorbidities, retrieval, IVC filter-related complications and subsequent thromboembolic events were obtained by direct chart review. Survival analyses and a Cox regression model were performed using JMP statistical software. Results: Over 3 years, 494 patients with IVC filters were identified; 305 (62%) were retrievable. The average age at placement was 69±16 years; 249 (50%) were men and 332 (67%) were Caucasian. After excluding patients who died or were lost to follow-up within 30 days of placement or were discharged to hospice from the index admission, 258 patients with retrievable filters remained (54 retrieved). Indications for IVC filter placement were PE ± DVT 90 (35%), proximal DVT 159 (62%) and prophylactic 9 (3%). Forty two percent of patients (109) were restarted on AC at discharge, while an additional 18% (total 155) received AC at some point thereafter. The rate of retrieval was 8% at 90 days, 23% at 1 year and 28% at 2 years (Figure A). The proportional hazards model identified resumption of AC at any time (HR 3.11, 95%CI 1.6-6.8, p=0.0006) as the strongest predictor of retrieval; AC at discharge was not predictive. Advanced age at placement (HR 0.97 per unit change, 0.96-0.99, p=0.004) and active malignancy (HR 0.5, 95%CI 0.24-0.98, p=0.04) were associated with a lower likelihood of retrieval. The initial thrombotic event, the reversibility of the contraindication to AC, the placing service, sex, ethnicity and other comorbid conditions did not have an impact on retrieval. Kaplan-Meier analysis revealed that subjects who ever resumed AC had significantly higher rates of retrieval at 90 days (11% vs 3.4%) and at 1 year (33% vs 9.7%, log-rank p=0.0003, Figure B) when compared to those who did not. Only four patients experienced IVC filter-related complications (2 filter thrombosis, 1 IVC penetration, 1 device tilting); all occurred 2 or more years after placement. Recurrent thromboembolic events occurred in 50 patients (5 PE, 48 proximal DVT) with no significant difference in frequency between subjects with retrieved and non-retrieved filters; one PE and one DVT occurred at 1 month and 1 week respectively after retrieval. Conclusion: Despite efforts to increase awareness of IVC filter-associated complications, the unweighted retrieval rate remained below the nationally reported average of 30%. Persistent risk factors for thrombosis such as active malignancy or increasing age and poor prognosis may play a role in the decision to defer retrieval. In our study, resumption of AC proved a powerful predictor of retrieval, with rates approaching expected values in this population. Active surveillance for resolution of contraindications to AC post-IVC filter placement is crucial in increasing retrieval rates. Figure Disclosures No relevant conflicts of interest to declare.

Medical Management of Retained Inferior Vena Cava Filters

Background Venous thromboembolism (VTE) is a common and often fatal medical event. VTE management often includes inferior vena cava filter (IVCF) placement when anticoagulation fails or is contraindicated. Controversial indications for IVCF placement include adjunctive treatment for deep vein thrombosis (DVT) without pulmonary embolism (PE) and VTE prophylaxis for high-risk patients (Deyoung and Minocha, 2016; Ho et al., 2019). Numerous device-associated mechanical and medical complications have been described (Ayad et al., 2019) and guidelines recommend early retrieval (Morales et al., 2013). There is limited evidence, however, to guide anticoagulation practices while IVCFs are retained. We aimed to characterize IVCF placement, retrieval, and interim medical management at our institution. Methods Retrospective chart review was performed for all patients who underwent IVCF placement at the University of Virginia Medical Center from January to December 2016. Data were collected from time of IVCF placement until either IVCF removal or 18 months post-placement, whichever occurred first. Indication for IVCF placement, baseline patient characteristics, IVCF complications, anticoagulation regimens, and bleeding and clotting events were identified. Baseline characteristics were recorded for all patients. Patients who did not survive the admission during which the IVCF was placed, underwent IVCF removal prior to discharge, or lacked adequate outpatient records during the period of IVCF retention were excluded from the event analysis cohort. Results IVCFs were placed in 140 patients during the study period (Table 1). A majority of patients were admitted to a surgical service, frequently following trauma (49 patients, 35%). IVCFs were placed for several indications, most commonly diagnosed VTE with a contraindication to anticoagulation (70 patients, 50%) and prophylaxis for high risk of VTE (44 patients, 31%). By the end of the study period, 88 patients (63%) had confirmed IVCF removal while 35 patients (25%) retained the IVCF for a clinical consideration. 33 patients (24%) lacking an adequately documented period of outpatient IVCF retention were excluded from the event analysis. Of the 107 patients included in the event analysis cohort, 76 patients (71%) underwent IVCF removal. Removal occurred &gt;60 days after placement in 82% of these cases and median time to removal was 95 days (Table 2). Outpatient follow up and anticoagulation management varied widely, though 75 patients (70%) received a therapeutic dose anticoagulant during the period of IVCF retention and only 15 patients (14%) were not exposed to either a prophylactic or therapeutic dose anticoagulant. 50 patients (47%) had at least one regimen change. Bleeding and/or clotting events occurred for 15 patients (14%, Table 3). All 8 bleeding events occurred during anticoagulant exposure. Patients were exposed to a therapeutic dose anticoagulant during 4 of the 6 observed major or clinically relevant non-major bleeding events. Of the 12 observed clotting events, 8 occurred in the absence of anticoagulation. Isolated DVT was the most common clotting event (8 events in 7 patients, 7%) and IVCF thrombus was observed in 2 patients (2%). Bleeding and clotting events were observed in patients with a wide range of indications for IVCF placement, including patients whose IVCFs were placed prophylactically. Conclusions The optimal medical management of retained IVCFs is uncertain. This retrospective study characterizes IVCF placement, removal, and interim medical management for a diverse patient population at a single institution. Outpatient follow up varied widely and anticoagulant exposure during IVCF retention was inconsistent. Despite considerable anticoagulant exposure across the cohort, major bleeding events were infrequent. Thrombotic events, often in the absence of anticoagulation and potentially preventable, were more common. Standardization of medical management during IVCF retention would likely benefit this heterogeneous patient population at high risk of both bleeding and thrombotic complications. Ongoing statistical modeling for the study cohort will seek to inform anticoagulant decision making by assessing for associations between anticoagulant exposure and these clinical events. Disclosures No relevant conflicts of interest to declare.

Predicting the Safety and Effectiveness of Inferior Vena Cava Filters Study: Design of a unique safety and effectiveness study of inferior vena cava filters in clinical practice

BackgroundDeath from venous thromboembolism remains a significant cause of death worldwide. Although anticoagulation is the cornerstone of treatment in patients at risk for venous thromboembolism, inferior vena cava (IVC) filter use has increased exponentially over the last decade driven predominantly by the prophylactic use in patients at risk for venous thromboembolism despite limited evidence supporting this practice. The Predicting the Safety and Effectiveness of Inferior Vena Cava Filters (PRESERVE) Study is being implemented by the Society for Vascular Surgery, Society of Interventional Radiology, U.S. Food and Drug Administration, and several IVC filter manufactures to better understand the safety, effectiveness, and current patterns of real-world use of IVC filters. MethodsThe PRESERVE Study includes IVC filters from seven manufacturers: ALN (ALN ± hook), Argon (Option Elite), B. Braun (LP, Vena Tech Convertible), CR Bard (Denali), Cook (Gunther Tulip), Cordis (OptEase, TrapEase), and Philips Volcano (Crux). The indications for filter placement, filter brand, complications, stability, frequency and success of retrieval, and clinical effectiveness of each filter will be recorded. Approximately 2100 patients (300 for each filter brand included in the study) are intended to be enrolled at 60 U.S. centers. ResultsMen and women age 18 years or older requiring IVC filters for prevention of venous thromboembolism will be included in the study if no contrast allergy is present and they are willing to commit to the prescribed study follow-up. Participants will be evaluated at discharge, 3, 6, 12, 18, and 24 months after filter placement and/or 1 month after retrieval, which ever occurs first. Intravascular ultrasound examination or venography will be done before and after IVC filter placement, with abdominal plain film at 3 months, and contrast enhanced computed tomography scans at 12 and 24 months to evaluate filter stability. The primary safety end point is a composite of clinical end points, including freedom from perforation, embolization, thrombosis, recurrent DVT, and defined serious adverse events. Secondary end points include mechanical stability and procedure related complications at 3 months, major adverse events at 6, 12, 18, and 24 months, and filter tilt of more than 15° at any point. ConclusionsThe PRESERVE Study represents the largest prospective study ever undertaken to investigate real-world outcomes with contemporary use of IVC filters. The investigators await results with the hope that it can improve patient care.

A RARE INSTANCE OF AN INFERIOR VENA CAVA FILTER FAILING TO PREVENT RECURRENT PULMONARY EMBOLISM

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is the third most frequent cause of cardiovascular disease [1]. PE is the most fatal clinical presentation of VTE with 1 month mortality between 9-11% and 3 month mortality up to 17% [2]. Anticoagulation by far remains the mainstay treatment for PE, however inferior vena cava (IVC) filters are placed to prevent recurrent PE in patients who have contraindications to anticoagulation. We hereby report an uncommon case of recurrent PE after placement of an IVC filter. CASE PRESENTATION: A 67 year old male with a past medical history of hyperlipidemia and family history of thrombotic events presented with reports of shortness of breath and left sided chest pain associated with cough and blood tinged sputum. On initial evaluation, he was tachypneic, tachycardic, and hypoxemic to 91% on room air. Computed tomography angiogram (CTA) demonstrated PE in the left lower lobe sub-segmental branches of the pulmonary artery (Image 1). Doppler studies of bilateral lower extremities demonstrated a DVT in the left peroneal vein. He was promptly started on a heparin drip and transferred to the intensive care unit (ICU). Due to continued hemoptysis, the decision was made to place an IVC filter and hold anticoagulation. However, three days after the placement of the IVC filter, he had worsening hypoxemia with new right sided chest pain. He underwent repeat CTA of the chest which revealed new PE involving the right main pulmonary artery (Image 2). He also got dopplers of bilateral upper and lower extremities which showed a new DVT in left posterior tibial vein along with DVT in left peroneal vein. He was again restarted on a heparin drip with close monitoring for hemoptysis, stabilized and discharged on oral anticoagulation in following weeks. DISCUSSION: Routine use of IVC filters in patients with PE is not recommended unless anticoagulation is contraindicated or there is recurrent PE while on adequate therapy for a DVT. Small thrombi can pass through filters or through collaterals around obstructed filters and lead to recurrent PE. However, data suggest that recurrent PE is unusual following filter insertion. One systematic review of retrievable IVC filters estimated an incidence of PE following filter placement of 1.3 % [3]. Though IVC filters are very efficient in preventing PE, our case represents one of those rare occurrences when IVC filters failed to prevent recurrent PE. In such cases, anticoagulation should be restarted as soon as possible after weighing risks and benefits. CONCLUSIONS: In high risk patients where anticoagulation is contraindicated, IVC filter placement remains an alternative to prevent PE. However, there remains a small risk of recurrent PE despite placement of IVC filters as evident by a small number of systematic reviews. Reference #1: Raskob GE, Angchaisukiri P, Blanco AN, et al. Thrombosis: a major contributor to global disease burden. Arterioscler Thromb Vasc Biol. 2014:34(11):2363-2371. [PubMed: 25304324] Reference #2: Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the international cooperative Pulmonary Embolism Registry (ICOPER). Lancet. 1999:353(9162):1386-1389. [PubMed: 10227218 Reference #3: Angel LF, Tapson V, Galgon RE, et al. Systematic review of the use of retrievable inferior vena cava filters. J Vasc Interv Radiol 2011; 22:1522 DISCLOSURES: No relevant relationships by John Mikhail, source=Web Response No relevant relationships by Mohammed Shariff, source=Web Response No relevant relationships by Vandan Upadhyaya, source=Web Response

Clinical outcomes of inferior vena cava filter in complicated pulmonary embolism.

Background: Previous observational studies suggest that inferior vena cava filter placement in pulmonary embolism patients complicated with congestive heart failure, mechanical ventilation, and shock may have a mortality benefit. We sought to analyze the survival benefits of inferior vena cava filter in pulmonary embolism patients complicated with acute myocardial infarction, acute respiratory failure, shock, or requiring treatment with thrombolytics. Methods: This retrospective observational study used hospital discharge data from the National Inpatient Sample Data (NIS). ICD-9-CM coding was used to identify complicated pulmonary embolism patients (N = 254,465) in NIS from 2002 to 2014, including the subgroups of acute myocardial infarction, acute respiratory failure, shock, and thrombolytics. Inferior vena cava filter recipients were 1:1 propensity score-matched on age, sex, race, deep vein thrombosis, Elixhauser comorbidities, and other pulmonary embolism comorbidities (45 covariates) to non-inferior vena cava filter recipients in complicated pulmonary embolism patients and separately in each subgroup. Clinical outcomes were compared between the inferior vena cava filter group and the non-inferior vena cava filter group. Results: Mortality rate in complicated pulmonary embolism patients with inferior vena cava filter placement was lower (20.9% vs. 33%; NNT = 8.28, 95% confidence interval (CI) 7.91-8.69, E-value = 2.53) and in the subgroups; acute myocardial infarction (17.9% vs. 30.1%; NNT = 8.19, 95% CI 7.52-8.92, E-value = 2.76), acute respiratory failure (19.5% vs. 29.7%; NNT = 9.76, 95% CI 8.67-11.16, E-value = 2.38), shock (30.7% vs. 47.1%; NNT = 6.08, 95% CI 5.73-6.47, E-value = 2.43), and with the use of thrombolytics (7% vs. 12.9 %; NNT 17.1, 95% CI 14.88-20.12, E-value = 3.01) (p < 0.001 for all). Conclusion: Inferior vena cava filter placement in pulmonary embolism complicated with acute myocardial infarction, acute respiratory failure, shock, or requiring thrombolytic therapy was associated with reduced mortality.

1859 Paperclip or Inferior Vena Cava Filter Probe? The Case of an Unusual Foreign Body

INTRODUCTION: Inferior vena cava (IVC) filters are mechanical devices used to prevent pulmonary embolism, often used in patients with recurrent venous thromboembolism while on anticoagulation, or who have a contraindication to anticoagulation. Despite its increasing popularity over the last two decades, they do not come without complications such as migration of the filter or its parts, perforation or protrusion into surrounding structures such as the small or large bowel, vasculature, diaphragm, or the retroperitoneal space. We herein present a case of duodenal perforation caused by a migrating IVC filter, of which there have only been a few reported cases. CASE DESCRIPTION/METHODS: The patient is a 61-year-old female with HTN, GERD, iron-deficiency anemia, and a history of DVT while on anticoagulation (s/p IVC filter placement in October 2011) who initially presented with complaints of dizziness. Her workup revealed a new anemia with no overt GI bleeding for which she underwent endoscopic evaluation. She was found to have a thin piece of metal in the second portion of her duodenum, thought to be a swallowed foreign body, possibly a paperclip, which was later denied by the patient. Several attempts at retrieval were unsuccessful. One week later, she developed sudden-onset, severe, epigastric pain with guarding. She presented to our emergency department where a CT abdomen/pelvis with contrast revealed an infrarenal IVC filter with protrusion of a prong through the lateral wall of the IVC into the duodenum, as well as protrusion of a prong through the posterior wall of the IVC into the superior aspect of the right iliopsoas muscle. Given the pain, she was ultimately taken for successful percutaneous removal via the right internal jugular vein by Vascular Surgery with endoscopic assistance by Gastroenterology. There was no involvement of the ampulla and the duodenum maintained insufflation following removal. DISCUSSION: With the advent of contemporary IVC filters, the migration rates are less than 1%. However, because of new prong hooks to prevent migration, they can lead to perforation of surrounding structures. Retrievable filters have been found to have higher rates of perforation than the permanent form, particularly when the retrievable filters are left in place longer than anticipated. As seen in this case, the importance of IVC filters are paramount to prevent pulmonary embolism, but in a patient with sudden onset abdominal pain, one must rule out IVC filter perforation into surrounding structures.

The role of an IVC filter retrieval clinic-A single center retrospective analysis.

Background:Inferior vena cava (IVC) filter placement still plays an essential role in preventing pulmonary embolism (PE) in patients with contraindications to anticoagulant therapy. However, IVC filter placement does have long-term risks which may be mitigated by retrieving them as soon as clinically acceptable. A dedicated IVC filter clinic provides a potential means of assuring adequate follow-up and retrieval.Aim:To assess the efficacy of our Inferior vena cava (IVC) filter retrieval clinic at improving the rate of patient follow-up, effective filter management, and retrieval rates.Materials and Methods:During the period of August 2017 through July 2018, 70 IVC filters were placed at our institution, and these patients were automatically enrolled into our IVC filter retrieval clinic for quarterly follow-up. We retrospectively reviewed data including appropriateness for removal at 3 months, overall retrieval rates, removal technique(s) employed, and technical success.Results:62.9% of the potentially retrievable filters were removed during the study period. The technical success of extraction, using a combination of standard and advanced techniques, was 91.7%. Overall, 15% of the patients were lost to follow-up.Conclusion:Our findings add to the growing body of literature to support the need for a robust IVC filter retrieval clinic to ensure adequate follow-up and timely retrieval of IVC filters.

2562 Duodenal Perforation From an Inferior Vena Cava Filter as a Rare Cause of Persistent Abdominal Pain

INTRODUCTION: Deep vein thrombosis (DVT) continues to be a significant source of morbidity for surgical patients. Inferior vena cava (IVC) filter placement is indicated for DVT in patients who have contraindications to anticoagulation or failure of anticoagulation. Over the last decade, there is exponential increase of IVC filter placement with increased complications reported. These include IVC penetration, IVC occlusion, insertion complication and filter migration. We report a rare case of symptomatic duodenal perforation by an IVC filter migration. CASE DESCRIPTION/METHODS: A 33-year-old female with a history of paraplegia secondary to motor vehicle accident, recurrent DVTs, and placement of IVC filter 10 years ago presented to the hospital for persistent epigastric pain for the past 5 years. Patient denied any nausea, vomiting, diarrhea, or hematochezia. Physical exam showed epigastric tenderness. Labs including complete blood count were unremarkable. CT scan showed a longstanding IVC occlusion with collaterals and displaced IVC filter into the duodenum and into the L3 vertebral body (Figure 1). An EGD confirmed prong migration to the second portion of the duodenum (Figure 2). This was distal to the ampulla and penetrating the duodenal wall with the tip embedding the opposite wall. Due to multiple workups being otherwise negative and symptomatic duodenal perforation of the IVC filter, she has been scheduled for an open IVC filter extraction with duodenal and caval repair. DISCUSSION: Duodenal and aortic perforations by IVC filters have been increasingly reported in the past 10 years although still rare. Penetration of the filter struts through the wall of the IVC can be asymptomatic. However symptomatic patients may present with epigastric pain, gastrointestinal bleeding and small bowel obstruction. Currently, there are no guidelines for the management of such patients. Most cases have been repaired using an open repair with excellent outcomes; however, endovascular retrieval and repair is being recognized as an alternative option especially in high risk patients. This case illustrates that even though IVC migration and perforation is a rare complication, it needs to be recognized as a potential cause for gastrointestinal symptoms in these patients. Retrievable IVC filters should always be removed if possible when deemed unnecessary to prevent complications such as migration from developing.

2566 Essential Thrombocythemia and AVM-Related Gastrointestinal Bleeding: A Rare Paradoxical Phenomenon

INTRODUCTION: Essential thrombocythemia (ET) is a myeloproliferative neoplasm characterized by excessive platelet production. It usually presents with thrombotic events. However, rarely, essential thrombocythemia may present with gastrointestinal (GI) bleeding. This phenomenon is seen paradoxically at very high platelet counts. We present a case of GI bleeding secondary to arteriovenous malformation (AVM) in a patient with platelet counts &gt;1 million/uL. CASE DESCRIPTION/METHODS: A 74 year old male with history of hypertension, myeloproliferative disease, on hydroxyurea therapy, complicated by deep vein thrombosis requiring inferior vena cava filter placement, ischemic stroke, was admitted to inpatient rehabilitation after suffering from acute ischemic stroke 2 weeks ago. The patient was started on clopidogrel for acute stroke. He was found to have melena and gradual drop in hemoglobin (11.5 g/dL down to 6.5 g/dL). Complete blood count showed progressive rise in his platelet count (from 937 k/uL to 2.4 million/uL). Upper endoscopy revealed one small AVM in the fourth portion of the duodenum, treated successfully with hemostatic spray. Clopidogrel was switched to aspirin and hydroxyurea dose was increased for cytoreductive therapy as suggested by hematology. Subsequent colonoscopy revealed two non-bleeding AVMs in the cecum, treated with argon plasma coagulation (APC). DISCUSSION: ET is known to increase the risk of thrombotic events, including cardiovascular events, deep vein thrombosis, pulmonary embolism, retinal artery occlusion, digit ischemia and hepatic or portal vein thrombosis. However, ET also increases the risk for bleeding paradoxically with incidence rates ranging from 5-30 percent at the time of diagnosis. In GI tract, the bleeding is mostly from AVMs in ET. This phenomenon has been associated with qualitative defects and alteration in the platelets aggregation due to depletion of high-molecular weight von Willebrand factor multimers and development of an acquired von Willebrand disease. Interestingly, incidence of bleeding in ET correlates with the severity of thrombocytosis, mostly seen with extreme thrombocytosis (platelet counts &gt;1 million/microL) [2-3]. Previous bleeding episode and use of antiplatelet drugs may further increases the risk of bleeding. Hydroxyurea is used for cytoreduction with platelet apheresis reserved for extreme cases where platelets exceed 1.5 Million/μl.

IMPACT OF PULMONARY EMBOLISM RESPONSE TEAM ON PATIENT OUTCOMES INCLUDING 30-DAY READMISSION RATES

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM PURPOSE: The rationale for Pulmonary Embolism Response Teams (PERT) is to optimize care for patients at high risk of mortality from acute Pulmonary Embolism (PE), by providing real-time, multidisciplinary consultation. We hypothesized that a PERT-based approach would optimize PE management and decrease readmission rates. METHODS: We performed a retrospective analysis of all 54 consecutive PERT activations over 2018 from two urban tertiary academic hospitals, to determine impact of PERT-guided therapy. We analyzed patient characteristics, and focused on significant outcomes including: in-hospital mortality, major bleeding as defined by the International Society of Thrombosis and Hemostasis (2015), 30-day readmission and clinic follow up. RESULTS: Median age was 64 years. 52% were women. There were 6 in-hospital deaths (11%), all of which were High Risk (HR) based on European Society of Cardiology classification. Cause of death was PE (n=4, 7%), major bleeding (n=1, 2%) and pneumonia (n=1, 2%). Major bleeding occurred in 4 (7%) patients, which was fatal in 1 (2%). Two patients on systemic anticoagulation (AC) alone and one post-catheter directed thrombolysis (CDT) developed major bleeding, necessitating inferior vena cava (IVC) filter placement. 47 (87%) patients were discharged and 6 (12%) were re-admitted within 30-days: 1 patient expired from massive PE and one suffered anticoagulation related gastrointestinal bleed. Four (8%) Non-PE related readmissions included one each for pneumonia, urinary tract infection, seizure, and bowel obstruction. One (11%) patient who had undergone CDT was readmitted within 30-days. 33 (70%) patients were seen within a month at either Internal Medicine or Pulmonary Clinics and 2 (4%) patients were discharged to hospice. CONCLUSIONS: Our data demonstrates comparable outcomes of PERT managed acute PE patients, compared to data from other PERT centers, with minimal PE-related mortality, major bleeding, and low rate of recurrent PE and re-admissions. CLINICAL IMPLICATIONS: Longer term follow up is needed to evaluate cardiac function and possible development of chronic thromboembolic pulmonary hypertension (CTEPH), bleeding risk from extended anticoagulation, and ensure appropriate IVC filter retrieval. DISCLOSURES: No relevant relationships by Madeline Ehrlich, source=Web Response No relevant relationships by Jason Filopei, source=Web Response No relevant relationships by James Salonia, source=Web Response No relevant relationships by Janet Shapiro, source=Web Response No relevant relationships by Adil Shujaat, source=Web Response No relevant relationships by Avinash Singh, source=Web Response No relevant relationships by David Steiger, source=Web Response No relevant relationships by Sean Zajac, source=Web Response

2029 Perforated IVC Filter Leading to Duodenocaval Fistula and Massive Gastrointestinal Bleeding

INTRODUCTION: Inferior Vena Cava (IVC) filters are primarily indicated for patients with a history of deep venous thrombosis (DVT) or pulmonary embolism (PE) who have contraindications to anticoagulation. In most patients, the indication for placement of a filter is temporary. Although filter penetration of the IVC wall has been reported to range from 9% to 24% for all IVC filters, symptomatic perforation is rare and is reported to occur in about 0.4%-0.8% of cases. We are presenting a rare case of duodenocaval fistula presenting as massive gastrointestinal bleeding. CASE DESCRIPTION/METHODS: A 39-year-old male with a history of motor vehicle accident 10 years ago resulting in paraplegia and multiple lower extremity DVTs which required the placement of an IVC filter at that time was admitted to the hospital with one day of nausea, vomiting and hematochezia. History was very concerning for high volume bright red bleeding per rectum with associated non-bilious vomiting and dizziness. On arrival, he was hypotensive with a blood pressure of 60/40 mmHg, physical examination significant for actively oozing bright red blood per rectum. Labwork was remarkable for a Hemoglobin of 7.0 mg/dL and a BUN of 35 mg/dL. A CT scan of abdomen/pelvis with contrast revealed an IVC filter strut travelling through the IVC wall and perforating to the adjacent small bowel with active extravasation of the IV contrast to the small bowel, suggestive of a fistulous communication between IVC and a perforated loop of bowel. The patient was emergently taken to the operating room for exploratory laparotomy. IVC filter strut was found to be eroding through the IVC and into the duodenum confirming the CT findings. Transverse venotomy was performed and the filter was removed. An area of small bowel serosal tear was incorporated into the enterectomy segment, and end to end small bowel anastomosis was performed. IVC was repaired, and hemostasis was secured. Post-operatively, patient stayed stable clinically and hemodynamically with cessation of hematochezia. DISCUSSION: Duodenocaval fistula is a very rare complication of IVC filter placement, with around 10 reported cases in the literature. Even though it is rare, our case highlights the importance of a thorough and timely sensitive workup for an unstable patient with gastrointestinal bleeding and history of an IVC filter placement to rule out IVC penetration into surrounding viscera, since this can lead to significant morbidity and mortality if not recognized early during the clinical course.

2660 Duodenal Perforation Caused by Inferior Vena Cava Migration

INTRODUCTION: The Inferior Vena Cava filter is known as an effective method for preventing pulmonary thromboembolism in patients with deep vein thrombosis. Usually, the remaining IVC filters are asymptomatic and do not cause clinical problems. We report two cases of duodenal perforation caused by a remaining IVC filter which is very rare. CASE DESCRIPTION/METHODS: Case 1: 67 year old female patient with past medical history of heartburn,IVC filter placement presented at the GI outpatient clinic with complains of abdominal pain and heartburn for 6 months.After initial negative work up, Upper Endoscopy done showed small polyp at the metallic clip adjacent to the ampulla.Endoscopic ultrasound subsequently revealed a metal object traversing the duodenal wall. No biopsies or additional manipulation of the metal object were done until we did a CT scan which showed two distal anterior legs of the IVC filter extending into the transverse duodenum.This patient was referred to vascular surgeon for IVC filter removal but the patient's symptoms started resolving and after discussion with the patient it was decided not to proceed with the surgery and manage her conservatively. CASE 2: 37 y/o female seen in GI clinic for repeated episodes of nausea, vomiting, and abdominal discomfort which had been going on for 4 months and after negative initial work up, patient was scheduled for an Upper endoscopy which showed a metal like foreign body in the second portion of the duodenum and irritation of the opposite wall of the second portion of the duodenum with nodularity and represented a prong of the IVC filter which migrated into duodenum.Patient was referred to vascular surgeon for IVC filter removal and after the procedure post operatively she was kept on intravenous antibiotics and was discharged after she was able to tolerate regulate diet and was ambulating well. DISCUSSION: IVC filter perforation of the duodenum is fairly uncommon. It can manifest with abdominal pain, gastrointestinal bleeding, cava-duodenal fistula, or small bowel obstruction. Diagnostic evaluation include plain abdominal radiographs, CT scan and/or Upper Endoscopy.To prevent potential sequelae caused by IVC filter leg penetration, like that reported in this case, the removal of the IVC filter, when possible, is preferred.Also manipulations of the foreign body should be avoided until further confirmation is done by abdominal imaging.