Prophylactic Vena Cava Filters Research Articles

SPIKED THROUGH THE HEART: A RARE COMPLICATION OF INFERIOR VENA CAVA (IVC) FILTER PLACEMENT

SPIKED THROUGH THE HEART: A RARE COMPLICATION OF INFERIOR VENA CAVA (IVC) FILTER PLACEMENT

“Death Knell” for Prophylactic Vena Cava Filters? A 20-Year Experience with a Venous Thromboembolism Guideline

The role of prophylactic vena cava filters (pVCFs) in trauma patients remains controversial. After 20 years of data collection and experience, we reviewed our venous thromboembolism guideline for the efficacy of pVCFs in preventing pulmonary embolism (PE). A retrospective cohort study was performed using our Level I trauma center registry from January 1997 thru December 2016. This population was then divided by the presence of pVCFs. Univariate analysis was performed comparing the incidence of PEs, deep vein thrombosis, and mortality between those with and without a pVCF. There were 35,658 patients identified, of whom 2 per cent (n = 847) received pVCFs. The PE rate was 0.4 per cent in both groups. The deep vein thrombosis rate for pVCFs was 3.9 per cent compared with 0.6 per cent in the no-VCF group (P < 0.0001). Given that there was no difference in the rates of PEs between the cohorts, the subset of patients with a PE were analyzed by their risk factors. Only ventilator days > 3 were associated with a higher risk in the no-pVCF group (0.2 vs 1.5%, P = 0.033). pVCFs did not confer benefit reducing PE rate. In addition, despite their intended purpose, pVCFs cannot eliminate PEs in high-risk trauma patients, suggesting a lack of utility for prophylaxis in this population.

Trends in vena cava filter insertions and “prophylactic” use

BackgroundProphylactic vena cava filter (VCF) use in patients without venous thromboembolism is common practice despite ongoing controversy. Thorough analysis of the evolution of this practice is lacking. We describe trends in VCF use and identify events associated with changes in practice. MethodsUsing the National Inpatient Sample, we conducted a retrospective observational study of U.S. adult hospitalizations from 2000 to 2014. Trends in prophylactic VCF insertion were analyzed both across the entire study population and within subgroups according to trauma status and type of concurrent surgery. Annual percentage change (APC) was calculated, and trends were analyzed using Poisson regression. ResultsAmong 461,904,314 adult inpatients (median [interquartile range] age, 58.1 [38.5-74.3] years; 39.6% male), the incidence of VCF insertion increased rapidly at first (from 0.19% to 0.35%; APC, 11.2%; 95% confidence interval [CI], 10.3%-12.2%; P < .001), then at a slower rate after the publication of the Prévention du Risque d'Embolie Pulmonaire par Interruption Cave 2 (PREPIC2) trial in 2005 (from 0.35% to 0.42%; APC, 4.4%; 95% CI, 2.8%-6.0%; P < .001), and it began decreasing after the 2010 Food and Drug Administration (FDA) safety alert (from 0.42% to 0.32%; APC, −5.5%; 95% CI, −6.5% to −4.6%; P < .001). The percentage of total VCFs that had a prophylactic indication increased quickly before publication of the PREPIC2 trial (APC, 19.5%; 95% CI, 17.9%-21.0%; P < .001), increased at a slower rate after publication in 2005 (APC, 4.4%; 95% CI, 2.6%-6.2%; P < .001), and dropped after the FDA safety alert, stabilizing at 18.5% for the last 3 years (APC, −0.3%; 95% CI, −2.2% to 1.7%; P = .8). Subgroups most associated with prophylactic VCF insertion were operative trauma (odds ratio [OR], 10.9; 95% CI, 10.2-11.7), orthopedic surgery (OR, 4.7; 95% CI, 4.3-5.2), and neurosurgical procedures (OR, 3.9; 95% CI, 3.6-4.2). All groups except orthopedic surgery experienced a deceleration in prophylactic VCF growth after the publication of PREPIC2. Meanwhile, the FDA safety alert was associated with a decrease in prophylactic VCF insertions for all groups except other major surgery. ConclusionsWhereas publication of the PREPIC2 trial led to a deceleration in prophylactic VCF insertion growth, the FDA alert had a bigger impact, leading to declining rates of prophylactic VCF use. Further investigations of prophylactic insertion of VCF in trauma, orthopedic, and neurosurgical patients are needed to determine whether current levels of use are justified.

Vena Cava Filter Use in Trauma and Rates of Pulmonary Embolism, 2003-2015

Vena cava filter (VCF) placement for pulmonary embolism (PE) prophylaxis in trauma is controversial. Limited research exists detailing trends in VCF use and occurrence of PE over time. To analyze state and nationwide temporal trends in VCF placement and PE occurrence from 2003 to 2015 using available data sets. A retrospective trauma cohort study was conducted using data from the Pennsylvania Trauma Outcome Study (PTOS) (461 974 patients from 2003 to 2015), the National Trauma Data Bank (NTDB) (5 755 095 patients from 2003 to 2014), and the National (Nationwide) Inpatient Sample (NIS) (24 449 476 patients from 2003 to 2013) databases. Temporal trends in VCF placement and PE rates, filter type (prophylactic or therapeutic), and established predictors of PE (obesity, pregnancy, cancer, deep vein thrombosis, major procedure, spinal cord paralysis, venous injury, lower extremity fracture, pelvic fracture, central line, intracranial hemorrhage, and blood transfusion). Prophylactic filters were defined as VCFs placed before or without an existing PE, while therapeutic filters were defined as VCFs placed after a PE. Of the 461 974 patients in PTOS, the mean (SD) age was 47.2 (26.4) and 61.6% (284 621) were men; of the 5 755 095 patients in NTDB, the mean age (SD) was 42.0 (24.3) and 63.7% (3 666 504) were men; and of the 24 449 476 patients in NIS, the mean (SD) age was 58.0 (25.2) and 49.7% (12 160 231) were men. Of patients receiving a filter (11 405 in the PTOS, 71 029 in the NTDB, and 189 957 in the NIS), most were prophylactic VCFs (93.6% in the PTOS, 93.5% in the NTDB, and 93.3% in the NIS). Unadjusted and adjusted temporal trends for the PTOS and NTDB showed initial increases in filter placement followed by significant declines (unadjusted reductions in VCF placement rates, 76.8% in the PTOS and 53.3% in the NTDB). The NIS demonstrated a similar unadjusted trend, with a slight increase and modest decline (22.2%) in VCF placement rates over time; however, adjusted trends showed a slight but significant increase in filter rates. Adjusted PE rates for the PTOS and NTDB showed significant initial increases followed by slight decreases, with limited variation during the declining filter use periods. The NIS showed an initial increase in PE rates followed by a period of stagnation. Despite a precipitous decline of VCF use in trauma, PE rates remained unchanged during this period. Taking this association into consideration, VCFs may have limited utility in influencing rates of PE. More judicious identification of at-risk patients is warranted to determine individuals who would most benefit from a VCF.

Changes in the rate of prophylactic vena cava filter insertion at a university hospital.

We previously demonstrated a high rate of prophylactic vena cava filter (VCF) insertion at our institution. We have since attempted to restrict the use of VCF to indications supported by Level-I evidence. This study was designed to evaluate the success of our interventions. All patients receiving VCF between 2007-2009 and 2012-2014 at a university hospital were reviewed. After assessing the use of VCF in the first period, a meeting was convened among the Departments of Radiology, Vascular Surgery and Trauma. Policy was implemented to avoid the inappropriate use of VCF. Data were prospectively collected in the second period to assess the effect of our intervention. There were 156 VCF placed from 2012 to 2014. VCF was absolutely indicated in 84% of cases, relatively indicated in 9% and prophylactic in 7%. These data contrast our previous experience from 2007 to 2009. In the earlier series, a total of 244 filters were placed, in which 54% of patients had an absolute indication, 14% relative, and 32% prophylactic. There was a significant decrease in filters placed for pure prophylaxis: whereas 76 prophylactic filters were placed between 2007 and 2009, only 11 were placed between 2012 and 2014 (p < 0.0001). No significant differences existed for relatively indicated filters. The department of trauma and surgical critical care (TSCC) observed the most dramatic change in practice. TSCC placed 61 prophylactic VCF between 2007 and 2009 (57% of all filters placed by the department), and 4 prophylactic VCF from 2012 to 2014 (15% of filters placed by TSCC) (p < 0.0001). These findings demonstrate a significant change in the attitudes regarding prophylactic VCF insertion between the two periods of study. Further investigations must be performed to assess changes in clinical outcomes that may result from the altered practice at our university.

Inferior Vena Cava Filter Thrombosis in Protein-S Deficiency Patient due to Withdrawal of Anticoagulation Therapy After operation

In protein S deficiency, if there was recurrent thrombotic event, ongoing anti-coagulation therapy should be administered. Especially, in case of life threatening recurrent pulmonary embolism, prophylactic inferior vena cava (IVC) filter with anti-coagulation therapy may be considered. But until now, there is no definite guideline for anti-coagulation therapy duration about recurrent thrombotic events in protein S deficiency patients. A 64-year old male patient who already was diagnosed with protein S deficiency accompanied with recurrent pulmonary embolism and was performed IVC filter was referred to our hospital due to manage both leg edema after operation. In the abdominal CT, we could find IVC filter thrombosis occurred to withdrawal anti-coagulation therapy for 2 weeks after spine operation. So we performed catheter-based procedure with anti-coagulation therapy and successfully treated IVC filter thrombosis. J Med Cases. 2013;4(9):612-615 doi: http://dx.doi.org/10.4021/jmc1417w

Pulmonary Embolism and Deep Venous Thrombosis Following Bariatric Surgery

The contribution of obesity to the thromboembolic risks of surgery suggests that patients undergoing bariatric surgery would have a particularly high risk of postoperative pulmonary embolism (PE) and/or deep venous thrombosis (DVT). This study aimed to assess the prevalence of in-hospital PE, DVT, and venous thromboembolism (VTE) following bariatric surgery in the USA from 2007 to 2009. We used the database of the Nationwide Inpatient Sample. The prevalence of PE was 4,500 of 508,230 (0.9 %). The prevalence of DVT not accompanied by PE was 6,480 of 508,230 (1.3 %) and VTE (either PE or DVT) occurred in 10,980 of 508,230 (2.2 %). In-hospital death among patients with PE was 130 of 508,231 (0.03 %). Vena cava filters were inserted in 1,515 of 508,230 (0.3 %) patients who underwent bariatric surgery. Among patients who had VTE, filters were inserted in 1,150 of 10,980 (10.5 %). Among patients who had neither PE nor DVT, prophylactic vena cava filters were inserted in 365 of 497,250 (0.07 %). Among patients with PE, in-hospital mortality was 25 of 635 (3.9 %) with a filter compared with 105 of 3,865 (2.7 %) (NS) without a filter. However, among patients with DVT alone, in-hospital mortality was 0 of 510 (0 %) with a filter compared with 80 of 5,970 (1.3 %) (P = 0.009) without a filter. This investigation establishes a baseline for the incidence of venous thromboembolic complications following bariatric surgery in recent years. Determination of the present in-hospital rate of PE and DVT may contribute to antithrombotic prophylactic considerations.

Pulmonary embolism and the use of vena cava filters after major trauma

Major trauma patients are at significant risk of developing pulmonary embolism (PE). We aimed to (i) analyse the current incidence and timing of PE after injury; (ii) identify risk factors that predispose major trauma patients to the occurrence of PE; and (iii) describe the use of vena cava filters (VCFs) following major trauma. Prospectively collected data from The Alfred Hospital's Trauma Registry were used to identify all major trauma patients admitted over a 7-year period. A multivariable logistic regression model was used to identify factors associated with the occurrence of PE. A similar model was developed to identify factors associated with the use of VCFs inserted at the discretion of the treating clinician. A total of 6344 major trauma patients were treated during this period, with 73.2% male, mean age of 44.2, 90.2% with a blunt mechanism of injury and mean injury severity score of 24.3. Prophylactic VCFs were inserted in 511 patients (8.1%), with a mean time to insertion of 3.6 days after injury. There were 45 PE, 2 of which were fatal. The mean time to PE was 12 days post-injury. Three variables were independently associated with the occurrence of PE: the absence of a VCF; number of injuries to the lower limb; and central venous catheterization. The PE rate was 0.71%. Lower limb injuries and central venous catheterization are independently associated with a higher risk of PE after major trauma and VCFs are associated with a reduced risk.

Central Venous Line Placement prior to Gastric Bypass Improves Operating Room Efficiency

Background. Bariatric surgery has increased across America. Venous access is difficult in these patients. Anesthesiologists often utilize valuable operating room (OR) time acquiring reliable intravenous lines. Our objective was to determine if outpatient central venous line (CVL) placement improves OR efficiency and professional reimbursement for CVL insertion. Methods. In our bariatric practice, selected surgery patients have outpatient CVLs placed during prophylactic vena cava filter placement. In a cohort of 268 gastric bypass patients operated between 1/01 and 11/06, we compared time-to-incision between 106 with pre-established CVLs and 162 without. In addition, we determined professional compensation rates for CVLs placed outpatient versus CVLs inserted in the OR. Results. Patients with preoperative (outpatient) CVLs required 35.6 ± 12.5 minutes to skin incision compared with 42.5 ± 13.9 minutes for controls (P < 0.0001), and 34.9% had skin incision in <30 minutes compared with 16.4% of controls. Radiologists collected 28.2% of outpatient billings for CPT code 36556, compared with anesthesiologists who collected <1% when placing CVLs in the OR. Conclusions. Outpatient CVLs prior to gastric bypass improve efficiency in the OR with earlier skin incision. Professional reimbursement is better for outpatient CVLs than intraoperative inpatient CVLs.

Filtro de veia cava: uma década de experiência em um centro de trauma nível I

To evaluate the data on the use of vena cava filter in the Division of Trauma, UCSD Medical Center - San Diego, CA / USA. A descriptive study was conducted at the Division of Trauma to evaluate the cumulated experience and the therapeutic approach in patients attended by the staff of the Division of Trauma and submitted to placement of a vena cava filter as a method of prevention or treatment of Pulmonary Thromboembolism (PTE) from January 1999 to December 2008. The study comprised 512 patients, mostly males (73%). As to the cause, automobile accident injuries predominated, followed by injuries caused by falls. The male / female ratio was 3:1. The most affected age group was the one between 21 to 40 years, representing 36% of patients. The percentage of prophylactic vena cava filters was 82%, whilst 18% had treatment purposes. Head trauma was the main cause for the indication of prophylactic filters followed by spinal cord trauma. The rate of pos-filter deep vein thrombosis (DVT) was 11%. In the presence of contraindications to the use of anticoagulants in patients who suffered severe trauma, the inferior vena cava filters have proven to be an effective and safe option. However, one should apply rigorous clinical judgment to all indications, even after the advent of retrievable filters.

Trends in vena caval interruption

This study examined the national use of vena cava filters (VCFs) from 1998 to 2005. Methods for complex surveys were used to examine hospital discharge data from the Nationwide Inpatient Sample (NIS) to determine the use of VCFs for the years 1998 to 2005. VCF placement in the absence of deep venous thrombosis (DVT) or pulmonary embolus (PE) was categorized as prophylactic. During the study period, the estimated rate of hospitalizations per year with a diagnosis of DVT (odds ratio [OR], 1.025; 95% confidence interval [CI], 1.019-1.032; P < .01) or PE (OR, 1.076; 95% CI, 1.069-1.083; P < .01) rose significantly. The estimated weighted frequency of VCF placement increased from 52,860 procedures in 1998 to 104,114 procedures in 2005 (0.15% and 0.27% of all discharges, respectively), representing an 80% increase. VCF placement significantly increased during hospitalizations with any diagnosis of DVT or PE, or both, and no DVT or PE (P < .01 for each). Logistic regression models revealed that the rate of prophylactic VCF placement increased at a significantly higher rate than VCF placement associated with DVT or PE (157% vs 42%; P < .01), after adjusting for age, gender, and hospital characteristics. Prophylactic VCF placement in the setting of morbid obesity (P < .01) and head injury (P = .03) rose significantly over time. From 1998 to 2005, the estimated rates of prophylactic VCF placement increased at a significantly higher rate than VCF placement in the setting of DVT or PE. Significant increases in the use of prophylactic VCFs were seen in the setting of morbid obesity and head injury.

Progressive Preoperative Pneumoperitoneum for Hernias with Loss of Domain

Acting as a pneumatic tissue expander, progressive preoperative pneumoperitoneum (PPP) pressurizes the abdomen to prepare patients with giant hernias and loss of domain for hernia repair. We review our experience with PPP. Between 2006 and 2008, a prospective hernia database revealed nine patients who underwent PPP prior to hernia repair. Mean patient age was 54 years (41-68) and mean BMI was 31.3 kg/m2 (25.2-36.5). Patients had prophylactic vena cava filters and intraperitoneal catheters placed. Over a mean 22.4 days (7-64), patients received 7.6 (3-13) injections of air. PPP complications included death from pulmonary mycetoma (1), deep venous thrombosis and acute renal failure (1), port infection (1), kinked catheter requiring reoperation (1). Seven patients underwent successful hernia repair; open ventral (6) and laparoscopic inguinal (1). Defect size averaged 387 cm2 (110-980) with a mesh size of 420 cm (180-1200). Operative time averaged 256 minutes (175-330) with a mean blood loss of 157 ml (50-500). Post-hernia repair length of stay was 10.3 days (4-22). Hernia repair complications included ventricular tachycardia (1) and hernia recurrence (1). PPP has an acceptable risk, and for patients with large hernias and loss of domain, it may be a useful adjunct prior to definitive hernia repair.

TS03 *THE EFFICACY AND SAFETY OF PROPHYLACTIC VENA CAVA FILTERS AFTER MAJOR TRAUMA

Purpose: Despite increasing use of vena cava filters (VCFs) for pulmonary embolism (PE) prophylaxis after trauma, there is continued debate regarding their safety and efficacy.Methods: Prospectively collected data from The Alfred Hospital's trauma registry were used to identify all major trauma patients admitted between 1/7/2001 and 1/7/2008. These data were matched to data from the Department of Radiology's VCF Database.Results: 6,344 major trauma patients were treated during this period with 73.2% male, mean age of 44.2 ± 21.0 SD, 90.2% with a blunt mechanism of injury and mean ISS of 24.3 ± 12.0 SD. Of these patients, 511 (8.1%) received prophylactic VCFs (inserted in absence of PE) at the discretion of the treating clinician. There were 45 PE (0.71%), 2 of which were fatal. Three variables were independently associated with the occurrence of PE in a multivariate logistic regression model: presence of prophylactic VCF (OR 0.28; 95%CI 0.09–0.89); number of injuries to the AIS body region lower limb (OR 1.31; 95%CI 1.17–1.47) and central venous catheterization (OR 1.87; 95%CI 1.88–6.17). Data were available on the VCF database for 429 of the 511 patients with VCFs (84.0%). The mean time to prophylactic VCF insertion was 3.6 ± 0.2 SEM days after admission. The VCF major complication rate was 2.6% (n = 11), including 4 non‐fatal PE. The technical success rate for retrieval was 92.4% (279 retrievals from 302 attempts) and the overall retrieval rate was 65.0% (279 retrievals from 429 placements).Conclusion: Prophylactic VCFs are associated with a reduced rate of PE when used in selected major trauma patients. In addition, prophylactic VCFs have a low major complication rate and high rate of technical success for retrieval.

Successful Percutaneous Retrieval of an Inferior Vena Cava Filter Migrating to the Right Ventricle in a Bariatric Patient

The use of an inferior vena cava filter has an important role in the management of patients who are at high risk for development of pulmonary embolism. Migration is a rare but known complication of inferior vena cava filter placement. We herein describe a case of a prophylactic retrievable vena cava filter migrating to the right ventricle in a bariatric patient. The filter was retrieved percutaneously by transjugular approach and the patient did well postoperatively. A review of the current literature is given.

Early Placement of Optional Vena Cava Filter in High-Risk Patients with Traumatic Brain Injury.

Patients sustaining severe trauma are at high risk for the development of venous thromboembolic events (VTE). Pharmacologic VTE prophylaxis may be contraindicated early after trauma due to potential bleeding complications. The purpose of this study was to evaluate safety and feasibility of early prophylactic vena cava filter (VCF) placement and subsequent retrieval in multiple injured patients with traumatic brain injury (TBI). Analysis of single-institution case series of consecutive patients who received a prophylactic VCF after severe TBI (Abbreviated Injury Scale, AiS ≥ 3) between August 2003 and October 2006. A total of 34 optional VCF were prophylactically placed with a median delay of 1 day after trauma (range, 0-7 days). All patients had sustained multiple injuries (median Injury Severity Score 41, range, 18-59) with severe TBI (median AiS 4, range 3-5). Median age was 41 years (range, 17-67 years). Two patients had succumbed before potential filter retrieval. Of the remaining patients, 27 (84%) had their filters uneventfully retrieved between 11 and 32 days (median, 18 days) after placement with no retrieval-related morbidity. Five VCF (16%) were left permanently. In one patient (3%) early inferior vena cava occlusion and deep venous thrombosis occurred 14 days after VCF placement. Symptomatic pulmonary embolism was observed in one patient (3%) 5 days after VCF retrieval. Overall trauma-related mortality was 9%. Early VCF placement may be of benefit for multiple injured patients with TBI when pharmacologic VTE prophylaxis is contraindicated. VCF retrieval is safe and feasible. Filter placement- and retrieval-related morbidity is low.

Asymptomatic thrombus trapping in vena cava filters: a case series.

The prophylactic use of vena cava filters (VCFs) remains controversial. Class I data supporting the placement of prophylactic VCFs are lacking. In addition, there are concerns regarding the long-term effects of permanent VCF placement in patients with a relatively brief period of thromboembolic risk. Venous thromboembolism can be a lethal event, occurring without a prodrome. Yet, this condition is potentially preventable. The efficacy of VCFs is difficult to determine, as it is likely that when a VCF actually traps a thrombus, the event is clinically asymptomatic. We present three cases of asymptomatic thrombus trapping in VCFs, recognized through incidental radiographic studies.

Early Experience with the Retrievable OptEase Vena Cava Filter in High-risk Trauma Patients

Prophylactic vena cava filters (VCF) are efficient in preventing pulmonary embolism. Filter retrieval avoids the potential long-term complications of permanent VCF. Clinical evaluation was focused on filter-related complications and feasibility of retrieval in high-risk trauma patients. Analysis of single-institution consecutive case series of patients who received a prophylactic OptEase VCF after multiple trauma between 08/2003 and 12/2004. Data were collected prospectively. A total of 37 OptEase filters were inserted prophylactically after multiple trauma (median patient age 35 years, range, 17-73 years, median ISS 41, range, 17-59). All patients had contraindications for pharmacological prophylaxis for thromboembolic events. 32 filters (86%) were retrieved after 16 days (range, 7-25 days). 12 of 33 filters (36%) demonstrated trapped clots/thrombosis within the filter structure on pre-retrieval cavography. Two patients received anticoagulation before filter retrieval due to filter thrombosis (6%). Symptomatic PE was observed in 1 patient (3%) 5 days after VCF retrieval. Minor caudal filter migration was observed in 1 patient (3%). Overall mortality was 3%. Retrieval of the OptEase filter is safe and feasible. Temporary filter placement avoids possible long-term complications of permanent VCF. It is an efficient form of PE prophylaxis when temporary contraindications to anticoagulation are present.

Prophylactic Insertion of Optional Vena Cava Filters in High-Risk Trauma Patients

Vena cava interruption is a form of pulmonary embolism prophylaxis that is being used in high-risk patients who do not tolerate pharmacologic prophylaxis. Retrievable prophylactic vena cava filters (VCFs) are of particular interest for severely injured patients where the necessity for VCF is often only temporary. In a single-institution case series of consecutive patients who received prophylactic VCFs after polytrauma, between 04/1998 and 07/2004, the demographic data, injury pattern and complications were analysed. Ninety-five prophylactic VCFs were placed in polytrauma patients (median ISS of 38). Median age was 38 years (range 16–80 years). Median delay between trauma and filter placement was 1 day (range 0–31 days). No complication was seen related to filter insertion or retrieval. Sixty-five VCFs (68.4%) were retrieved after 4–25 days (median 13 days). One filter migration (1.1%) was observed. Retrieval failed in two patients (3.0%). A total of 30 VCFs (31.6%) were left permanently. One non-fatal PE (1.1%) occurred 21 days after filter retrieval despite prophylaxis with LMWH. DVT developed in two patients (2.1%) including one vena caval occlusion (1.1%). Overall mortality was 7.4%. Early prophylactic placement of VCF in a high-risk trauma patient should be considered when anticoagulation is contraindicated. Filter insertion and retrieval is safe with a low complication rate.

Removal of the OptEase Retrievable Vena Cava Filter Is Not Feasible after Extended Time Periods Because of Filter Protrusion Through the Vena Cava

Therapeutic and prophylactic vena cava filters (VCFs) are used to prevent pulmonary embolism. Concerns exist over placing a permanent filter in a young trauma patient. Recently, retrievable VCFs have become available. One such filter is the OptEase, which has a recommended time of removal of up to 23 days after insertion. Data supporting this recommendation are sparse. Many trauma patients will need filters for more than 2 weeks, and there are no data evaluating the safety of removal after extended time periods. The purpose of this study was to determine the safety, feasibility, and reaction of the vena cava when removing the OptEase retrievable VCF at different time intervals. Twenty Yorkshire cross pigs (80-113 kg) underwent general anesthesia with tiletamine and zolazepam. Filters were placed in the infrarenal vena cava (VC) through the femoral vein under fluoroscopic guidance. Animals were then divided into four groups. In group 1, filters were removed at 14 days; in group 2, at 30 days; in group 3, at 60 days; and in group 4, at 90 days. Removal was attempted using a snare-and-sheath technique through the femoral vein. Animals with successful filter removal were allowed to recover; then, the animals underwent autopsy (gross and microscopic VC examination) 2 months later. Animals with unsuccessful filter removal underwent autopsy immediately after attempted removal. Venacavograms were taken at filter insertion, at removal, and before autopsy to evaluate any VC abnormalities. Successful removal of the filter in all five pigs (100%) was reliably performed only in the 14-day group. In this group, the initial VC transverse diameter was 19.4 +/- 0.8 mm and was significantly reduced to 9.8 +/- 1.1 mm (p < 0.05) immediately after removal. Sixty days later, before autopsy, VC diameter had increased to 15.3 +/- 1.9 mm, which was significantly larger than at removal (p < 0.05) but not different from the initial value. In the 30-day group, removal was successful in only one of five animals. Although removal was successful in the one pig, autopsy at 2 months postremoval revealed total occlusion of the VC. Filters could not be removed from 60- and 90-day groups. At autopsy, the VCF struts were embedded or protruded through the VC wall. Microscopic examination of the VC revealed significant scarring underneath and between the struts. Removal of the retrievable OptEase VCF may be successfully performed up to 14 days after insertion. Strut protrusion through the VC wall prohibited successful and safe removal at extended time intervals.

Thromboembolism after trauma: an analysis of 1602 episodes from the American College of Surgeons National Trauma Data Bank.

Venous thromboembolic events (VTE) are potentially preventable causes of morbidity and mortality after injury. We hypothesized that the current clinical incidence of VTE is relatively low and that VTE risk factors could be identified. We queried the ACS National Trauma Data Bank for episodes of deep venous thrombosis (DVT) and/or pulmonary embolism (PE). We examined demographic data, VTE risk factors, outcomes, and VTE prophylaxis measures in patients admitted to the 131 contributing trauma centers. From a total of 450,375 patients, 1602 (0.36%) had a VTE (998 DVT, 522 PE, 82 both), for an incidence of 0.36%. Ninety percent of patients with VTE had 1 of the 9 risk factors commonly associated with VTE. Six risk factors found to be independently significant in multivariate logistic regression for VTE were age > or = 40 years (odds ratio [OR] 2.01; 95% confidence interval [CI] 1.74 to 2.32), lower extremity fracture with AIS > or = 3 (OR 1.92; 95% CI 1.64 to 2.26), head injury with AIS > or = 3 (OR 1.24; 95% CI 1.05 to 1.46), ventilator days >3 (OR 8.08; 95% CI 6.86 to 9.52), venous injury (OR 3.56; 95% CI 2.22 to 5.72), and a major operative procedure (OR 1.53; 95% CI 1.30 to 1.80). Vena cava filters were placed in 3,883 patients, 86% as PE prophylaxis, including in 410 patients without an identifiable risk factor for VTE. Patients who need VTE prophylaxis after trauma can be identified based on risk factors. The use of prophylactic vena cava filters should be re-examined.