Underwent 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.

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.

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.

Detecting and Characterizing Inferior Vena Cava Filters on Abdominal Computed Tomography with Data-Driven Computational Frameworks

Two data-driven algorithms were developed for detecting and characterizing Inferior Vena Cava (IVC) filters on abdominal computed tomography to assist healthcare providers with the appropriate management of these devices to decrease complications: one based on 2-dimensional data and transfer learning (2D + TL) and an augmented version of the same algorithm which accounts for the 3-dimensional information leveraging recurrent convolutional neural networks (3D + RCNN). The study contains 2048 abdominal computed tomography studies obtained from 439 patients who underwent IVC filter placement during the 10-year period from January 1st, 2009, to January 1st, 2019. Among these, 399 patients had retrievable filters, and 40 had non-retrievable filter types. The reference annotations for the filter location were obtained through a custom-developed interface. The ground truth annotations for the filter types were determined based on the electronic medical record and physician review of imaging. The initial stage of the framework returns a list of locations containing metallic objects based on the density of the structure. The second stage processes the candidate locations and determines which one contains an IVC filter. The final stage of the pipeline classifies the filter types as retrievable vs. non-retrievable. The computational models are trained using Tensorflow Keras API on an Nvidia Quadro GV100 system. We utilized a fine-tuning supervised training strategy to conduct our experiments. We find that the system achieves high sensitivity on detecting the filter locations with a high confidence value. The 2D + TL model achieved a sensitivity of 0.911 and a precision of 0.804, and the 3D + RCNN model achieved a sensitivity of 0.923 and a precision of 0.853 for filter detection. The system confidence for the IVC location predictions is high: 0.993 for 2D + TL and 0.996 for 3D + RCNN. The filter type prediction component of the system achieved 0.945 sensitivity, 0.882 specificity, and 0.97 AUC score with 2D + TL and 0. 940 sensitivity, 0.927 specificity, and 0.975 AUC score with 3D + RCNN. With the intent to create tools to improve patient outcomes, this study describes the initial phase of a computational framework to support healthcare providers in detecting patients with retained IVC filters, so an individualized decision can be made to remove these devices when appropriate, to decrease complications. To our knowledge, this is the first study that curates abdominal computed tomography (CT) scans and presents an algorithm for automated detection and characterization of IVC filters.

Association of vena cava filters and catheter-directed thrombolysis for deep vein thrombosis with hospital readmissions

BackgroundAcute deep vein thrombosis (DVT) affects >350,000 patients each year in the United States. Contemporary rehospitalization rates and predictors of acute DVT have not been well-characterized. We aimed to evaluate the all-cause 30-day readmission rate and its association with catheter-directed thrombolysis and vena cava filters in patients with proximal and caval DVT. MethodsPatients with an index hospitalization for acute proximal lower extremity DVT were evaluated for unplanned readmission rates at 30 days using the Nationwide Readmission Database from 2016 to 2017. We used Cox proportional hazard model to determine the predictors of 30-day readmissions and their association with inferior vena cava (IVC) filter and CDT use. ResultsWe identified 58,306 adult patients with an index hospitalization for acute proximal DVT. The unplanned 30-day rehospitalization rate was 14.7% (95% confidence interval [CI], 14.5-15.0%). There were 4995 patients (10.0%) who underwent CDT and 6085 (12.2%) who underwent IVC filter placement. In multivariable analysis, only CDT was associated with a lower hazard for rehospitalization (hazard ratio [HR], 0.77; 95% CI, 0.71-0.84; P < .001), whereas IVC filter placement (HR, 1.26; 95% CI, 1.19-1.34; P < .001), Charlson Comorbidity Index of >3 (HR, 1.47; 95% CI, 1.38-1.56; P < .001), malignancy (HR, 1.45; 95% CI, 1.34-1.57; P < .001), and length of stay >5 days (HR, 1.39; 95% CI, 1.33-1.46; P < .001), and acute kidney injury (HR, 1.18; 95% CI, 1.11-1.25; P < .001) were associated with higher readmission rates. ConclusionsThe 30-day unplanned rehospitalization rate continues to be high in patients with acute proximal DVT. CDT was associated with lower rehospitalization rates, whereas IVC filter placement was associated with increased rehospitalization rates.

Relationship Between Language Spoken and Inferior Vena Cava Filter Retrieval Rates at a Single Center

The majority of inferior vena cava (IVC) filters placed are intended to be retrievable after the patient’s risk of pulmonary embolism has decreased. However, studies have shown that there are many factors that play into whether these filters are actually removed. Even socioeconomic factors such as insurance status, age, and race can influence retrieval rates. No study to date has identified a link between IVC retrieval rates and patient language although without proper interpretive services patient language may be a barrier to effective communication and may decrease the likelihood that patients have their filter removed. We performed a retrospective chart review of all patients who underwent IVC filter placement at our institution from January 1, 2017, to July 1, 2022. This time frame intentionally excluded the six most recent months to allow appropriate time for filter retrieval. Demographic, procedural, and comorbidity information was collected through the electronic medical record review. Patients who either had their filter removed or who died with the filter in place were counted as a retrieved filter, and those who did not have their filter removed and remained living were coded as filter remaining in place. The Pearson χ2 analysis was used to compare the groups. From January 1, 2017, to July 1, 2022, 150 patients underwent placement of an IVC filter. The overall filter modified (accounting for patient death) retrieval rate was 83%. There was a significantly decreased filter retrieval rate in patients who were listed as speaking a language other than English (61.5%) when compared with English speakers (85.4%, P < .05). Cantonese was the language with the lowest retrieval rate with just 20% of the filters retrieved in patients who spoke Cantonese. In patients whose filter was removed, there was no difference in average days the filter remained in place based on language. In our single institution study, patients who spoke a language other than English had a decreased rate of IVC filter retrieval. The identification of this difference is imperative to creating and implementing programs to ensure equal care across all socioeconomic backgrounds.

Association of Inferior Vena Cava Filter Placement With Rates of Pulmonary Embolism in Patients With Cancer and Acute Lower Extremity Deep Venous Thrombosis

Venous thromboembolism is the second overall leading cause of death for patients with cancer, and there is an approximately 2-fold increase in fatal pulmonary embolism (PE) in patients with cancer. Inferior vena cava (IVC) filters are designed to prevent PE, but defining the appropriate use of IVC filters in patients with cancer remains a substantial unmet clinical need. To evaluate the association of IVC filters with the development of PE in patients with cancer and deep venous thrombosis (DVT). A population-based cohort study was conducted using administrative data on 88 585 patients from the state inpatient databases for California (2005-2011) and Florida (2005-2014). Based on diagnostic and procedure codes, patients with cancer and acute lower extremity DVT were identified. All subsequent hospital visits for these patients were evaluated for the placement of an IVC filter, the development of new PE, the development of new DVT, and in-hospital mortality. Data analysis was performed from September 1 to December 1, 2019. Placement of an IVC filter. The association of IVC filter placement with rates of new PE and DVT was estimated using a propensity score matching algorithm and competing risk analysis. The study cohort comprised 88 585 patients (45 074 male; median age, 71.0 years [range, 1.0-104.0 years]) with malignant neoplasms who presented to a health care institution with a diagnosis of acute lower extremity DVT. Of these patients, 33 740 (38.1%) underwent IVC filter placement; patients with risk factors such as upper gastrointestinal bleeding (odds ratio, 1.32; 95% CI, 1.29-1.37), intracranial hemorrhage (odds ratio, 1.21; 95% CI, 1.19-1.24), and coagulopathy (odds ratio, 1.09; 95% CI, 1.08-1.10) were more likely to receive an IVC filter. A total of 4492 patients (5.1%) developed a new PE after their initial DVT diagnosis. There was a significant improvement in PE-free survival for these patients compared with those who did not receive IVC filters across the full, unbalanced study cohort as well as after propensity score matching and competing risk analysis (hazard ratio, 0.69; 95% CI, 0.64-0.75; P < .001). Furthermore, IVC filter placement reduced the development of PE in patients with very high-risk malignant neoplasms (eg, pancreaticobiliary cancer), high-risk malignant neoplasms (eg, lung cancer), and low-risk malignant neoplasms (eg, prostate cancer). After accounting for anticoagulation use and imbalanced risk factors, IVC filter placement did not increase the risk of new DVT development. This study suggests that, for patients with cancer and DVT and bleeding risk factors, IVC filter placement is associated with an increased rate of PE-free survival.

Changes in inferior vena cava filter placement and retrieval practice patterns from a population health perspective.

Inferior vena cava (IVC) filters are placed to reduce venous thromboembolism (VTE)-related morbidity and mortality, though the evidence supporting this practice is limited. In 2010, the Food and Drug Administration (FDA) released a device safety advisory due to the risk of filter migration, fracture, and thrombosis with long-term use. The purpose of this study was to evaluate trends and predictors for IVCF placement and retrieval over a 10-year time period from a population health perspective. De-identified patient information from the State Inpatient Databases (SID) and the States Ambulatory Surgery and Services Databases (SASD) for Florida and California were used to identify all patients who underwent IVC filter placement from 2005 to 2014 and 2005 to 2011, respectively. Hospital practice patterns were assessed as a function of time as well as IVC filter placement and retrieval volume. Temporal trends were evaluated for statistical significance using the Cochran-Armitage test. A total of 181,260 IVC filters were placed in 178,327 patients over the study period. IVC filter placements peaked in 2010; following the FDA advisory in 2010, however, IVC filter placements monotonically decreased each subsequent year. The proportion of IVCF placement patients with both acute DVT and PE (17.6% vs 11.8%, P < 0.001) at the time of hospitalization increased; likewise, the proportion of IVCF patients with acute DVT or PE with a concomitant acute contraindication to anticoagulation at the time of hospitalization increased as well following 2010 (17.0% vs 11.9%, P < 0.001). From 2005 to 2014, there was a continual increase in both filter retrieval procedures as well overall percentage of filters retrieved. However, estimated retrieval rates remained low, with a retrieval rate of less than 6% in 2014. Following the FDA warning in 2010, there was a significant decrease in IVC filter placements, with filter placements more frequently performed in patients with poorer health. While retrieval rates increased over time, they remained low.

Abstract No. 671 The effect of inferior vena cava size on filter complications: one size does not fit all

To determine the effect of inferior vena cava (IVC) size on development of complications as determined on post placement CT scan, including filter tilt, penetration, and thrombosis. Patients that underwent IVC filter placement between March 2015-December 2017 were included in the study. Coronal and sagittal CT scan images before placement of the filter were used to measure the medio-lateral (ML) and antero-posterior (AP) diameters of the IVC, 2 cm below the right renal vein. Two- dimensional (2D) axial IVC size at this level was then calculated using the ML and AP diameters. CT scan images after placement of the filter were reviewed for any complications, including filter tilt, penetration and thrombosis. IVC filter ML diameter, AP diameter and 2D axial sizes were then compared between patients with and without complications in CT scan. A total of 86 patients (female = 59%, male = 41%, age: 67 ± 14.1 years) were enrolled. The CT scan before placement of filter was available at 2.2 ± 5.2 months. The complications noted in the post filter placement CT scan (interval = 5.4 ± 6.75 months) were tilt in 32(37%) patients, penetration in 4(4.7%) and thrombosis in 8(9.3%) patients. Patients with tilt had significantly larger 2D axial IVC size compared to patients without tilt. Almost significant association was also noted in terms of ML diameter; however, no significant difference was noted in terms of AP diameter. There is significant association between the two-dimensional (2D) size of the IVC and future complications such as tilt noted on post placement CT scan. Two-dimensional evaluations of the IVC could provide clinicians better insight regarding the anatomy of the IVC, particularly considering the variability of the IVC size with hydration status and respiration. Future large sample studies should further define the filter specific thresholds.Tabled 1IVC AP diameter (mm)IVC ML diameter (mm)No tilt (n=54)15.9 ± 4.819.3 ± 2.9992.7 ± 400.7Tilt (n=32)17.7 ± 4.820.8 ± 3.61184.7 ± 452.8P value0.110.050.04 Open table in a new tab

Extreme obesity is associated with angulation during inferior vena cava filter placement

BackgroundPlacement of inferior vena cava (IVC) filters can be complicated by venous injury, filter misplacement, angulation, insertion site injury, and procedure-related death. Currently, no studies exist evaluating the correlation between obesity and adverse outcomes of IVC filters. We aimed to assess the outcomes of IVC filter placement in the obese population using the Vascular Quality Initiative database. MethodsThe Vascular Quality Initiative registry identified 7258 patients who underwent IVC filter placement from January 2013 to June 2017. Patients were divided into three groups based on their body mass index (BMI): normal/overweight (BMI <30), obese (BMI 30-40), and extremely obese (BMI >40). Periprocedural outcomes were analyzed. ResultsThe mean age was 63.6 ± 16.6 years and 3444 patients (47%) were female. BMI was less than 30 in 4115 (56.7%), 30 to 40 in 2148 (29.6%), and greater than 40 in 995 (13.7%) patients. A complication or IVC filter-related death occurred in 142 patients (2.6%). Adverse events included angulation (1.3%), IVC filter misplacement (0.5%), insertion site injury (0.3%), IVC filter-related death (0.1%), and venous injury (0.06%). In multivariable analysis, increased BMI was found to be associated with angulation (P = .03), but was not associated with IVC filter misplacement (P = .43), or any complication or IVC filter-related death (P = .22). A subgroup analysis of IVC filter placements using only fluoroscopy demonstrated that the risk of angulation was significantly higher in patients with a BMI of greater than 40 compared with a BMI of less than 30 (odds ratio, 2.12; 95% confidence interval, 1.07-4.21; P = .03). There was not enough evidence to conclude that BMI was associated with any other outcome. ConclusionsIVC filter insertion has low complication rates. Increased BMI is associated with an increased risk of IVC filter angulation; there is no evidence of association between BMI and other periprocedural complications.

03:18 PM Abstract No. 153 The influence of IVC filters on the rate of pulmonary embolism in cancer patients with deep venous thrombosis: a population-based study

Inferior vena cava (IVC) filters are placed to reduce pulmonary embolism (PE) in patients with lower extremity deep venous thrombosis (DVT). The purpose of this population based study was to evaluate the influence of IVC filters in the prevention of PE for cancer patients with DVT. Using administrative data from all discharges from acute care hospitals in California (2005-2011) and Florida (2005-2014), cancer patients with DVT were identified. All subsequent hospital visits for these patients were evaluated for the placement of an IVC filter, the development of PE, as well as bleeding and venous thrombosis risk factors. The influence of IVC filter placement on PE rates was estimated using a propensity score matching algorithm. A total of 89,041 cancer patients with DVT were identified who accounted for 289,233 inpatient hospital encounters. These patients comprised the study cohort. Of the total 24,470 (27.4%) patients who underwent IVC filter placement, 85.3% (20,875) underwent IVC filter placement within 30 days of initial DVT diagnosis. IVC filter patients had higher rates of bleeding risk factors including intracranial hemorrhage (2.6% vs 1.6% P < 0.001), lower GI bleed (8.1% vs 4.4%, P < 0.001), and hematuria (5.6% vs 3.4%, P < 0.001). In addition, IVC filter patients had higher rates of proximal DVT (53.9% vs 41.6%, P < 0.001) as well as the thrombosis risk factors of metastatic disease (47.7 vs 35.8%, P < 0.001) and coagulopathies (15.8% vs 12.3%, P < 0.001). After the initial DVT presentation, a total of 1,944 (2.2%) patients were diagnosed with PE. Adjusting for risk factors and anticoagulation use by a propensity matching algorithm, patients who received an IVC filter were noted to have a significantly improved PE-free survival at 6, 12, and 24 months relative to those who did not receive an IVC filter (96.6% vs 94.4%, 95.5% vs 92.3%, 94.0% vs 89.7%, P < 0.001). In cancer patients with DVT and bleeding risk factors, IVC filter placement is associated with an improved rate of PE-free survival.Tabled 1IVC filterNo IVC filterP ValuePatients (N)24,47065,571Age (median in years)7070NSGender (% female)50.750.6NSRace (%)NS White70.170.1 Black11.811.3 Hispanic14.114.1Intracranial hemorrhage (%)2.6%1.6%< 0.001Upper GI bleed (%)1.8%0.7%< 0.001Lower GI bleed (%)8.1%4.4%< 0.001Hematuria5.6%3.4%< 0.001Proximal DVT (%)53.9%41.6%< 0.001Metastatic disease (%)47.7%35.8%< 0.001Coagulopathy (%)15.8%12.3%< 0.001 Open table in a new tab

Retrievable Inferior Vena Cava Filters: A Tertiary Centre Perspective and Quality Assurance Study

PurposeTo conduct a retrospective review and quality assurance study of inferior vena cava (IVC) filter retrieval over a two-year period at a tertiary care centre. MethodsPatients who underwent IVC filter placement or retrieval over a two-year period were identified. Medical records were reviewed for patient characteristics, filter indication, time to filter retrieval, and complications. ResultsIVC filters were placed in 229 patients between January 1, 2015 and December 31, 2016. 113 retrievals were attempted and 101 filters were successfully retrieved (89.4%). Median time to first retrieval attempt was 48 days (range of 5–728). Seventy-one patients died in the interval after filter insertion before a retrieval attempt at a median time of 27 days (range of 3–430). In 17 patients, retrieval was complicated by or delayed because of penetration of IVC wall (n = 6), large thrombus burden trapped by filter (n = 5), filter tilt or migration (n = 3), and unclear reasons (n = 3). Time-to-first unsuccessful retrieval attempt was 141 days (median). Of all filters placed, 55.9% were never retrieved. Excluding deceased patients with in-situ filters (n = 71) and unsuccessful retrievals left in-situ as permanent filters (n = 5), there remains 52 patients (33%), with a median filter in-situ time of 488 days. ConclusionOur study indicates that as many as 33% of patients may have been lost to follow-up of their in-situ IVC filter. Considering widespread reports of long-term complications and the recent safety alert issued by Health Canada, it is evident that a unified strategy is needed to track patients post filter insertion.

Contemporary Trends and Comparative Outcomes With Adjunctive Inferior Vena Cava Filter Placement in Patients Undergoing Catheter-Directed Thrombolysis for Deep Vein Thrombosis in the United States: Insights From the National Inpatient Sample

ObjectivesThe aim of this study was to investigate the contemporary trends and comparative effectiveness of adjunctive inferior vena cava filter (IVCF) placement in patients undergoing catheter-directed thrombolysis (CDT) for treatment of proximal lower extremity or caval deep vein thrombosis. BackgroundCDT is being increasingly used in the management of proximal deep vein thrombosis. Although a significant number of patients treated with CDT undergo adjunctive IVCF placement, the benefit of this practice remains unknown. MethodsThe National Inpatient Sample database was used to identify all patients with proximal or caval deep vein thrombosis who underwent CDT (with and without adjunctive IVCF placement) in the United States between January 2005 and December 2013. A propensity score–matching algorithm was then used to derive 2 matched groups of patients (IVCF and no IVCF) for comparative outcomes (mortality and major and minor bleeding) and resource use analysis. ResultsOf the 7,119 patients treated with CDT, 2,421 (34%) received IVCFs. There was no significant difference in in-hospital mortality (0.7% vs 1.0%; p = 0.20), procedure-related hemorrhage (1.4% vs. 1.0%; p = 0.23), or intracranial hemorrhage (0.7% vs. 0.6%; p = 0.70) between the IVCF (n = 2,259) and no-IVCF (n = 2,259) groups, respectively. Patients undergoing IVCF placement had higher rates of hematoma (3.4% vs 2.1%; p = 0.009), higher in-hospital charges ($104,049 ± 75,572 vs. $92,881 ± 80,194; p < 0.001) and increased length of stay (7.3 ± 5.6 days vs. 6.9 ± 6.9 days; p = 0.046) compared with the no-IVCF group. ConclusionsThis nationwide observational study suggests that one-third of all patients undergoing CDT receive IVCFs. IVCF use was not associated with a decrease in in-hospital mortality but was associated with higher inpatient charges and longer length of stay.

3:00 PM Abstract No. 51 The influence of inferior vena cava filters on the rate of pulmonary embolism in patients with deep venous thrombosis: a population-based study

Inferior vena cava (IVC) filters are placed to reduce pulmonary embolism (PE) rates in patients with lower extremity deep venous thrombosis (DVT), though the evidence supporting this practice is limited. The purpose of this study was to evaluate the influence of IVC filter placement on preventing the development of PE in patients with DVT. Using administrative data from all discharges from acute care hospitals in California (2005-2011) and Florida (2005-2014), patients with an initial presentation of DVT without PE were identified. All hospital visits for these patients were then evaluated for the placement of an IVC filter, the development of PE, as well as bleeding and venous thrombosis risk factors. The influence of IVC filter placement on PE rates was estimated using a propensity score matching algorithm. A total of 256,923 patients were identified who accounted for 1,590,610 hospital encounters. 72,383 (28%) patients underwent IVC filter placement; 59,016 (23.0%) underwent IVC filter placement within 30 days of initial DVT diagnosis. IVC filter patients had higher rates of bleeding risk factors including intracranial hemorrhage (4.9 vs 2%, P < 0.001), GI bleed (10.5 vs 5.9%, P < 0.001), and hematuria (4.4 vs 2.3%, P < 0.001). IVC filter patients had higher rates of proximal DVT (54.2% vs 46.1%, P < 0.001) as well as thrombosis risk factors including malignancy (19.7 vs 17.4%, P < 0.001), lower extremity fracture (1.9 vs 0.9%, P < 0.001), and coagulopathies (11.3% vs 8.5%, P < 0.001). A total of 10,432 (4.1%) patients were diagnosed with PE after the initial DVT presentation. After adjusting for these risk factors as well as anticoagulation use by a propensity matching algorithm, patients who received an IVC filter were noted to have a significantly lower rate of PE (3.9% vs 6.7%, P < 0.001) than patients who did not receive an IVC filter. In patients with DVT and bleeding risk factors, IVC filter placement is associated with a decreased rate of pulmonary embolism.Tabled 1IVC FilterNo IVC FilterP ValueAge (median)7470< 0.001Gender (% female)53520.003Intracranial hemorrhage (%)4.92.0< 0.001GI bleed (%)10.55.9< 0.001Hematuria (%)4.42.3< 0.001Proximal DVT (%)54.246.1< 0.001Malignancy (%)19.717.4< 0.001Leg fracture (%)1.90.9< 0.001Coagulopathy (%)11.38.5< 0.001 Open table in a new tab

Inferior Vena Cava Filters as a Potential Non-immune Cause of Low Serum Haptoglobin

Objective: Serum haptoglobin level is commonly used as a marker of hemolysis. We hypothesized that inferior vena cava (IVC) filters may be a potential non-immune etiology for subclinical hemolysis and low haptoglobin in some patients, after encountering a patient with an IVC filter, mild macrocytic anemia and unexplained severe haptoglobinemia. IVC filters can be associated with pressure gradients and turbulent blood flow in the presence of trapped clots and thrombus formation. Methods: Prospective study in patients undergoing IVC filter placement at our institution over a 3-month period in 2008. All patients had a haptoglobin level prior to filter placement, and then daily for a period of 3-14 days. The absolute and relative change in haptoglobin compared to pre-procedure levels was determined. Results were evaluated by t-test (paired, 2-tail). Statistics and graphics were performed with commercial software. Results: A total of 22 patients underwent IVC filter placement. Four patients were excluded due to low preprocedure haptoglobin levels. At least one post-procedure haptoglobin values was available until day 3 in 18/18 eligible patients. Nine patients were followed for a period of 1-2 weeks. Although the majority of patients had an increase in haptoglobin after IVC filter placement, 3/9 (30%) had >50% decrease in haptoglobin by day 7, including one patient with severe haptoglobinemia by day 14. Patients with decreased haptoglobin levels also had decreases in platelet count over the same period. Conclusion: These results suggest that IVC filters may be another non-immune, device-related cause of decreased haptoglobin in some patients.

Inferior Vena Cava Filter - Appropriate Use and Retrieval

Inferior vena cava (IVC) filters, first introduced in 1998, have been utilized to reduce risk of pulmonary embolism (PE) in the setting of an inability to anticoagulate patients. The use of IVC filters has increased and continues to rise, especially with the introduction of retrievable IVC filters. Since their initial introduction, guidelines have been developed on the appropriate use of IVC filters. According to the American College of Chest Physicians (ACCP), the use of an IVC filter is limited to patients with an absolute contraindication to therapeutic anticoagulation or failure or complication of anticoagulation in the setting an acute proximal venous thrombus. Relative indications for IVC filter placement include high clot burden in setting of low cardiopulmonary reserve, high risk patients, or severe trauma without documented thrombosis. In 2010, the FDA announced a safety communication recommending removal of retrievable IVC filters due to reports of several adverse clinical outcomes associated with retained filters including thrombus formation, recurrent PE, filter migration, erosion or perforation through the IVC wall, and filter fracture with fragment embolization. In 2014, the FDA recommended removal of the IVC filter within 2 months after filter placement if the patient's risk of thrombosis had passed.In this retrospective analysis of IVC filter management, we reviewed indications for placement according to current guidelines as set by the ACCP, initiation of appropriate anticoagulation, complication rates, and retrieval rates. In addition, we compared the data prior to the FDA recommendations in late 2014 and data after the recommendations to determine if there was a change in practice.After reviewing 179 patients, 89 patients in 2014 and 90 patients in 2015, who underwent IVC filter placement, only 81% (N=145) of patients had appropriate indications for IVC filter placement and 30% (N=54) of patients had inappropriate anticoagulation after IVC filter placement, given as prophylactic dosing of low molecular weight heparin. A comparison of retrieval rates prior to and after the FDA warning, showed a 19% (60% in 2014 vs 79% in 2015) improvement in IVC filter removals. There was an 11% complication rate, mainly related to IVC filter related acute DVT or IVC occlusion.A root cause analysis specifically for inappropriate IVC filter placement and appropriate anticoagulation and determined that familiarity of the guidelines and non-evidence based recommendations from consultants were major factors. Based on the analysis, we next plan to utilize the electronic health record system to help clinicians understand indications and when to initiate appropriate anticoagulation, with the opportunity for hematology consultants to be involved in situations that do not clearly fit within published guidelines. DisclosuresNo relevant conflicts of interest to declare.

Temporary and Permanent Inferior Vena Cava Filters in the Oncology Population

BackgroundThe use of both temporary and permanent inferior vena cava (IVC) filters continues to rise yet randomized data regarding efficacy and complication rates are limited, especially in cancer patients. Temporary IVC filters are associated with higher costs and can have more long-term complications than permanent IVC filters. In this study, we examined the use of temporary and permanent IVC filters in the cancer population, a group at high risk for venous thromboembolism (VTE) as well as complications of anticoagulation.MethodsThis single-institution study included patients with active malignancy receiving adjuvant chemotherapy or considered for future chemotherapy that received an interventional radiology (IR) placed temporary (N=179) or permanent (N=207) IVC filter from 2009 to 2013. Patients were followed prospectively from the time of filter placement. The database included patient demographics, type of malignancy, indication for filter placement, time to filter retrieval, complications of placement/retrieval, rates of VTE recurrence and cause of death (if applicable).ResultsPatient demographic information is shown in Table 1. The most common reasons cited for filter placement included a contraindication to anticoagulation from bleeding (36%), recent or upcoming procedure (19%), thrombocytopenia (17%), and surgical prophylaxis (8%). 21% of filters were placed in patients with no contraindication to anticoagulation or failure of anticoagulation. Of these, 35% of the temporary filters were not removed. IVC filters were most frequently placed in patients with underlying hematologic malignancies (22%), gastrointestinal malignancies (22%) and lung cancer (16%). The majority of patients had stage III or IV cancer (62%).Of the 179 temporary filters placed, 60% were not retrieved. The most common reasons for failure of filter retrieval included: progressive disease/clinical deterioration (51%), continued contraindication to anticoagulation (23%) and loss of follow-up (8%). Only 2% of filters could not be removed because of mechanical reasons. Of the 81 attempted filter removals, 5 had in-filter thrombus, 4 had surrounding fibrin sheaths, 4 had filter tilt, 1 had IVC in-growth, 1 had broken struts and 1 had a procedure-related infection.The rate of recurrent VTE in all patients studied was 23% (21% in temporary filter group, 24% in permanent filter group), including 20 pulmonary emboli (PE) and 14 thromboses within the IVC filter. The majority of recurrences occurred off of anticoagulation (58%). Only 34% could be maintained on therapeutic anticoagulation. By study end, 72% of patients had died, most commonly due to progressive cancer. Median time from filter placement to death was 2.9 months (range: 0.1-64.7 months). Seventy-five patients (19%) died within 30 days of filter placement. They were more likely to have stage IV disease (78% vs. 54%). Of these 75 patients, three experienced recurrent VTE, two with lower extremity DVTs and one with an IVC thrombus. Data on filter costs were also collected. Costs were attributable to the placement and retrieval procedures when applicable ($10,983.00 and $8,824.00, respectively) as well as the device itself ($1,576.00).ConclusionsMalignancy-associated thrombosis is common and associated with a high rate of recurrence. While most recurrent VTE after IVC filter placement were deep vein thromboses, a relatively large number of PE's occurred after filter placement as well. A significant number of patients with malignancy-associated thrombosis who underwent IVC filter placement had no contraindication to anticoagulation or recurrent VTE while on anticoagulation. Better prospective studies are needed to assess the safety and efficacy of IVC filters in the setting of hemodynamic compromise, extensive clot burden or for surgical prophylaxis, especially in the oncology population. In this cohort, the majority of filters were placed in patients with advanced cancer with likely short life expectancies, suggesting the patient selection for filter placement could be optimized. Finally, the cost of filter placement and retrieval is substantial, further emphasizing the need for better prospective data to identify the subset of patients who will derive the most benefit from filter use. [Display omitted] DisclosuresStein:Incyte Corporation: Membership on an entity's Board of Directors or advisory committees, Research Funding. Lewandowski:Cook Medical: Consultancy; Boston Scientific: Membership on an entity's Board of Directors or advisory committees.

Inferior Vena Cava Filter (IVCF) Placement in a Community Hospital: Adherence to Guidelines, Retrieval Rates, and Complications

Background: IVCF use has been increasing in recent years (Stein et al., Am J Med 2011) and published work demonstrates that a significant proportion of IVCF placements are performed for prophylaxis rather than for therapeutic indications (63.4% Swami et al. Clin Appl Thromb Hemost 2014 and 41.7% Rottenstreich et al. Eur J Haematol 2015). We studied the patterns of the IVCF use, rate of filter retrieval and complications associated with IVCF use in a community hospital.Methods: Between 2010 and 2014 a total of 145 patients (92 males, 53 females) with median age of 69 years (range 20- 98), received an IVCF at a 254-bed community hospital. All of these patients' charts were reviewed and the indications for IVCF placement, types of filters used, retrieval rates, and complications were assessed for adherence to published guidelines (Caplin et al., J Vasc Interv Radiol 2011). IVCF use in cancer patients were assessed separately.Results: All of the 145 filters used at this hospital were designed to be retrievable. The median duration of follow up after IVCF placement was 27.4 months. Gunther Tulip and Bard Denali filters were used most frequently (65.5% and 27.5% respectively). Of the 145 filters placed, 103 (71%) were used in patients with accepted therapeutic indications. These 103 patients included 84 with bleeding on anticoagulant (AC), 12 pts with venous thromboembolic event (VTE) undergoing surgery, 2 with VTE on anticoagulation (AC), and 5 undergoing thrombolysis. Other therapeutic indications for use of IVCF placement included decreased cardiopulmonary reserve in 3, inability to achieve therapeutic levels of anticoagulation in 8, medical comorbidities with high risk of falls in 5, and poor compliance with medications in 2 patients.Twenty one (14.5%) patients underwent IVCF placement after deep venous thrombosis (DVT) or pulmonary embolism (PE) without any obvious contraindications to AC. Of the 145 filters inserted, only 22 (15.2%) were retrieved. Filters remained in place for a median of 91 days (range 20 - 365). No complications were encountered during the removal.Among the patients who received an IVCF, 27 (18.6%) had an underlying cancer. Therapeutic indications for IVCF use were found in 24 (88.9%) of these patients. These included bleeding in 15 patients, primary brain cancer or brain metastases in 8, and DVT despite high INR in 1. In cancer patients 3 of the 27(11.1%) filters placed were retrieved. Differences in the rates of filter placement for therapeutic indications and retrieval rates between cancer and non-cancer patients were not statistically significant.Complications of IVCF were mainly thrombotic with propagation of DVT in 21 (14.5%) patients, PE in 8, and clot in the IVCF in 3 pts. These numbers exclude thrombotic complications which occurred in the first 7 days after IVCF placement, as we considered that they could be a consequence of the initial thrombotic event unrelated to the presence of the filter. Non- thrombotic complications included three patients with IVC penetration and one in whom migration of the filter caused duodenal perforation and bleeding.Conclusions: Our results demonstrate that 71% of the IVC filters in our community hospital are placed for therapeutic indications. This compares favorably to the observations of Swami et al.(op.cit.) who found that only 36.6% of patients met therapeutic criteria for filter placement, and Rottenstreich et al.(op.cit.) who reported therapeutic reasons for placement in 58.3%. Elucidation of the factors which led to the high compliance rate reported here could result in improvement of general practice patterns. It is noteworthy that high adherence to guidelines for IVCF placement was found in patients with an underlying diagnosis of cancer (88.9%).In general, the rate of filter retrieval was low (15.2% overall and 11.1% in cancer patients) and needs improvement. More emphasis on measures to improve the rate of IVCF retrieval is warranted. DisclosuresNo relevant conflicts of interest to declare.

Evaluation of nonpermanent inferior vena cava filter placement in patients with deep venous thrombosis after lower extremity fracture: A single-center retrospective study.

To investigate nonpermanent inferior vena cava (IVC) filter in the prevention of perioperative pulmonary embolism (PE) in patients of lower extremity and/or pelvic bone fracture with deep vein thrombosis (DVT). Lower extremity or pelvic bone fracture patients with lower extremity DVT hospitalized in our hospital from January 2003 to October 2014 were retrospectively analyzed. Data was analyzed for age, gender, position of fracture, position of proximal of thrombosis, indications of placement, complications, retrieval rate, and rate of entrapped filter clot. Patients who underwent IVC filter placement were selected as the filter group. The patients who did not perform IVC filter placement after 2008 and the cases between January 2003 and December 2007 were selected as control group 1 and control group 2, respectively. The incidence of perioperative symptomatic PE and mortality were analyzed. A total of 2763 cases complicated with DVT underwent orthopedic surgery between January 2003 and October 2014. 823 nonpermanent filters were inserted. All filters were successfully deployed with no major complications. After a mean 14.2 days indwelling time, all of temporary filters were removed. Retrieval was attempted in 556 patients with retrievable filters and was successful in 545 (98%); mean indwelling time was 16.3 days. The total retrieval rate was 90%. The incidence of PE in the filter group was significantly lower compared with the two control groups. Among the patients who received chemical anticoagulant therapy, the incidence of PE in filter group, control group 1 and control group 2 were 0.14%, 1.60% and 2.10%, respectively. The incidence of PE in filter group was also significant lower compared with control groups. Nonpermanent IVC filter placement seems like to be a safe and effective method for preventing perioperative symptomatic and fatal PE in bone fracture patients with DVT in the present retrospective study.