Use Of Inferior Vena Cava Filters Research Articles

Perioperative management of acetabular and pelvic fractures: evidence-based recommendations.

The American Academy of Orthopaedic Surgeons does not currently provide clinical practice guidelines for management of PAF. Accordingly, this article aims to review and consolidate the relevant historical and recent literature in important topics pertaining to perioperative management of PAF. A thorough literature review using PubMed, Cochrane and Embase databases was performed to assess preoperative, intraoperative and postoperative management of PAF fracture. Topics reviewed included: time from injury to definitive fixation, the role of inferior vena cava filters (IVCF), tranexamic acid (TXA) use, intraopoperative cell salvage, incisional negative pressure wound therapy (NPWT), intraoperative antibiotic powder use, heterotopic ossification prophylaxis, and pre- and postoperative venous thromboembolism (VTE) prophylaxis. A total of 126 articles pertaining to the preoperative, intraoperative and postoperative management of PAF were reviewed. Articles reviewed by topic include 13 articles pertaining to time to fixation, 23 on IVCF use, 14 on VTE prophylaxis, 20 on TXA use, 10 on cell salvage, 10 on iNPWT 14 on intraoperative antibiotic powder and 20 on HO prophylaxis. An additional eight articles were reviewed to describe background information. Five articles provided information for two or more treatment modalities and were therefore included in multiple categories when tabulating the number of articles reviewed per topic. The literature supports the use of radiation therapy for HO prophylaxis, early (< 5days from injury) surgical intervention and the routine use of intraoperative TXA. The literature does not support the routine use of iNPWT or IVCF. There is inadequate information to make a recommendation regarding the use of cell salvage and wound infiltration with antibiotic powder. While the routine use of chemical VTE prophylaxis is recommended, there is insufficient evidence to recommend the optimal agent and duration of therapy.

Inferior Vena Cava Filters and Heparin-Induced Thrombocytopenia: Yet Another Example of the Data Vacuum?

Despite being available for several decades, the clinical use of inferior vena cava filters (IVCFs) is largely informed by retrospective data and societal guidelines. Although data from prospective randomized controlled trials (RCTs) (1,2) exist that routinely discourage the use of IVCF when anticoagulants can be administered, in the majority of clinical scenarios that are encountered in daily practice, there are no such data to guide practice. In such cases, we continue to rely on data from smaller, usually retrospective, studies.

Thrombotic Risk Associated with Inferior Vena Cava Filter Placement in Patients with Heparin-Induced Thrombocytopenia

PurposeThis study sought to define thromboembolic risk and mortality in patients with heparin-induced thrombocytopenia (HIT) undergoing inferior vena cava filter (IVCF) placement, in light of the American Society of Hematology’s 2018 guidelines against routine use of IVCFs in this population. MethodsA total of 26 patients with HIT who received IVCFs were retrospectively reviewed, and the outcomes of this group were compared with those of 4,707 controls with either HIT or IVCFs alone and with reported outcomes in prior studies. ResultsThe patient group demonstrated 6- and 12-month mortality rates of 26.9% and 30.8%, respectively, which did not differ significantly from those of the control groups and were in line with published mortality rates in the literature. The measured thromboembolic risk of 19.2% in the patient group was also within the range of published rates for patients with HIT or IVCF alone. ConclusionsIVCF placement did not significantly increase the risk of thromboembolism or death in patients with HIT and may be a viable option in the subset of these patients who are not candidates for anticoagulation.

Adherence to Clinical Practice Guideline Recommendations on Low-Value Injury Care: A Multicenter Retrospective Cohort Study

ObjectivesLow-value clinical practices have been identified as one of the most important areas of excess healthcare spending. Nevertheless, there is a knowledge gap on the scale of this problem in injury care. We aimed to identify clinical practice guideline (CPG) recommendations pertaining to low-value injury care, estimate how frequently they are used in practice, and evaluate interhospital variations in their use. MethodsWe identified low-value clinical practices from internationally recognized CPGs. We conducted a retrospective cohort study using data from a Canadian trauma system (2014-2019) to calculate frequencies and assess interhospital variations. ResultsWe identified 29 low-value practices. Fourteen could be measured using trauma registry data. The 3 low-value clinical practices with the highest absolute and relative frequencies were computed tomography (CT) in adults with minor head injury (n = 5591, 24%), cervical spine CT (n = 2742, 31%), and whole-body CT in minor or single-system trauma (n = 530, 32%). We observed high interhospital variation for decompressive craniectomy in diffuse traumatic brain injury. Frequencies and interhospital variations were low for magnetic resonance imaging, intracranial pressure monitoring, inferior vena cava filter use, and surgical management of blunt abdominal injuries. ConclusionsWe observed evidence of poor adherence to CPG recommendations on low-value CT imaging and high practice variation for decompressive craniectomy. Results suggest that adherence to recommendations for the 10 other low-value practices is high. These data can be used to advance the research agenda on low-value injury care and inform the development of interventions targeting reductions in healthcare overuse in this population.

Inferior Vena Cava Filter Utilization at Kingston Health Sciences Centre: A Comparison of Practice with Guidelines

Background: Inferior vena cava (IVC) filters offer mechanical protection against pulmonary embolism in high risk patients. Guidelines have recommended their use be limited. “Don't use inferior IVC filters routinely in patients with acute venous thromboembolism” (ASH Choosing Wisely, 2013). “For patients with acute VTE who are treated with anticoagulation, the guideline recommends against the use of an inferior vena cava filter.” (CHEST Antithrombotic Therapy and Prevention of Thrombosis, 2016) IVC filters implanted for longer than 100 days confer a significantly higher risk of complications (Odds Ratio 2.3, Dinglasan et al. 2013). We sought to determine compliance with these recommendations at Kingston Health Sciences Center (KHSC), an academic tertiary referral center with 440 inpatient beds at Queen's University in Kingston, Ontario, Canada.Methods: Approval was obtained from the Queen's Health Services Research Ethics Board.Consecutive patients with IVC filter implantation at KHSC from August 1st, 2013 to August 1st, 2016 were identified through Interventional Radiology records. All charts were retrospectively reviewed in depth by one investigator followed by review and discussion. Data extracted included: patient demographics and disposition, details surrounding IVC filter insertion and removal, and IVC filter related complications. The indication for filter implantation was classified as clearly consistent or not clearly consistent with CHEST guidelines. The category ‘lesser indication’ was subsequently added for cases of a more subjective nature where definitive categorization was challenging.Results: Between August 2013 and August 2016, 95 IVC filters were implanted at KHSC. Among these, 42 (44.2%) patients were male and the median age was 67 (ages ranged from 17 to 91). The most responsible services ordering IVC filter implantation were Critical Care Medicine (37.9%), Internal Medicine (32.6%), Surgery (12.6%) and other services such as Neurology, Family Medicine and Emergency Medicine (16.9%).Complications arose in 21 patients (22.1%) including filter-associated thrombosis (11), filter migration or tilt (8), IVC penetration (5), IVC perforation (2), and one instance of suspected IVC filter seeding with methicillin sensitive Staphylococcus aureus (MSSA) leading to bacteremia. The mean dwell time of filters that were successfully removed (n=52, 54.7%) was 69.2 days, with thirteen (18.1%) remaining indwelling beyond 100 days. Of those in whom the filter was not removed (n=43), unsuccessful retrieval attempts were made in eight, 23 patients died with their filters in situ within 100 days of implantation, and in 12 patients no record of an attempt to retrieve the device was found.Indication for IVC filter insertion was clearly consistent with CHEST guidelines in 58 (61.1%) patients. Insertion alongside therapeutic anticoagulation/thrombolysis or for prophylaxis in patients without VTE occurred in 26 patients (27.4%) and was considered not consistent with current recommendations. In 8 (8.4%) patients, a ‘lesser indication’ was identified. Lesser indications included cases where there was a need to withhold anticoagulation for less than 24 hours for procedures or surgeries, such as endoscopic retrograde cholangiopancreatography (ERCPs) or ankle open reduction internal fixations (ORIFs). Three charts had insufficient information to determine compliance.Discussion: The main limitation of this study is its retrospective nature with reliance on chart documentation. In addition, it is recognized that guidelines surrounding IVC filter use do not apply to all possible clinical scenarios. Nonetheless, restricting the use of IVC filters to appropriate indications is an important endeavour. These devices are costly, can cause harm, and do not have a strong evidentiary basis. Educational initiatives are underway to optimize use of IVC filters at KHSC. Additional interventions under consideration include development of a specific requisition form listing recommended indications, and creation of an IVC filter insertion database as a prompt for timely removal. DisclosuresHay:Celgene: Research Funding; Roche: Research Funding; Abbvie: Research Funding; Kite: Research Funding; Amgen: Research Funding; Janssen: Research Funding; Novartis: Research Funding.

Association of Vena Cava Filters and Catheter-Directed Thrombolysis for Deep Vein Thrombosis With Hospital Readmissions

OBJECTIVES: The objective was to evaluate all-cause 30 days readmission rate and its association with inferior vena cava filters (IVCF) placement and catheter-directed thrombolysis (CDT) in patients with proximal and caval DVT. BACKGROUND: The rehospitalization rates and its predictors in acute proximal DVT have not been well characterized, including the impact of IVCF placement and CDT.METHODS: Patients with index hospitalization for acute proximal lower extremity DVT were evaluated for unplanned readmission rates at 30 days using Nationwide Readmission Database from 2016 to 2017. We used Cox proportional hazard model to determine the predictors of 30-days readmissions and its association with IVCF and CDT use. RESULTS: 58,306 adult patients were identified with an index hospitalization for acute proximal DVT. 533 patients died during the index admission or within 30 day from initial discharge. The unplanned 30-day rehospitalization rate among survivors of initial hospitalization was 14.7% (95% confidence interval [CI]: 14.5-15.0%). In multivariable analysis, only CDT was associated with a lower hazard for rehospitalization (HR 0.77, 0.71-0.84), whereas IVCF placement (HR 1.26, P<0.001, 95% CI 1.19-1.34), malignancy (HR 1.45, P<0.001, 95% CI 1.34-1.57), and length of stay more than 5 days (HR 1.39, P<0.001, 95% CI 1.33-1.46) were associated with higher readmission rates. CONCLUSIONS: The 30-day unplanned rehospitalization rate continues to be high in patients with acute proximal DVT. CDT was associated with lower rehospitalization rates, while IVCF placement was associated with increased rehospitalization rates. FUNDING STATEMENT: This research was funded by the Division of Cardiovascular Disease, Temple University Hospital. DECLARATION OF INTERESTS: Dr Bashir has equity interest in Thrombolex Inc. Dr. Bikdeli reports that he is a consulting expert, on behalf of the plaintiff, for litigation related to specific brand models of IVC filters. Dr. Anthony J. Comerota is an unpaid member of the Scientific Advisory Board of Thrombolex, Inc. No other disclosures are reported. ETHICS APPROVAL STATEMENT: NRD is publicly available and contains deidentified patient information, hence, the study was exempted from institutional review board assessment.

Venous Thromboembolism in Trauma: The Role of Anticoagulation and Inferior Vena Cava Filters.

Venous thromboembolism (VTE) is a significant contributor to morbidity and mortality among patients with severe trauma. Historically, prophylactic inferior vena cava filters (IVCFs) were used in high-risk trauma patients with suspected risk factors for VTE, including prolonged immobilization, and concurrent contraindication to anticoagulation. Mounting data regarding the efficacy of IVCF in this cohort, as well as concerns regarding morbidity of an in situ IVCF, have challenged this practice paradigm. In this review, we discuss the comanagement of VTE and trauma, including anticoagulation and the use of IVCF.

Efficacy and Safety of Mechanical IVC Filtration for Preventing Pulmonary Embolism in High-Risk Orthopedic Patients Undergoing Total Hip or Knee Arthroplasty

BackgroundTo determine the efficacy and safety of inferior vena cava (IVC) filters in preventing pulmonary embolism (PE) in high-risk patients undergoing hip or knee arthroplasty. Methods2857 hip or knee arthroplasty procedures between January 2013 and December 2018 were retrospectively reviewed. Patients with a preoperative history of venous thromboembolism (VTE), either PE or deep venous thrombosis (DVT), were categorized as high-risk patients. The incidence of overall VTE, PE, and DVT were compared between patients with filters and those without. The subgroup analysis was also performed by patient risk, and filter status and the incidence of VTE, PE, and DVT were compared. Variables such as filter placement, history of hypercoagulability etcetra were evaluated as risk factors for the development of postoperative VTE. ResultsIn the high-risk group, the use of IVC filters was significantly associated with a lower incidence of pulmonary embolism (0.8% vs 5.5%, P = .028). When compared with the low-risk group, the high-risk group had significantly higher incidence of PE (3.8% vs 2.0%, P = .038), DVT (11.6% vs 5.3%, P < .001), and overall VTE (15.0% vs 6.8%, P < .001). The history of VTE was associated with postoperative VTE (P < .001), PE (P = .042), and DVT (P < .001). There was no significant correlation between filter placement and postoperative VTE, DVT, or PE in the low-risk group. Filter retrieval was successful in 100% (96/96) of attempted patients with no complications. ConclusionThe use of IVC filters is significantly associated with a lower incidence in pulmonary embolism in high-risk arthroplasty patients. High-risk patients demonstrated an incidence of postoperative VTE over two times greater than other patients. Prophylactic placement of IVC filters in hip/knee arthroplasty is safe.

Dilemmas in anticoagulation and use of inferior vena cava filters in venous thromboembolism; a survey of Respiratory Physicians, Haematologists and Medical Oncologists and a review of the literature

Twenty percent of patients with Cancer Associated Thrombosis receive an inferior vena cava filter annually. Insertion is guided by practice guidelines, which do not specify or discuss the use of inferior vena cava filters in malignancy. Adherence to these guidelines is known to be variable. We aimed to see if there was consistent management of venous thromboembolism among Medical Oncologists/Haematologists and Respiratory Physicians, with respect to inferior vena cava filter use in the setting of suspected and confirmed malignancy. Medical Oncologists, Haematologists and Respiratory Physicians were surveyed with four theoretical cases. Case 1 concerns a patient who develops a pulmonary embolism following spinal surgery. Cases 2 and 4 explore the use of inferior vena cava filters in the setting of malignancy. Case 3 covers the role of inferior vena cava filters in recurrent thrombosis despite systemic anticoagulation. There were 56 responses, 32 (57%) Respiratory Physicians and 24 (43%) Haematologists/Oncologists. Respiratory Physicians were significantly more likely to insert an inferior vena cava filter in case 1 (p = 0.04) whilst Haematologists/Medical Oncologists were more likely to insert an inferior vena cava filter in case 3 (p = 0.03). No significant differences were found in cases 2 and 4. There were significant disparities in terms of type and timing of anticoagulation. Consistency of recommendations with guidelines was variable likely in part because guidelines are themselves inconsistent. The heterogeneity in responses highlights the variations in venous thromboembolism management, especially in Cancer Associated Thrombosis. International Societies should consider addressing inferior vena cava filter use specifically in the setting of Cancer Associated Thrombosis. Collaboration between interested specialities would assist in developing consistent, evidence-based guidelines for the use of inferior vena cava filters in the management of venous thromboembolism.

Inferior vena cava filters: a framework for evidence-based use.

Venous thromboembolism (VTE) is a common cause of morbidity and mortality. Although most patients can be managed safely with anticoagulation, inferior vena cava filters (IVCFs) represent an important alternative to anticoagulation in a small subset of patients. IVCF use has expanded exponentially with the advent of retrievable filters. Indications for IVCFs have liberalized despite limited evidence supporting this practice. Because indiscriminate use of IVCFs can be associated with net patient harm, knowledge of the risks and benefits of these devices is essential to optimal evidence-based practice. Patients with acute VTE and absolute contraindications to anticoagulation or major complications from anticoagulation are universally agreed indications for IVCFs. However, the reliance on IVCFs for primary VTE prophylaxis in high-risk patients is not substantiated by the available literature. This review examines trends in IVCF use, practice-based recommendations on IVCF use in various clinical scenarios, complications associated with indwelling IVCFs, and indications for IVCF retrieval.

Utility of Inferior Vena Cava Filter in the Management of Venous Thromboembolism Among Patients with Brain Metastases: A Population-Based Study

Background: Brain metastases are a frequently occurring and devastating complication of solid organ malignancies. Individuals with brain metastases are noted to be high risk for venous thromboembolism (VTE) due to hypercoagulability from their malignancy, immobility, and need for cancer directed therapies. The management of VTE in patients with brain metastases is challenging due to the risk of intracranial hemorrhage (ICH) with therapeutic anticoagulation. Inferior vena cava filter (IVCF) are often used to mitigate the risk of ICH, however the utility of this practice and the impact on survival is not clear. Methods: We performed a retrospective cohort study using the linked California Cancer Registry (CCR) and California Patient Discharge Database (PDD) between 2005-2017 with follow up available to 2018. We identified individuals with breast and lung cancer (because they are common), and renal cell carcinoma and melanoma (because of bleeding tendency of brain metastases) who had an incident hospitalization with VTE (either pulmonary embolism, deep vein thrombosis or both). Brain metastasis were identified using the presence of International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) code 198.3 or ICD-10-CM code C79.31 present anytime in PDD and cases were classified as having brain metastases if the code was present prior to or at the time of the index VTE. Cases with multiple malignancies were excluded. ICD-9-CM code 38.7 and ICD-10-CM code 02HV was used to identify patients who received an IVCF. Univariate analysis was used to determine differences in baseline characteristics between those that did and did not receive an IVCF. A logistic regression model that included patient and index VTE hospital characteristics was used to develop a propensity score for IVCF placement. The primary outcomes were 30-day mortality and 180-day intracranial hemorrhage (ICH) determined by ICD codes. A Cox proportional hazards model, inverse propensity weighted for IVCF placement, was used to assess the effect of IVCF placement (as a time-dependent variable) on 30-day mortality. The effect of IVCF on ICH was assessed with a 1:3 propensity matched Fine-Gray model, accounting for the competing risk of death. Results: There were 17,182 patients with a diagnosis of VTE present on admission and an active first primary cancer diagnosis of interest, of these 3,309 (19.3%) had a diagnosis of brain metastasis with median follow-up of 96.8 months. The baseline characteristics of patients are summarized in Table 1. Among patients with brain metastases, 757 of 3309 (22.9%) had an IVCF inserted versus 1801 of 13873 (13.0%) in those without brain metastases (p&amp;lt;0.001). In a multivariable logistic regression model the presence of brain metastasis was an independent predictor for the placement of IVCF (Odds Ratio (OR) 1.84 (95% CI 1.64-2.05). Using balanced (standardized mean difference less than 0.1 for all covariates included in the model) IPW-adjusted Cox regression model, the use of IVCF did not reduce the 30-day risk of death in those with acute VTE (Hazard Ratio (HR) 1.08 (95% CI 0.95-1.23). The presence of brain metastases was associated with a higher 30-day risk of death (HR 1.23 (95% CI 1.13- 1.35). Using IPW-adjusted Cox model restricted to those with brain metastasis, IVCF use was associated with a trend towards reduced 30-day risk of death (HR 0.86 (95% CI 0.73-1.01). In a propensity matched Cox regression competing risk model, the presence of brain metastases was significantly associated with an increased 180-day risk of ICH (HR 6.91 (95% CI 3.54-13.48), with no difference for those that received an IVCF (HR 1.31 (95% CI 0.85-2.01). When compared to breast cancer patients, those with lung cancer had lower risk of ICH (HR 0.28, CI 0.13-0.64), but melanoma and renal cell cancer did not have higher risk. Conclusions: This real-world retrospective population-based study demonstrated the use of IVCF was higher for patients with brain metastases among these four tumor types. There was a suggestion of reduced short-term mortality associated with IVCF placement in VTE patients and brain metastases, but this was not statistically significant. Although limited by the lack of data on anticoagulation use, there was no effect of IVCF placement on the risk of ICH. Randomized clinical trials are needed to determine the effect of IVCF on clinically relevant outcomes for VTE in patients with brain metastasis. Disclosures Key: Takeda: Research Funding; Grifols: Research Funding; Uniqure: Consultancy; Novo Nordisk: Other: Chair of Grants Committee. Wun:Glycomimetics, Inc.: Consultancy.

Long-term effects of non-retrieved inferior vena cava filters on recurrences of venous thromboembolism in cancer and non-cancer patients: From the COMMAND VTE registry

There is a paucity of data comparing the long-term outcomes after inferior vena cava (IVC) filters placement for patients with acute venous thromboembolism (VTE) between those with and without active cancer. In the COMMAND VTE Registry, we evaluated the effects of IVC filter use on the long-term clinical outcomes stratified by the presence and absence of active cancer. Among 2,626 patients with acute symptomatic VTE, there were 604 patients with active cancer, and 2022 patients without active cancer. IVC filters were placed and not retrieved in 455 patients (17%) in the entire cohort, in 150 patients (24.8%) in the active cancer stratum, and in 305 patients (15.1%) in the non-cancer stratum. In the entire cohort, non-retrieved IVC filter placement was not associated with a lower adjusted risk for PE recurrence (HR 0.59, 95% CI 0.30-1.15, P=0.122), but with an increased adjusted risk for DVT recurrence (HR 2.27, 95% CI 1.43-3.60, P<0.001). In the non-cancer stratum, the non-retrieved IVC filter placement was associated with a decreased risk for PE (HR 0.29, 95% CI 0.09-0.93, P=0.037), but not with an increased risk for DVT (HR 1.73, 95% CI 0.89-3.38, P=0.108), while in the active cancer stratum, it was associated with an increased risk for DVT (HR 2.47, 95% CI 1.24-4.91, P=0.010), but not with a decreased risk for PE (HR 0.82, 95% CI 0.34--1.96, P=0.650). There were some differences in the risk-benefit balance between VTE patients with and without active cancer.

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 Care for Acute Pulmonary Embolism Through A Multidisciplinary Pulmonary Embolism Response Team

BackgroundOptimal management of acute pulmonary embolism requires expertise offered by multiple subspecialties. As such, pulmonary embolism response teams (PERTs) have increased in prevalence, but the institutional consequences of a PERT are unclear. MethodsWe compared all patients that presented to our institution with an acute pulmonary embolism in the 3 years prior to and 3 years after the formation of our PERT. The primary outcome was in-hospital pulmonary embolism-related mortality before and after the formation of the PERT. Sub-analyses were performed among patients with elevated-risk pulmonary embolism. ResultsBetween August 2012 and August 2018, 2042 patients were hospitalized at our institution with acute pulmonary embolism, 884 (41.3%) pre-PERT implementation and 1158 (56.7%) post-PERT implementation, of which 165 (14.2%) were evaluated by the PERT. There was no difference in pulmonary embolism-related mortality between the two time periods (2.6% pre-PERT implementation vs 2.9% post-PERT implementation, P = .89). There was increased risk stratification assessment by measurement of cardiac biomarkers and echocardiograms post-PERT implementation. Overall utilization of advanced therapy was similar between groups (5.4% pre-PERT implementation vs 5.4% post-PERT implementation, P = 1.0), with decreased use of systemic thrombolysis (3.8% pre-PERT implementation vs 2.1% post-PERT implementation, P = 0.02) and increased catheter-directed therapy (1.3% pre-PERT implementation vs 3.3% post-PERT implementation, P = 0.05) post-PERT implementation. Inferior vena cava filter use decreased after PERT implementation (10.7% pre-PERT implementation vs 6.9% post-PERT implementation, P = 0.002). Findings were similar when analyzing elevated-risk patients. ConclusionPulmonary embolism response teams may increase risk stratification assessment and alter application of advanced therapies, but a mortality benefit was not identified.

Permanent inferior vena cava filters offer greater expected patient utility at lower predicted cost

ObjectiveRetrievable inferior vena cava (IVC) filters were first approved for use in the United States in 2003 to address the long-term complications of migration, thrombosis, fracture, and perforation observed with permanent IVC filter implantation. Although Food and Drug Administration approval of retrievable IVC filters includes permanent implantation, the incidence of complications from long-term implantation appears to be greater than that reported with existing permanent IVC filters. Also, only a small fraction of such retrievable IVC filters are ever retrieved. The purpose of the present study was to determine the threshold retrieval rate at which the use of retrievable IVC filters could be justified. MethodsA Markov decision tree was constructed comparing retrievable and permanent IVC filters regarding their effectiveness and cost. A review of the reported data provided outcome probabilities, and the Tufts Medical Center Cost-Effectiveness Analysis Registry was the source of the utility values for the various potential outcomes. Medicare reimbursement rates served as a proxy for costs. A sensitivity analysis was performed for various parameters, primarily to determine the retrieval rate threshold at which the use of retrievable IVC filters would outperform the use of permanent IVC filters. ResultsBase case analysis demonstrated a greater predicted effectiveness for permanent compared with retrievable IVC filter implantation (5.41 quality-adjusted life-years [QALY] vs 5.33 QALY) at a lower cost ($2070 vs $4650). Monte Carlo simulation at 10,000 iterations confirmed the expected utility (5.4 ± 3.0 QALY vs 5.3 ± 3.0 QALY; P = .0002) and cost ($1900 ± $7400 vs $4800 ± 9900; P < .0001) to be statistically superior for permanent IVC filters. A sensitivity analysis for the filter retrieval rate demonstrated that the strategy of using a retrievable IVC filter was never preferable for utility or cost. The superiority of permanent IVC filter placement for effectiveness and cost persisted, regardless of anticipated patient-predicted annual mortality. A two-way sensitivity analysis for both IVC filter removal rate and annual patient mortality confirmed the superiority of permanent IVC filter placement at all levels. ConclusionsThe predicted effectiveness of permanent IVC filters was greater and the predicted cost lower than those for retrievable IVC filters, regardless of the IVC filter retrieval rate. This interpretation of existing reported data using Markov decision analysis modeling supports the argument that unless the long-term complication rate of retrievable IVC filters can be significantly improved, their use should be abandoned in favor of currently available permanent IVC filters.

Racial disparities in inferior vena cava filter use in metabolic and bariatric surgery patients: Nationwide insights from the MBSAQIP database

BackgroundProphylactic inferior vena cava (IVC) filter use in bariatric surgery patients is a physician- and patient-dependent practice pattern with unclear safety and efficacy. Factors that mediate physicians’ decisions for IVC filter placement preoperatively remain unclear. The role of race in decision-making also remains unclear. MethodsFrom the 2015–2016 MBASQIP database, patient characteristics leading to IVC filter use and outcomes after IVC filter placement were compared between Black and White primary bariatric surgery patients. ResultsProphylactic IVC filter was used in 0.66% of Black and White patients. IVC filter use was three-fold higher in Black patients, despite this cohort having a lower venous thromboembolism (VTE) risk profile than White counterparts. Black race was an independent predictor for IVC filter placement on multivariate analysis. After receiving an IVC filter, Black patients had higher rates of 30-day adverse outcomes. ConclusionsIn this study, Black race was independently associated with the likelihood of receiving a prophylactic IVC filter, despite lower rates of VTE risk factors and lack of recommendations for its use. Further research is needed to explore why this disparity in clinical practice exists.

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.

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.

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