Guidelines for the Use of Retrievable and Convertible Vena Cava Filters: Report from the Society of Interventional Radiology Multidisciplinary Consensus Conference

Endovascular Retrieval of an Inferior Vena Cava Filter With Simultaneous Caval, Aortic, and Duodenal Perforations

A 47-year-old female presented to the emergency department complaining of diffuse abdominal pain and melena. She previously had a Bard G2X inferior vena cava filter placed before undergoing a laparoscopic Roux-en-Y gastric bypass 3 years before her current presentation. She had a history of an anastomotic ulcer that was treated medically. A repeat endoscopic evaluation revealed no evidence of a recent bleed and the ulcer was healed. Computed tomography revealed evidence of multiple filter struts penetrating through the caval wall into the duodenum and aorta. The filter was successfully removed using an En Snare without complications. Reviewing the current literature, open surgical repair has been the treatment of choice for similar patient presentations. We present a successful case of the endovascular retrieval of an inferior vena cava filter with simultaneous caval, aortic, and duodenal penetrations.

Vena cava filter practices of a regional vascular surgery society

BACKGROUND

Vena cava filter (VCF) use in the United States has increased dramatically with prophylactic indications for placement and the availability of low-profile retrievable devices, which are overtaking the filter market. We surveyed the practice patterns of a large group of vascular surgeons from a regional vascular surgery society to see whether they mirrored current national trends.

METHODS

A 17-question online VCF survey was offered to all members of the Southern Association of Vascular Surgery. The responses were analyzed using the χ(2) goodness of fit tests.

RESULTS

Of the 276 members surveyed, 126 (46%) responded, with 118 (93%) indicating that they placed filters during their practice. Highly significant differences were identified with each question (at least P < 0.002). Regarding the inferior vena cava, the preferred permanent filters were the Greenfield (31%), the TrapEase (15%), the Vena Tech (5%), and a variety of retrievable devices (49%). Fifty percent of the respondents placed retrievable filters selectively; 26% always placed them; and 24% never did. Filters were placed for prophylactic indications <50% of the time by 63% of the respondents. Overall, retrievable filters (when not used as permanent filters) were removed <25% of the time by 64% of the respondents and <50% of the time by 78% of the respondents. The femoral vein was the preferred access site for 84% of the respondents. Major complications were few but included filter migration to the atrium (one), atrial perforation (one), abdominal pain requiring surgical filter removal (two), inferior vena cava thrombosis (12 vena cava thrombosis--4 due to TrapEase filters), strut fracture with embolization to heart or lungs (three Bard retrievable filters), and severe tilting precluding percutaneous retrieval and protection from pulmonary emboli (8 filters with severe tilt--7 of which were Bard). Of the respondents, 59% had never placed a superior vena cava filter, and 28% had placed five or fewer.

CONCLUSIONS

Although VCF insertion overall appears safe, some complications are specific to biconical and certain retrievable filters. Given the low removal rate and lack of long-term experience with retrievable filters, routine use of these devices as permanent filters should be questioned. If used on a temporary basis, there should be a plan for filter removal at the time of implantation.

Improving the tracking and removal of retrievable inferior vena cava filters

Therapeutic and prophylactic inferior vena cava (IVC) filters should be placed based on currently accepted indications to prevent a fatal pulmonary embolism (PE). The protective effect of filters is offset by the potential for lower extremity deep venous thrombosis (DVT), caval thrombosis, and possible otherwise unnecessary life-long anticoagulation (AC). The duration of treatment for most DVTs or PEs is 3 to 6 months of AC/filter. Filters should be retrieved when duration of treatment for a DVT/PE has been met, the risk of a PE is no longer high, and/or there is no longer a contraindication to AC. An effective system that leads to improving the retrieval rate of filters must include education of the patient, a tracking system to minimize patient lost to follow-up, and dedicated personnel to oversee the process. If these goals are accomplished, interventionalists can help decrease the incidence of a fatal PE during the high-risk period, and also decrease the risk of a DVT or the use of otherwise unnecessary life-long AC in subsequent years. Currently, there is much room for improvement in the frequency that IVCF patients are systematically followed and filters are retrieved. The principles discussed in this report will be helpful in this process.

Deep vein thrombosis: current status and nanotechnology advances

Deep vein thrombosis (DVT) affects up to 2 million people in the United States, and worldwide incidence is 70 to 113 cases per 100,000 per year. Mortality from DVT is often due to subsequent pulmonary embolism (PE). Precise diagnosis and treatment is thereby essential for the management of DVT. DVT is diagnosed by a thorough history and physical examination followed by laboratory and diagnostic tests. The choice of laboratory and diagnostic test is dependent on clinical pretest probability. Available laboratory and diagnostic techniques mainly involve D-dimer test, ultrasound, venography, and magnetic resonance imaging. The latter two diagnostic tools require high doses of contrast agents including either radioactive or toxic materials. The available treatment options include lifestyle modifications, mechanical compression, anticoagulant therapy, inferior vena cava filter, and thrombolysis/thrombolectomy. All of these medical and surgical treatments have serious side effects including improper clot clearance and increased risk of hemorrhage occurrence. Therefore, research in this field has recently focused on the development of non-invasive and accurate diagnostics, such as ultrasound enhanced techniques and molecular imaging methods, to assess thrombus location and its treatment course. The frontier of nanomedicine also shows high prospects in tackling DVT with efficient targeted drug delivery. This review describes the pathology of DVT along with successive medical problems such as PE and features a detailed listing of various diagnostic and therapeutic modalities that have been in use and are under development.

Symptomatic inferior vena cava perforation by a retrievable filter: Report of two cases and a literature review

Inferior vena cava filters have been used frequently for decades to prevent pulmonary embolism in medical, surgical and trauma patients. With the advent of temporary or retrievable filters, the use of these filters has increased substantially. However, the enhanced design and attributes that make these devices attractive for short-term benefit and retrieval are not without risk. Two cases of symptomatic inferior vena cava wall penetration are reported - one of which required surgical intervention.

Complications of temporary vena cava filter placement

BACKGROUND

Temporary vena cava filters have been used for protection from potentially fatal pulmonary embolism. However, recent reports suggested that they may be associated with serious adverse complications including filter-related thrombosis. The purpose of this study was to examine the clinical complications of temporary vena cava filter placement.

METHODS

We enrolled 40 consecutive patients from January 2006 to December 2010 who underwent percutaneous temporary vena cava filter insertion in Saitama Medical Center, Jichi Medical University.

RESULTS

Major filter complications related to temporary vena cava filters were filter thrombosis in 4 patients (10.2%), filter dislocation in 4 (10.2%), and catheter-related infection in 3 (7.7%). Massive pulmonary embolism and cardiogenic shock was observed in one case (2.5%) at the time of retraction.

CONCLUSION

Temporary filter placement was associated with a high incidence of device-related complications. The benefit of temporary filter placement should be judiciously weighed against the risk of complications.

Advances in the diagnosis and treatment of acute pulmonary embolism

Over the past two decades, considerable progress in technology and clinical research methods have led to advances in the diagnosis, treatment and prevention of acute venous thromboembolism. Despite this, however, the diagnosis is still often missed and preventive methods are often ignored. Published guidelines are useful, but are limited by the existing evidence base so that controversies remain with regard to topics such as duration of anticoagulation, indications for placement and removal of inferior vena caval filters, and when and how to administer thrombolytic therapy. The morbidity and mortality of this disease remain high, particularly when undiagnosed. While preventive approaches remain crucial, the focus of this review is on the diagnostic and therapeutic approach to acute venous thromboembolism, with an emphasis on acute pulmonary embolism.

Systematic review of the use of retrievable inferior vena cava filters

PURPOSE

To review the available literature on retrievable inferior vena cava (IVC) filters to examine the effectiveness and risks of these devices.

MATERIALS AND METHODS

Investigators searched MEDLINE for clinical trials evaluating retrievable filters and reviewed the complications reported to the Manufacturer and User Facility Device Experience (MAUDE) database of the U.S. Food and Drug Administration (FDA).

RESULTS

Eligibility criteria were met by 37 studies comprising 6,834 patients. All of the trials had limitations, and no studies were randomized. There were 11 prospective clinical trials; the rest were retrospective studies. Despite the limitations of the evidence, the IVC filters seemed to be effective in preventing pulmonary embolism (PE); the rate of PE after IVC placement was 1.7%. The mean retrieval rate was 34%. Most of the filters became permanent devices. Multiple complications associated with the use of IVC filters were described in the reviewed literature or were reported to the MAUDE database; most of these were associated with long-term use (> 30 days). At the present time, the objective comparison data of different filter designs do not support superiority of any particular design.

CONCLUSIONS

In high-risk patients for whom anticoagulation is not feasible, retrievable IVC filters seem to be effective in preventing PE. Long-term complications are a serious concern with the use of these filters. The evidence of the effectiveness and the risks was limited by the small number of prospective studies.

Vena cava interruption

Anticoagulation has been proven to be effective in preventing and treating deep vein thrombosis and pulmonary embolus. However, many critically ill patients are unable to receive anticoagulation or suffer recurrent venous thromboembolism despite adequate treatment. This article examines the use of vena cava filters in the critically ill. Indications for, techniques, and complications of vena cava filter insertion are reviewed. The importance of vena cava filters with the option to be retrieved and bedside insertion in the intensive care unit is emphasized.

Current status and trends in the treatment of acute pulmonary thromboembolism

Untreated acute pulmonary thromboembolism (APTE) is associated with high mortality, which is reduced by prompt treatment. Anticoagulation is fundamental in the treatment of APTE and should be initiated from suspicion. The efficacy and safety of novel anticoagulant drugs, such as oral anti-Xa and anti-IIa inhibitors, are topics in the treatment of APTE and are now under investigation. Thrombolytic therapy is a widely accepted treatment strategy for massive APTE, but its use for submassive APTE is controversial. Catheter intervention, percutaneous cardiopulmonary support and surgical embolectomy are also necessary and effective for some patients with APTE. A retrievable inferior vena cava filter is preferred for transient protection against APTE. Some studies have demonstrated the feasibility of outpatient treatment in patients with APTE after risk stratification.

A method for following patients with retrievable inferior vena cava filters: results and lessons learned from the first 1,100 patients

PURPOSE

Patients who have undergone implantation of a retrievable inferior vena cava (IVC) filter require continued follow-up to have the device removed when clinically appropriate and in a timely fashion to avoid potential long-term filter-related complications. The efficacy of a method for patient follow-up was evaluated based on a retrospective review of a single-institutional retrievable IVC filter experience.

MATERIALS AND METHODS

Patients with retrievable IVC filters were tracked via a prospectively collected database designed specifically for patient follow-up. Follow-up consisted of periodic review of the electronic medical record. Patients were contacted by mail (at regular intervals one or more times) when removal of the filter was deemed appropriate. A retrospective review of the ultimate fate of the first 1,127 retrievable IVC filters placed at a single institution was performed. Retrieval rates were compared with those seen in the initial experience, during which no structured follow-up was performed.

RESULTS

Of 1,127 filters placed, 658 (58.4%) were removed. Filter removal or declaration of the device as permanent was achieved in 860 patients (76.3%). Filter removal, declaration of the device as permanent, or establishment of the need for continued follow-up was achieved in 941 patients (83.5%). Only 186 patients (16.5%) were lost to follow-up.

CONCLUSIONS

The follow-up method described in the present study resulted in a statistically significant difference (P < .001) in the likelihood of a patient returning for IVC filter removal compared with a lack of follow-up (59% vs 24%).

Inferior vena cava filters: a concise review

Venous thromboembolic disease is associated with significant morbidity and mortality. Anticoagulation has been the mainstay of treatment and prevention. Unfortunately, anticoagulation frequently fails or is contraindicated. Use of inferior vena cava filters can be an effective alternative in these scenarios. Though inferior vena cava filters have been used for > 4 decades, the evidence behind their use is limited. Use of IVC filters is associated with both minor and major complications. More randomized prospective trials are needed to evaluate these devices. In this article, we review issues concerning the use of inferior vena cava filters.

Optional inferior vena cava filters in the trauma patient

Trauma patients are at exceedingly high risk of development of venous thromboembolism (VTE) including deep venous thrombosis and pulmonary embolism (PE). The epidemiology of VTE in trauma patients is reviewed. PE is thought to be the third major cause of death after trauma in those patients who survive longer than 24 hours after onset of injury. In fact, patients recovering from trauma have the highest rate of VTE among all subgroups of hospitalized patients. Various prophylactic and surveillance methods have been evaluated and found helpful in certain situations, but VTE complications can occur despite such measures. Therapeutic and prophylactic uses of inferior vena cava (IVC) filters in trauma patients are reviewed. Prophylactic IVC filter use is revealed to be a controversial subject with valid arguments on both sides of the issue. With the lack of prospective randomized trials of IVC filter use in trauma, it is impossible to make evidence-based recommendations. Unfortunately, two sets of guidelines are available for insertion of filters in trauma patients, with conflicting recommendations. The introduction of retrievable IVC filters seems to offer a unique solution for VTE protection in the trauma patient population, which often consists of younger members of our population. Lastly, current generations of FDA-approved retrieval filters are discussed.

Inferior vena cava filters

Venous thromboembolism (VTE) remains a common disease with significant clinical impact upon our patients. Diagnostic challenges occur because of the nonspecific nature of the presenting symptoms. The advent of multidetector computed tomography, methods to stratify patients into VTE risks (low, intermediate, high) along with serological assays (D-dimers), have helped direct patients through proper workup and into conclusive diagnosis. In most cases, standard medical therapy for VTE is anticoagulation therapy (OAT). In situations where standard OAT is either contraindicated or complications result from that therapy, insertion of inferior vena cava (IVC) filters is considered. Recent reports suggest that although IVC filters are able to prevent pulmonary emboli (PE) in the short and intermediate term, there appear to be long-term consequences including excess recurrent deep venous thombosis (DVT and IVC/filter occlusions). Recognition of the time sequence of IVC filter benefits and complications has encouraged development of optional IVC filters, which can be left in place indefinitely or removed usually before certain time constraints. This article will attempt to address the timing of IVC filter placements to protect patients from significant PE.

[Vena cava filters in trauma patients]

BACKGROUND

The introduction of removable inferior vena cava filters (IVCF) has created new options for the prevention of pulmonary embolisms in surgical trauma patients. We have observed increasing use in trauma patients.

PATIENTS AND METHODS

A retrospective analysis was carried out of 49 trauma patients out of 85 who received IVCFs at our level 1 trauma centre in 2008.

RESULTS

The indications for IVCF placement were multiple trauma in 33 patients, severe head injury in 13 and spinal injury in 3 patients. Of the patients 34 underwent successful removal, 11 (22%) patients had had no retrieval attempt by December 2009 and attempts at removal were unsuccessful in 3 patients. The mean age of the patients was 33.3 years.

CONCLUSION

In 2008 the vast majority of IVCFs were inserted for prophylaxis in trauma patients. To increase the number of retrieved IVCFs, responsibility for the removal should be clarified in every hospital. The indications, advantages, safety and also the design of IVCFs are still under debate. A randomized controlled trial is needed to determine the appropriate use and indications for this potentially useful device in trauma patients.

Bilateral inferior vena cava filter insertion in a patient with duplication of the infrarenal vena cava

BACKGROUND

Inferior vena cava (IVC) filter insertion is a commonly performed procedure for indications such as recurrent pulmonary emboli or contraindication to anticoagulation. Symptomatic duplication of the IVC is exceedingly rare with only a handful of cases being described in the literature.

AIM

We report an unusual case of a patient with symptomatic duplication of the IVC.

RESULT

A 53-year-old woman presented at our hospital for resection of a cerebral metastasis from a non-small cell lung cancer following a recent diagnosis of bilateral lower limb deep venous thrombosis. This required perioperative reversal of anticoagulation and IVC filter insertion. Conventional venography performed during filter insertion documented the existence of a duplicated IVC.

CONCLUSION

We present a case of a symptomatic duplication of the IVC requiring filter insertion. We review the developmental anatomy of the IVC along with the diagnostic findings and management strategies available.

Venous thromboembolism: a clinical review

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism, represents a significant source of morbidity and mortality. It is readily diagnosed with noninvasive modalities when there is a clinical suspicion. Most patients presenting with signs and symptoms of DVT have well-known risk factors, such as a history of VTE, malignancy, recent illness, or immobilization. A subset of individuals with idiopathic VTE have no readily identifiable risk factors. Therapeutic anticoagulation is the cornerstone of management in all patients with VTE. Adjunctive measures, such as thrombolysis and the use of vena cava filters, are indicated in select cases. The ideal duration of anticoagulation is unknown, but is often maintained long-term in patients with acquired or inherited thrombophilia. Warfarin is the only oral anticoagulant approved by the US Food and Drug Administration. Warfarin carries a substantial annual risk of bleeding complications, requires ongoing monitoring, and has extensive drug-drug interactions, which are causes for concern in patients requiring long-term anticoagulation. Alternative oral anticoagulants, such as direct thrombin inhibitors and factor Xa inhibitors, are subjects of active research in alternative agents for oral anticoagulation, and have been recently approved for prophylaxis in Canada and the European Union.

Prospective implementation of an algorithm for bedside intravascular ultrasound-guided filter placement in critically ill patients

BACKGROUND

Although contrast venography is the standard imaging method for inferior vena cava (IVC) filter insertion, intravascular ultrasound (IVUS) imaging is a safe and effective option that allows for bedside filter placement and is especially advantageous for immobilized critically ill patients by limiting resource use, risk of transportation, and cost. This study reviewed the effectiveness of a prospectively implemented algorithm for IVUS-guided IVC filter placement in this high-risk population.

METHODS

Current evidence-based guidelines were used to create a clinical decision algorithm for IVUS-guided IVC filter placement in critically ill patients. After a defined lead-in phase to allow dissemination of techniques, the algorithm was prospectively implemented on January 1, 2008. Data were collected for 1 year using accepted reporting standards and a quality assurance review performed based on intent-to-treat at 6, 12, and 18 months.

RESULTS

As defined in the prospectively implemented algorithm, 109 patients met criteria for IVUS-directed bedside IVC filter placement. Technical feasibility was 98.1%. Only 2 patients had inadequate IVUS visualization for bedside filter placement and required subsequent placement in the endovascular suite. Technical success, defined as proper deployment in an infrarenal position, was achieved in 104 of the remaining 107 patients (97.2%). The filter was permanent in 21 (19.6%) and retrievable in 86 (80.3%). The single-puncture technique was used in 101 (94.4%), with additional dual access required in 6 (5.6%). Periprocedural complications were rare but included malpositioning requiring retrieval and repositioning in three patients, filter tilt >/=15 degrees in two, and arteriovenous fistula in one. The 30-day mortality rate for the bedside group was 5.5%, with no filter-related deaths.

CONCLUSIONS

Successful placement of IVC filters using IVUS-guided imaging at the bedside in critically ill patients can be established through an evidence-based prospectively implemented algorithm, thereby limiting the need for transport in this high-risk population.

Permanent or temporary IVC filtration with a novel double-ring anchoring technology optional nitinol filter

Permanent or temporary implantation of inferior vena cava filters for protection against pulmonary embolism is well established. There have been numerous devices developed for this purpose, each of which has proprietary design considerations that affect performance and potentially impose limitations with regard to positioning, efficacy and risk profile. This article describes a recently developed, unique inferior vena cava filter design that employs a separated filtration component and a novel double-ring anchoring system that allows intraprocedural capture and repositioning for optimized placement. In addition, early experience suggests easy removal when desired, a high rate of filtration success and excellent caval patency.

Retrievable vena cava filters: a clinical review

Vena cava filters were developed as a method of preventing pulmonary embolism (PE) in patients with venous thromboembolism (VTE) at risk for bleeding from therapeutic anticoagulation. However, the long-term complications of filter placement, such as caval thrombosis, have mitigated some of the benefits, particularly in those patients with only a temporary contraindication to anticoagulation. Retrievable filters were designed to avoid the long-term risks of a permanent filter while still providing short-term protection against PE. As a result, their use has expanded from patients with known thrombosis to those without VTE who are at high risk for developing PE. In this review, we discuss the different types of retrievable filters, indications for their placement, complications that can occur during and after placement, and their use as prophylaxis in surgical patients. Although the use of retrievable filters in patients with known VTE is clear, further studies are needed to establish their prophylactic efficacy in the surgical patient. Until this evidence is available, we recommend that retrievable filters should be used only in patients with acute VTE who are at risk for recurrent thromboembolism and have a transient risk for bleeding.

Optional vena cava filters: indications, management, and results

BACKGROUND

When anticoagulation is contraindicated or ineffective, optional vena cava filters can be used to prevent pulmonary embolism. These devices can be removed within a defined period of time or can remain in the vena cava permanently.

METHODS

The status of optional vena cava filters was studied by a review of the relevant literature found in a selective Medline search from 2000 to 2008, including a Cochrane review and published guidelines.

RESULTS

Optional vena cava filter can be removed up to 20 weeks or even longer after insertion (depending on the filter model) in a small interventional radiological procedure if therapeutic anticoagulation has been achieved or the patient is no longer at risk for venous thromboembolism. Current studies show comparable results for optional filters and permanent filters, but there have not yet been any prospective studies comparing the two filter types.

CONCLUSIONS

Optional vena cava filters are an important addition to the management of venous thromboembolic disease. As only limited data are available to date, the use of optional filters should be considered on an individual case basis.

Guidelines and the use of inferior vena cava filters: a review of an institutional experience

BACKGROUND AND OBJECTIVES

Based on the American College of Chest Physicians 2004 antithrombotic therapy for venous thromboembolism (VTE) and the Eastern Association for the Surgery of Trauma 2002 guidelines, placement of an inferior vena cava (IVC) filter is indicated in patients who either have, or are at high risk for, VTE, but have a contraindication or failure of anticoagulation. Our aim is to compare clinical characteristics and outcomes of patients receiving IVC filters within-guidelines (WG) and outside-of-guidelines (OOG).

METHODS

The 558 patients who received an IVC filter were divided into two groups called WG or OOG. The WG group met the criteria described above and the OOG group did not have a contraindication to or a failure of anticoagulation.

RESULTS

The WG group had 362 patients and the OOG group had 196 patients. The OOG group had one (0.5%) patient with post-filter pulmonary embolism (PE), two (1%) with IVC thrombosis, and seven (3.6%) with deep vein thrombosis (DVT). The WG group had five (1.4%) patients with post-filter PE, 13 (3.6%) with IVC thrombosis, and 34 (9.4%) with DVT. All patients who developed post-filter PE had a DVT before filter placement, and patients who did not have a prior VTE event were at a significantly lower risk of developing post-filter IVC thrombosis and PE.

CONCLUSION

Our data do not support the use of an IVC filter outside of guidelines in patients without prior VTE who can tolerate anticoagulation because of the low risk of developing PE.

[Care of acute pulmonary embolism]

Pulmonary embolism (PE) is common and potentially serious. Three stages are described: mild PE, moderate PE (associated with an ultrasound right ventricular dysfunction) and severe PE (associated with a shock). In the first category, the prognosis is highly favourable (mortality under 5%) and the initial phase of anticoagulant treatment is well documented and codified: the treatment is based on heparin therapy (non fractionated or derivatives) and oral anticoagulants. In the severe forms, fibrinolysis is indicated in addition to the heparin therapy, given the very high mortality (up to 50%). However, the optimum care of moderate PE (intermediate mortality between 10 and 15%) remains uncertain, due to the inability to demonstrate a benefits-risk ratio in favour of fibrinolysis. In addition, this entity is still poorly defined. Although cardiac ultrasound data is useful, other parameters, such as pro-BNP, provide a better identification of these forms of intermediate prognosis. Although the evaluation of the new oral and injectable anticoagulants is promising, it mainly concerns mild PE. In addition, trials are currently under way in patients with a gloomier prognosis. The purpose is to validate or invalidate the indication of classic treatments (fibrinolysis) or new treatments (optional caval filters).