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Desai SP, Yu CZ, Evangelista F, Gill JR. Perforation of the Heart During Elective Removal of an Inferior Vena Cava Filter. Am J Forensic Med Pathol 2024:00000433-990000000-00183. [PMID: 38833346 DOI: 10.1097/paf.0000000000000947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
ABSTRACT A common treatment for venous thromboembolic disease in patients with contraindications to anticoagulation includes placement of an inferior vena cava (IVC) filter. Temporary filters are available to avoid the risk of long-term permanent placement. A woman in her 60s with a history of uterine serous carcinoma presented to the emergency department with cardiac arrest following elective attempted IVC filter removal. Three months prior, a temporary filter was placed because anticoagulation medication was stopped in preparation for a hysterectomy. During the IVC retrieval procedure, which was performed using an intravascular approach from the right jugular vein, the filter was tilted, requiring the use of a different retrieval sheath. During catheter reentry, the patient complained of discomfort in the chest and neck, after which she became hypotensive, lost consciousness, and died. Autopsy revealed 2 cardiac perforations, one in each ventricle. Approximately 600 mL of liquid and clotted blood was within the tense pericardial sac. An IVC filter was found in place, with no adjacent hemorrhage.To our knowledge, this is the first reported fatality due to cardiac perforation by an access sheath during intravascular removal of an IVC filter. This instance also documents the time course of the cardiac perforations to the resultant loss of consciousness.
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Affiliation(s)
- Sapna P Desai
- From the Office of the Chief Medical Examiner, Farmington, CT
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Stawicki S, Sims C, Sharma R, Weger N, Truitt M, Cipolla J, Schrag S, Lorenzo M, Chaar MEL, Torigian D, Kim P, Sarani B. Vena Cava Filters: A Synopsis of Complications and Related Topics. J Vasc Access 2018. [DOI: 10.1177/112972980800900204] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Deep venous thrombosis and pulmonary embolism constitute common preventable causes of morbidity and mortality. The incidence of venous thromboembolism (VTE) continues to increase. Standard anticoagulation therapy may reduce the risk of fatal PE by 75% and that of recurrent VTE by over 90%. For patients who are not candidates for anticoagulation, a vena cava filter (VCF) may be beneficial. Despite a good overall safety record, significant complications related to VCF are occasionally seen. This review discusses both procedural and non-procedural complications associated with VCF placement and use. We will also discuss VCF use in the settings of pregnancy, malignancy, and the clinical need for more than one filter.
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Affiliation(s)
- S.P. Stawicki
- Department of Surgery, Division of Critical Care, Trauma and Burns, The Ohio State University Medical Center, Columbus, OH - USA
- OPUS 12 Foundation, Inc, King of Prussia, PA - USA
| | - C.A. Sims
- Department of Surgery, Division of Traumatology and Surgical Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA - USA
- OPUS 12 Foundation, Inc, King of Prussia, PA - USA
| | - R. Sharma
- Department of Surgery, Easton Hospital, Easton, PA - USA
- OPUS 12 Foundation, Inc, King of Prussia, PA - USA
| | - N.S. Weger
- Beth Israel Medical Center, Newark, NJ - USA
- OPUS 12 Foundation, Inc, King of Prussia, PA - USA
| | - M. Truitt
- Department of Surgery, Methodist Hospital, Dallas, TX - USA
- OPUS 12 Foundation, Inc, King of Prussia, PA - USA
| | - J. Cipolla
- St. Luke's Regional Resource Level I Trauma Center, Bethlehem, PA - USA
- OPUS 12 Foundation, Inc, King of Prussia, PA - USA
| | - S.P. Schrag
- Department of Surgery, Division of Trauma and Surgical Critical Care, Vanderbilt University School of Medicine, Nashville, TN - USA
- OPUS 12 Foundation, Inc, King of Prussia, PA - USA
| | - M. Lorenzo
- Department of Surgery, Methodist Hospital, Dallas, TX - USA
- OPUS 12 Foundation, Inc, King of Prussia, PA - USA
| | - M. EL Chaar
- Department of Surgery, Methodist Hospital, Dallas, TX - USA
- OPUS 12 Foundation, Inc, King of Prussia, PA - USA
| | - D.A. Torigian
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA - USA
| | - P.K. Kim
- Department of Surgery, Division of Traumatology and Surgical Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA - USA
- OPUS 12 Foundation, Inc, King of Prussia, PA - USA
| | - B. Sarani
- Department of Surgery, Division of Traumatology and Surgical Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA - USA
- OPUS 12 Foundation, Inc, King of Prussia, PA - USA
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Urias D, Silvis J, Mesropyan L, Oberlander E, Simunich T, Tretter J. Retrievable inferior vena cava filters in geriatric trauma: Is there an age bias? Injury 2017; 48:148-152. [PMID: 27503315 DOI: 10.1016/j.injury.2016.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 05/02/2016] [Accepted: 07/04/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Trauma patients are at increased risk for developing venous thromboembolic (VTE) disease. The EAST (Eastern Association for the Surgery of Trauma) practice management guidelines identified risk factors for VTE, as well as indications for prophylactic inferior vena cava filters (IVCF). In a 2009 study, our institution found a 26% retrieval rate for IVCF. Lack of retrieval was most consistently due to lack of follow-up. Our study is a follow-up analysis for retrieval rate of IVCF, since the formation of a geriatric trauma service. We anticipated that geriatric trauma patients would have a lower rate of IVCF retrieval compared to the general trauma patient. METHODS Our study population consisted of trauma patients admitted from January 2008 to August 2013, with documented VTE or high risk for VTE with contraindication to anticoagulation. INCLUSION CRITERIA IVCF placed in trauma patients. EXCLUSION CRITERIA permanent filters, retrievable filters placed permanently, non-trauma patients, superior vena cava filters and patients who died before discharge. RESULTS During the study period, 160 trauma patients had an IVCF placed, of which 147 survived and were discharged. Of those patients, 66% (97/147) were planned for retrieval. Overall, the retrieval rate was 34% (33/97). Following age categorization, rates were 47% (30/64) and 9% (3/33) for those <65 and >/=65 years old, respectively. Applying Fisher's Exact Test to a crosstab of planned retrieval by age category yielded a statistically significant difference, p<0.0005 at alpha=0.05. In the geriatric population with IVCFs not retrieved, 23% (7/30) died and 67% (20/30) were lost to follow-up. CONCLUSION IVCF plays a critical role in the management of trauma patients with VTE, particularly the geriatric population. Since our 2009 study, we have improved nearly ten percentage points (26% to 34%); however, we exposed an age bias with retrieval rate being lower in patients >/=65 compared to those <65 (9% vs. 47%).
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Affiliation(s)
- Daniel Urias
- General Surgery Resident Conemaugh Memorial Medical Center, Johnstown, PA, United States.
| | - Jennifer Silvis
- General Surgery Resident Conemaugh Memorial Medical Center, Johnstown, PA, United States.
| | - Lusine Mesropyan
- General Surgery Resident Conemaugh Memorial Medical Center, Johnstown, PA, United States.
| | - Emma Oberlander
- General Surgery Resident Conemaugh Memorial Medical Center, Johnstown, PA, United States.
| | - Thomas Simunich
- Research Associate Conemaugh Memorial Medical Center, Johnstown, PA, United States.
| | - James Tretter
- Vascular Surgeon Valley Health Winchester, VA, United States.
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Abstract
Venous thromboembolism (VTE) is a common complication among patients in the intensive care unit. While anticoagulation remains standard therapy, vena caval filters are an important alternative when anticoagulation is contraindicated. To determine the safety and efficacy of vena caval filters in the treatment of VTE, a comprehensive review of the English-language medical literature was performed. Except for one randomized controlled trial, the literature supporting the use of vena caval filters consists almost exclusively of case series, which in many instances are limited by incomplete and short follow-up. While case series suggest that filters function effectively in the prevention of pulmonary embolism (2%-4% symptomatic pulmonary embolism [PE], fatal PE < 2%), recent higher quality studies indicate that filters may not provide significant additional protection to that provided by anticoagulation alone. Furthermore, filters are associated with a 2- fold increase in the incidence of recurrent DVT. Until randomized comparative studies are available, the safety and efficacy of all the available devices should be considered to be roughly equivalent. Since filters do not inhibit continued clot formation, all filter patients should receive anticoagulation for durations appropriate for their thrombotic disorder. Although extended anticoagulation may prevent thrombotic complications associated with filter placement, this strategy has yet to be experimentally tested. While many additional indications for vena caval filter use have been proposed (VTE in cancer patients, PE prophylaxis in trauma patients, etc), well-designed clinical trials demonstrating their efficacy in these situations are lacking. Further development of temporary/retrievable filters, which offer the potential to avoid the long-term complications of permanent filters, should be a research priority. Until additional data are available, vena caval filters should generally be restricted to patients with VTE who cannot receive anticoagulation.
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Affiliation(s)
- Michael B Streiff
- Department of Medicine, Division of Hematology, Johns Hopkins University School of Medicine, Ross Research Building, Room 1025, 720 Rutland Avenue, Baltimore, MD 21205, USA
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Vrachliotis TG, Tachtaras A, Doundoulakis N, Sheiman RG, Papadopoulos V, Stringaris KA. Percutaneous Management of Extensive Clot Trapped in a Temporary Vena Cava Filter. J Endovasc Ther 2016; 10:1001-5. [PMID: 14656168 DOI: 10.1177/152660280301000525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To present percutaneous management of extensive clot trapped in a temporary inferior vena cava (IVC) filter. Case Report: A 20-year-old man with a large sacral tumor and left external iliac vein thrombosis had a wire-mounted Günther temporary filter (GTF) prophylactically placed in the infrarenal IVC prior to tumor resection. The 7-day postsurgical venogram prior to filter removal showed extensive clot trapped by the filter, as well as interval cephalic migration, with the filter tip now at the level of the renal veins. A Günther Tulip MReye (GTM) filter was deployed but not released above the renal veins to prevent clot migration during caudal withdrawal of the wire-mounted GTF. After creating enough space in the infrarenal IVC, the GTM was repositioned and fully released with its apex now below the renal veins. The GTF was then uneventfully removed. There was no clinical evidence for significant pulmonary embolism 12 months after placement. Conclusions: Cephalic migration of a clotted temporary IVC filter can be managed with intraprocedural protection against pulmonary embolism by first deploying a Günther Tulip filter above the renal veins, with subsequent advancement below the renal veins before temporary filter removal.
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Affiliation(s)
- Thomas G Vrachliotis
- Department of Diagnostic Imaging/Interventional Radiology, Henry Dynant Hospital, Athens, Greece.
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Outcomes of patients requiring insertion of an inferior vena cava filter. Blood Coagul Fibrinolysis 2014; 25:266-71. [DOI: 10.1097/mbc.0000000000000050] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Preventing venous thromboembolism in major orthopaedic surgery. CURRENT ORTHOPAEDIC PRACTICE 2013. [DOI: 10.1097/bco.0b013e31828b2b07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ni H, Win LL. Retrievable inferior vena cava filters for venous thromboembolism. ISRN RADIOLOGY 2013; 2013:959452. [PMID: 24967292 PMCID: PMC4045516 DOI: 10.5402/2013/959452] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 03/25/2013] [Indexed: 11/23/2022]
Abstract
Inferior vena cava (IVC) filters are used as an alternative to anticoagulants for prevention of fatal pulmonary embolism (PE) in venous thromboembolic disorders. Retrievable IVC filters have become an increasingly attractive option due to the long-term risks of permanent filter placement. These devices are shown to be technically feasible in insertion and retrieval percutaneously while providing protection from PE. Nevertheless, there are complications and failed retrievals with these retrievable filters. The aim of the paper is to review the retrievable filters and their efficacy, safety, and retrievability.
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Affiliation(s)
- Han Ni
- Internal Medicine, Faculty of Medicine, SEGi University, No. 9 Jalan Teknologi, Taman Sains Selangor, Kota Damansara, PJU 5, 47810 Petaling Jaya, Selangor, Malaysia
| | - Lei Lei Win
- Paediatrics, Faculty of Medicine, SEGi University, No. 9 Jalan Teknologi, Taman Sains Selangor, Kota Damansara, PJU 5, 47810 Petaling Jaya, Selangor, Malaysia
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Baptista R, Fonseca J, Marconi L, Furriel F, Prieto D, Bento C, Antunes MJ, Figueiredo A. An unusual cause of acute cardiogenic shock in the operating room. Echocardiography 2013; 30:E75-7. [PMID: 23305136 DOI: 10.1111/echo.12094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A 51-year-old man with a renal carcinoma with inferior vena cava (IVC) invasion was referred to our hospital for the performance of a radical nephrectomy with IVC thrombus excision. To prevent embolism, an IVC filter was implanted the day before surgery below the suprahepatic veins. On nephrectomy completion, the clinical status of the patient started to deteriorate and an unsuccessful attempt was made to excise the IVC thrombus. The patient developed profound refractory hypotension without significant bleeding and worsening splanchnic stasis was noted. A transesophageal echocardiogram was immediately performed in the operating room, revealing a hemispheric mass protruding from the IVC ostium to the right atrium, completely blocking all venous return. Volume depletion was evident by low left and right atrial volumes and increased septum mobility. No other abnormalities were found that could explain the shock, namely ventricular dysfunction or valvular disease. Cardiac surgery consultation was immediately obtained, ultimately deciding to perform a median sternotomy with direct exploration of right atrium. Under cardiopulmonary bypass, a 6-cm long thrombotic mass was identified, involving the IVC filter, blocking all lower body venous return; the removal of the mass reversed the shock. The patient had an uneventful recovery. Adverse outcomes associated with IVC filters are common. Our case highlights the importance of a team approach to rapid changes in hemodynamic status in the operating room, including the surgeon, the anesthesiologist, and the cardiologist. It also emphasizes the pivotal role of transesophageal echocardiogram in the clinical evaluation of severely unstable patients.
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Affiliation(s)
- Rui Baptista
- Department of Cardiology, Coimbra University Hospital, Coimbra, Portugal
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Xiao L, Shen J, Tong JJ, Zhang Z, Mu XL, Yi ZJ, Bai S, Xu K. Transcatheter thrombolytic therapy for symptomatic thrombo-occlusion of inferior vena cava filter. Exp Ther Med 2012; 5:533-538. [PMID: 23403505 PMCID: PMC3570124 DOI: 10.3892/etm.2012.843] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 11/19/2012] [Indexed: 01/26/2023] Open
Abstract
Thrombus within an inferior vena cava (IVC) filter reduces filter patency and venous return from the lower extremities, and may progress to complete IVC occlusion. The clinical experiences and outcomes of transcatheter thrombolytic therapy for symptomatic IVC thrombosis following filter implantation have not been widely reported. The aim of the current study was to evaluate the efficiency and safety of trans-catheter thrombolysis for the treatment of symptomatic IVC thrombosis in patients with implanted IVC filters. Transcatheter thrombolysis was used to treat 5 patients with thrombosis of the filter-bearing IVC causing symptoms in 10 limbs from October 2005 to September 2010. The patients were implanted with a second IVC filter through the right internal jugular vein, followed by recanalization of the occluded IVC and intravenous transcatheter thrombolysis. The IVC filters were retrieved through the femoral or right internal jugular vein after the thrombus had dissolved. Technical and clinical outcome, complications and postoperative pulmonary embolism were monitored. A total of 5 filters were implanted and 6 filters were retrieved later. Technically and clinically successful recanalization and thrombolysis were achieved in 5 of 5 patients and 10 of 10 symptomatic limbs. The median thrombolysis period was 13 days (range, 8-14 days). The median dwell time for the filters that were removed was 50.5 days (range, 14-73 days). No major bleeding occurred during the current study. During clinical follow-up, no clinically detectable pulmonary embolism was observed. Endovascular recanalization and transcatheter thrombolysis of IVC thrombosis are efficient, feasible and safe in the presence of an IVC filter.
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Affiliation(s)
- Liang Xiao
- Department of Radiology, The First Hospital of China Medical University, Liaoning, Shenyang 110001
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McClendon J, Oʼshaughnessy BA, Smith TR, Sugrue PA, Halpin RJ, Morasch M, Koski T, Ondra SL. Comprehensive assessment of prophylactic preoperative inferior vena cava filters for major spinal reconstruction in adults. Spine (Phila Pa 1976) 2012; 37:1122-9. [PMID: 22281478 DOI: 10.1097/brs.0b013e31824abde2] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective data analysis. OBJECTIVE To report a comprehensive assessment of preoperative prophylactic inferior vena cava (IVC) filter placement in spine surgery. SUMMARY OF BACKGROUND DATA Venous thromboembolism (VTE) is a serious complication after major spinal reconstructive surgery in adults. Specifically, pulmonary embolism (PE) can result in significant morbidity and mortality, and it has been reported in up to 13% of patients. Prophylactic IVC filter placement was initiated for all "high-risk" spinal surgery patients after a pilot study demonstrated decreased VTE-related morbidity and mortality. METHODS After institutional review board approval, the medical records of all patients receiving an IVC filter at a single institution from 2000 to 2007 were reviewed. Age, sex, surgical approach, postoperative deep vein thrombosis (DVT), postoperative superficial thrombus, presence of pulmonary or paradoxical embolus, mortality, and IVC filter complications were all evaluated. Indications for IVC filter placement included history of DVT or PE, malignancy, hypercoagulability, prolonged immobilization, staged procedures of longer than 5 segment levels, combined anterior-posterior approaches, iliocaval manipulation during exposure, and anesthetic time of more than 8 hours. Descriptive statistics were used for the analysis of patient characteristics. Nonparametric frequency statistics (odds ratios [OR], χ) were used for analysis of main outcomes. RESULTS A total of 219 patients (150 women, 69 men) with a mean age of 58.8 (range, 17-86) years, were analyzed. There were 2 complications from IVC filter placement (66 Greenfield filters; 157 retrievable filters). The incidence of lower extremity DVT was 18.7% (41/219) in 36 patients. PE incidence was 3.7% (8/219 patients), and the paradoxical embolus rate was 0.5% (1 patient). Prophylactic IVC filter use reduced the odds of developing a pulmonary embolus (OR = 3.7, P < 0.05) compared with population controls. Patients receiving Greenfield filters had significantly higher VTE incidence than those receiving retrievable filters (OR = 2.8, P = 0.008). Anesthesia duration of more than 8 hours significantly increases VTE incidence (P = 0.029). No statistical significance (P < 0.05) was noted with combined anterior-posterior approach (118 patients) versus posterior-only approach (101 patients) and the incidence of DVT (24/118, 20.3% for former; 17/101, 16.8% for latter). There were a total of 14 deaths; none related to PE or paradoxical embolism during an 8-year period. Mean and median follow-up was 2.8 and 2.4 years, respectively, with 126 achieving 2 or more years of follow-up. CONCLUSION VTE-related morbidity and mortality have heightened the awareness within the spine community to the perioperative management of patients undergoing major spinal reconstruction. Prophylactic IVC filter placement significantly lowers VTE-related events, including PE development, than population controls.
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Affiliation(s)
- Jamal McClendon
- Department of Surgery, Northwestern Memorial Hospital, Chicago, IL 60611, USA.
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Caplin DM, Nikolic B, Kalva SP, Ganguli S, Saad WEA, Zuckerman DA. Quality improvement guidelines for the performance of inferior vena cava filter placement for the prevention of pulmonary embolism. J Vasc Interv Radiol 2011; 22:1499-506. [PMID: 21890380 DOI: 10.1016/j.jvir.2011.07.012] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Revised: 07/18/2011] [Accepted: 07/16/2011] [Indexed: 02/03/2023] Open
Affiliation(s)
- Drew M Caplin
- Department of Radiology, Division of Interventional Radiology, North Shore University Hospital, Manhasset, New York, USA.
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Vo NJ, Wieseler KW, Burdick TR, Goswami GK, Vaidya SS, Andrews RT. The use of paired optionally retrievable günther tulip filters in trauma patients with anatomical variants. Semin Intervent Radiol 2011; 24:20-8. [PMID: 21326731 DOI: 10.1055/s-2007-971197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Inferior vena cava (IVC) filtration is commonly performed to protect against pulmonary embolism in acutely injured patients with contraindications for anticoagulation therapy. Increasingly, optionally retrievable IVC filters are utilized, particularly in younger patients with longer life expectancies. There are well-described anatomical variants that preclude the typical infrarenal deployment of IVC filters. We describe three cases in which trauma patients with congenital anomalies required temporary prophylaxis with IVC filters. One patient had a duplication of the IVC requiring filter deployment in each IVC limb. The second patient had a low inserting accessory left renal vein, and a third patient had a megacava. Both of these patients required filter deployment in each common iliac vein. In each case, a pair of optionally retrievable Günther Tulip filters was deployed and subsequently retrieved.
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Affiliation(s)
- Nghia-Jack Vo
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Washington and Harborview Medical Center, Seattle, Washington
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Hill N, Hassan M, Chaudhari L, Asem AA. The use of vena cava filters in laparoscopic removal of the cervix after subtotal hysterectomy. J OBSTET GYNAECOL 2011; 31:87-8. [PMID: 21281006 DOI: 10.3109/01443615.2010.522270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- N Hill
- Department of Obstetrics and Gynecology, Princess Royal University Hospital, Farnborough, UK.
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Spangler EL, Dillavou ED, Smith KJ. Cost-effectiveness of guidelines for insertion of inferior vena cava filters in high-risk trauma patients. J Vasc Surg 2010; 52:1537-45.e1-2. [PMID: 20843631 DOI: 10.1016/j.jvs.2010.06.152] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Revised: 06/07/2010] [Accepted: 06/07/2010] [Indexed: 01/28/2023]
Abstract
BACKGROUND Inferior vena cava filters (IVCFs) can prevent pulmonary embolism (PE); however, indications for use vary. The Eastern Association for the Surgery of Trauma (EAST) 2002 guidelines suggest prophylactic IVCF use in high-risk patients, but the American College of Chest Physicians (ACCP) 2008 guidelines do not. This analysis compares cost-effectiveness of prophylactic vs therapeutic retrievable IVCF placement in high-risk trauma patients. METHODS Markov modeling was used to determine incremental cost-effectiveness of these guidelines in dollars per quality-adjusted life-years (QALYs) during hospitalization and long-term follow-up. Our population was 46-year-old trauma patients at high risk for venous thromboembolism (VTE) by EAST criteria to whom either the EAST (prophylactic IVCF) or ACCP (no prophylactic IVCF) guidelines were applied. The analysis assumed the societal perspective over a lifetime. For base case and sensitivity analyses, probabilities and utilities were obtained from published literature and costs calculated from Centers for Medicare & Medicaid Services fee schedules, the Healthcare Cost & Utilization Project database, and Red Book wholesale drug prices for 2007. For data unavailable from the literature, similarities to other populations were used to make assumptions. RESULTS In base case analysis, prophylactic IVCFs were more costly ($37,700 vs $37,300) and less effective (by 0.139 QALYs) than therapeutic IVCFs. In sensitivity analysis, the EAST strategy of prophylactic filter placement would become the preferred strategy in individuals never having a filter, with either an annual probability of VTE of ≥ 9.6% (base case, 5.9%), or a very high annual probability of anticoagulation complications of ≥ 24.3% (base case, 2.5%). The EAST strategy would also be favored if the annual probability of venous insufficiency was <7.69% (base case, 13.9%) after filter removal or <1.90% with a retained filter (base case, 14.1%). In initial hospitalization only, EAST guidelines were more costly by $2988 and slightly more effective by .0008 QALY, resulting in an incremental cost-effectiveness ratio of $383,638/QALY. CONCLUSIONS Analysis suggests prophylactic IVC filters are not cost-effective in high-risk trauma patients. The magnitude of this result is primarily dependent on probabilities of long-term sequelae (venous thromboembolism, bleeding complications). Even in the initial hospitalization, however, prophylactic IVCF costs for the additional quality-adjusted life years gained did not justify use.
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Affiliation(s)
- Emily L Spangler
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Preoperative placement of inferior vena cava filters and outcomes after gastric bypass surgery. Ann Surg 2010; 252:313-8. [PMID: 20622663 DOI: 10.1097/sla.0b013e3181e61e4f] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess relationships between inferior vena cava (IVC) filter placement and complications within 30 days of gastric bypass surgery. SUMMARY OF BACKGROUND DATA IVC filters are increasingly being used as prophylaxis against postoperative pulmonary embolism in patients undergoing bariatric surgery, despite a lack of evidence of effectiveness. METHODS On the basis of data from a prospective clinical registry involving 20 Michigan hospitals, we identified 6376 patients undergoing gastric bypass surgery between 2006 and 2008. We then assessed relationships between IVC filter placement and complications within 30 days of surgery. We used propensity scores and fixed effects logistic regression to control for potential selection bias. RESULTS A total of 542 gastric bypass patients (8.5%) underwent preoperative IVC filter placement, most of whom (65%) had no history of venous thromboembolism. The use of IVC filters for gastric bypass patients varied widely across hospitals (range, 0%-34%). IVC filter patients did not have reduced rates of postoperative venous thromboembolism (adjusted odds ratio [OR], = 1.28; 95% confidence interval [CI], 0.51-3.21), serious complications (adjusted OR, = 1.40; 95% CI, 0.91-2.16), or death/permanent disability (adjusted OR, = 2.49; 95% CI, 0.99-6.26). More than half (57%) of the IVC filter patients in the latter group had a fatal pulmonary embolism or complications directly related to the IVC filter itself, including filter migration or thrombosis of the vena cava. In subgroup analyses, we were unable to identify any patient group for whom IVC filters were associated with improved outcomes. CONCLUSIONS Prophylactic IVC filters for gastric bypass surgery do not reduce the risk of pulmonary embolism and may lead to additional complications.
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Endovascular Treatment Options in the Management of Lower Limb Deep Venous Thrombosis. Cardiovasc Intervent Radiol 2009; 32:861-76. [DOI: 10.1007/s00270-009-9662-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2008] [Revised: 06/28/2009] [Accepted: 06/30/2009] [Indexed: 12/17/2022]
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Hoppe H. Optional vena cava filters: indications, management, and results. DEUTSCHES ARZTEBLATT INTERNATIONAL 2009; 106:395-402. [PMID: 19623306 DOI: 10.3238/arztebl.2009.0395] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Accepted: 12/22/2008] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Hanno Hoppe
- Institut für Diagnostische, Interventionelle und Pädiatrische Radiologie, Inselspital, Universitätsspital Bern, Schweiz.
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Contractor SG, Merkulov A, Bhatti W, Lee M, Gardner K. Penetration of Günther Tulip filter struts through an introducer sheath: case report and safety concerns. J Vasc Interv Radiol 2009; 20:1093-5. [PMID: 19560939 DOI: 10.1016/j.jvir.2009.04.068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2008] [Revised: 04/23/2009] [Accepted: 04/26/2009] [Indexed: 10/20/2022] Open
Abstract
The authors present a patient who had a Günther-Tulip inferior vena cava filter placed under fluoroscopic guidance. The filter struts were seen to penetrate through the introducer sheath at deployment. This was believed to be secondary to a kink in the sheath at the site of venous entry and was due to the patient's nuchal obesity as well as his inability to turn his head to the opposite side. The introducer sheath was then placed through a long reinforced metal sheath through which the filter was then placed without complication.
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Affiliation(s)
- Sohail G Contractor
- Department of Radiology, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, 150 Bergen Street, Newark, NJ 07101, USA.
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Oshima K, Kunimoto F, Hinohara H, Ohkawa M, Saito S. The effect of a temporary inferior vena cava filter in the treatment of deep vein thrombosis in critically-ill patients. Int Heart J 2009; 49:713-21. [PMID: 19075487 DOI: 10.1536/ihj.49.713] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We studied the clinical courses of patients with deep vein thrombus (DVT) who underwent insertion of temporary inferior vena cava filters (tIVCF) and evaluated the effectiveness of the tIVCF. From January 2003 to March 2008, tIVCF were placed in 12 patients with a diagnosis of DVT in the Intensive Care Unit (ICU) of Gunma University Hospital. The mean age of the patients was 52 +/- 16 years (range, 18-82). Eight were medical patients who had not undergone any prior surgery, and 4 were postoperative patients, including 3 with a malignancy. The diagnosis of DVT was made using enhanced computed tomography. The Toray Neuhaus Protect catheter (6Fr, Toray Medical, Tokyo) was used as a tIVCF in all 12 patients. We evaluated the clinical course of the patients before and after placement of a tIVCF and studied their prognosis. DVT occurred on 15 +/- 9 days after surgery or admission to hospital. Pulmonary thromboembolism (PTE) was detected in 7 patients prior to the placement of a tIVCF, 3 of whom required cardiopulmonary resuscitation. The mean duration of tIVCF placement was 18 +/- 9 days; no episodes of PTE occurred after tIVCF placement. DVT completely or almost completely disappeared during the period of tIVCF placement; subsequently, tIVCFs were successfully removed in 10 patients (83%). A permanent IVCF was placed in only 1 patient, and the tIVCF was removed in the remaining patient because of suspected catheter infection. There were 2 complications related to tIVCF placement: infection at the insertion site and suspected catheter infection. tIVCF placement could prevent the occurrence of PTE without provoking life-threatening complications. The results suggest that tIVCF is useful in the prevention of PTE in patients with DVT.
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Doody O, Given MF, Kavnoudias H, Street M, Thomson KR, Lyon SM. Initial experience in 115 patients with the retrievable Cook Celect vena cava filter. J Med Imaging Radiat Oncol 2009; 53:64-8. [DOI: 10.1111/j.1754-9485.2009.02039.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Schmelzer TM, Christmas AB, Taylor DA, Heniford BT, Sing RF. Vena cava filter retrieval in therapeutically anticoagulated patients. Am J Surg 2008; 196:944-6; discussion 946-7. [DOI: 10.1016/j.amjsurg.2008.07.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2008] [Revised: 07/08/2008] [Accepted: 07/08/2008] [Indexed: 11/25/2022]
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Given MF, McDonald BC, Brookfield P, Niggemeyer L, Kossmann T, Varma DK, Thomson KR, Lyon SM. Retrievable Gunther Tulip inferior vena cava filter: Experience in 317 patients. J Med Imaging Radiat Oncol 2008; 52:452-7. [DOI: 10.1111/j.1440-1673.2008.01969.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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25
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Sendon S, Dalmas AF, Lions C, Legrand A, Deruelle P. Use of temporary inferior vena cava filter placement in pregnant women near term. Eur J Obstet Gynecol Reprod Biol 2008; 140:143-4. [DOI: 10.1016/j.ejogrb.2007.10.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2007] [Revised: 08/18/2007] [Accepted: 10/31/2007] [Indexed: 11/29/2022]
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26
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Murphy EH, White RA, Rosenthal D, Johnson ED, Zarins CK, Fogarty TJ, Arko FR. Evaluation of the Crux IVC Filter in an Animal Model. J Endovasc Ther 2008; 15:292-9. [DOI: 10.1583/08-2374.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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27
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Hidaka N, Hachisuga M, Tsukimori K, Onohara T, Maehara Y, Wake N. Intrapartum placement of an inferior vena cava filter for a woman with hereditary antithrombin III deficiency: its role in the prevention of fatal pulmonary embolism. J Obstet Gynaecol Res 2008; 34:95-9. [PMID: 18226138 DOI: 10.1111/j.1447-0756.2007.00708.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We present a case of a pregnant woman with hereditary antithrombin III deficiency and deep vein thrombosis of the left lower extremity managed by perinatal unfractionated heparin injection with antithrombin III replacement as well as by intrapartum placement of a temporary inferior vena cava filter. A massive thrombus of the right common iliac vein occurred during the intrapartum period despite antithrombin III replacement. An inserted filter could prevent fatal pulmonary embolism in this patient. Hereditary antithrombin III deficiency increases risk of thrombosis during pregnancy. However, discussion on intrapartum management, when anticoagulants are contraindicated due to possible hemorrhage, is minimal. Our experience suggests that thrombosis can occur and develop during the intrapartum period in an antithrombin III deficient woman despite antithrombin III replacement. It may be advisable to manage deliveries with temporary inferior vena cava filters to prevent fatal pulmonary embolism.
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Affiliation(s)
- Nobuhiro Hidaka
- Department of Obstetrics and Gynecology, Graduate School of Medical Sciences, Kyushu University, Higashiku, Fukuoka, Japan.
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Mismetti P, Rivron-Guillot K, Quenet S, Décousus H, Laporte S, Epinat M, Barral FG. A prospective long-term study of 220 patients with a retrievable vena cava filter for secondary prevention of venous thromboembolism. Chest 2007; 131:223-9. [PMID: 17218580 DOI: 10.1378/chest.06-0631] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The immediate and long-term clinical events associated with the placement and removal of a retrievable filter (ALN filter; ALN Implants Chirurgicaux; Ghisonaccia, France) remain largely unknown. METHODS This was a prospective cohort study with an 18-month follow-up. All consecutive patients scheduled for placement of an ALN filter between April 1999 and June 2005 in the Radiology Department of our hospital were included. RESULTS During the study period, placement of an ALN filter was indicated in 220 patients (mean age, 70.8 years), who were followed up for a median duration of 338.5 days (range, 1 to 561 days); 148 patients (67.3%) completed the 18-month follow-up. No patients were unavailable for follow-up. All patients had an acute or past venous thromboembolism. Main indications were recurrent venous thromboembolism despite adequate anticoagulation therapy (10.9%), transient bleeding event (21.8%), definitive contraindication for anticoagulant therapy (26.8%), or obligation to stop anticoagulant therapy due to major surgery, major trauma, or invasive procedure (37.7%). Filter insertion was successful in 98.6% of patients and resulted in an immediate complication in 11.8%. The median duration of filter implantation was 166 days (first to third quartiles, 34 to 478 days). Meanwhile, 17.0% (37 of 217 patients) had at least one venous thromboembolic event. Filter retrieval was attempted in 25.3% of patients after a median of 51 days (range, 6 to 352 days); removal was successful at the first attempt in 92.7% of patients. CONCLUSIONS The filter could be easily inserted and successfully removed up to 1 year after insertion. Its safety and efficacy in preventing pulmonary embolism should be properly assessed in a randomized study.
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Affiliation(s)
- Patrick Mismetti
- Thrombosis Research Group, CIC-EC, Clinical Pharmacology Department, University Hospital, Saint-Etienne, France
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29
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Halmi D, Kolesnikov E. Preoperative placement of retreivable inferior vena cava filters in bariatric surgery. Surg Obes Relat Dis 2007; 3:602-5. [PMID: 17544920 DOI: 10.1016/j.soard.2007.04.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2006] [Revised: 03/15/2007] [Accepted: 04/12/2007] [Indexed: 11/22/2022]
Abstract
BACKGROUND Postoperative pulmonary embolism (PE) is a major source of mortality after bariatric surgery. In conjunction with pharmacologic thromboprophylaxis, lower extremity pneumatic compression devices, and early ambulation, preoperative placement of a retrievable inferior vena cava (IVC) filter may reduce the risk of thromboembolic complications. METHODS From June 2003 to October 2005, 652 patients underwent mini-open Roux-en-Y gastric bypass. Of the 652 patients, 557 were women and 95 were men. The mean patient age was 40.7 +/- 3.6 years (range 18-67), mean body mass index was 44.7 +/- 4.6 kg/m(2) (range 35-78), and mean operative time was 60.2 +/- 5.3 minutes (range 42-79). The high-risk PE group consisted of 27 patients (4.1%; 9 men and 18 women) who received preoperative retrievable IVC filters placed by the interventional radiology staff 2 hours before bypass surgery. Their mean age was 47 +/- 4.4 years (range 31-66) and mean body mass index 48.7 +/- 4.2 kg/m(2) (range 38-75). The indications for filter placement were previous deep vein thrombosis/PE, thrombophlebitis, a hypercoagulable state, pulmonary hypertension, an inability to ambulate, a body mass index >65 kg/m(2), and the presence of severe sleep apnea. The filters were removed 18.2 +/- 2 days (range 15-21) postoperatively. RESULTS All 27 patients who received a prophylactic IVC filter tolerated the procedure well, without major complications. One retrievable filter was not removed because of prolonged hospitalization secondary to small bowel obstruction. No thromboembolic complications occurred in this high-risk group. CONCLUSION Preoperative placement of retrievable IVC filters is a safe measure for the prophylaxis of PE in high-risk bariatric patients. The filters can be placed efficiently just before surgery, and most filters can be removed 2-3 weeks postoperatively. Additional investigation is necessary to prove the effectiveness of retrievable IVC filters in bariatric surgery.
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Affiliation(s)
- Denis Halmi
- Virginia Weight Loss Surgery Center, Potomac Hospital, Woodbridge, Virginia, USA
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Abstract
Inferior vena cava (IVC) filters, both retrievable and permanent, are indicated for the prevention of pulmonary embolism (PE) in patients contraindicated for anticoagulant therapy, in those with anticoagulant therapy complications, and perhaps for those with recurrent PE despite therapeutic anticoagulation. Because of the lack of randomized controlled trials (only 1 has been published), clinicians have little evidence-based information to assist them in determining proper use of IVC filters. The introduction of retrievable filters and the ease of insertion have stimulated increased use of these devices without strong evidence or follow-up to assess either efficacy or longer-term clinical outcomes. Current evidence-based guidelines recommend IVC filter insertion only in patients with proven venous thromboembolism and an absolute contraindication for anticoagulation.
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Affiliation(s)
- Mark A Crowther
- Division of Hematology, McMaster University, Hamilton, Ontario, Canada.
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31
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Thonar B, Patel NH, Ferral H, Behrens G. AJRTeaching File: Chest Pain in a Woman with an Inferior Vena Cava Filter. AJR Am J Roentgenol 2007; 189:S24-5. [PMID: 17715072 DOI: 10.2214/ajr.06.1037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Fotiadis NI, Sabharwal T, Dourado R, Fikrat S, Adam A. Technical Error During Deployment Leads to Vena Cava Filter Migration and Massive Pulmonary Embolism. Cardiovasc Intervent Radiol 2007; 31 Suppl 2:S174-6. [PMID: 17726631 DOI: 10.1007/s00270-007-9159-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2007] [Revised: 07/25/2007] [Accepted: 07/29/2007] [Indexed: 11/25/2022]
Abstract
The Günther Tulip vena cava filter is a safe, effective, well-established device for pulmonary embolism prophylaxis. We report a patient in whom there was migration of the filter to the right atrium, 2 weeks after insertion, caused by a technical error during deployment. An attempt to retrieve the filter percutaneously failed, necessitating removal at open-heart surgery. The potential causes of migration are described and the lessons learned from this unusual case are outlined.
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Affiliation(s)
- Nikolas I Fotiadis
- Interventional Radiology Department, Guy's and St. Thomas' Hospital, Lambeth Palace Road, London SE1 7EH, UK.
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Kobayashi R, Yamashita A, Gohra H, Furukawa S, Oda T, Hamano K. Pulmonary and Deep Vein Thrombosis in a Young Patient with Protein S Deficiency: Report of a Case. Surg Today 2007; 37:660-3. [PMID: 17643209 DOI: 10.1007/s00595-007-3479-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2006] [Accepted: 01/08/2007] [Indexed: 11/26/2022]
Abstract
A 27-year-old man, who was diagnosed as having familial protein S deficiency, developed deep vein thrombosis complicated with pulmonary thromboembolism. Anticoagulant therapy and thrombolytic therapy were commenced after the insertion of a temporary inferior vena cava filter (t-IVC-f). However, on day 5 after t-IVC-f insertion, IVC venography showed filter thrombosis. On day 13, we made a venotomy and removed the captured thrombi and inserted a permanent IVC-f. After removal of the t-IVC-f via the right brachial vein, thrombi that had not been seen earlier appeared in the right atrium (RA). It was suspected that the thrombi around the catheter had likely been stripped off during the catheter removal procedure. After the abdomen was closed, an extra operation was immediately performed. Under complete extracorporeal circulation, the RA was opened and the all thrombi were removed. The patient recovered well and was discharged on the 21st postoperative day without any complications.
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Affiliation(s)
- Rie Kobayashi
- Department of Surgery, Saiseikai Yamaguchi General Hospital, 2-11 Midorimachi, Yamaguchi 753-0078, Japan
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Nomura T, Komatsu S, Arihara M, Hayashi H, Syudo T, Harada Y, Hosomi Y, Hirano S, Matsubara H. Double-filter technique for deployment of a permanent inferior vena cava filter while avoiding the risk of pulmonary embolism from a thrombus trapped by a temporary filter. Heart Vessels 2007; 22:199-201. [PMID: 17533525 DOI: 10.1007/s00380-006-0953-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2006] [Accepted: 09/13/2006] [Indexed: 10/23/2022]
Abstract
Because temporary caval filters have not been associated with any long-term complications, their use seems practical as long as indications are accurately assessed. However, problems about further dealing with the emboli trapped in a temporary filter remain. This case report describes a new approach to managing a thrombus captured by a temporary filter during the exchange for a permanent filter. We applied the Anthéor temporary filter (Boston Scientific, Natick, MA, USA) as the device for thrombus capturing, then successfully placed the permanent filter with no clinical evidence of pulmonary embolism. Intravascular ultrasound was also useful for monitoring the entire procedure.
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Affiliation(s)
- Tetsuya Nomura
- Department of Cardiology, National Hospital Organization, Maizuru Medical Center, 2410 Yukinaga, Maizuru, Kyoto, 625-8502, Japan.
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Guidelines for the Use of Retrievable and Convertible Vena Cava Filters: Report from the Society of Interventional Radiology Multidisciplinary Consensus Conference. World J Surg 2007. [DOI: 10.1007/s00268-006-0292-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Caronno R, Piffaretti G, Tozzi M, Lomazzi C, Rivolta N, Riva F, Laganà D, Carrafiello G, Castelli P. Mid-term Experience with the ALN Retrievable Inferior Vena Cava Filter. Eur J Vasc Endovasc Surg 2006; 32:596-9. [PMID: 16782366 DOI: 10.1016/j.ejvs.2006.05.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2006] [Accepted: 05/08/2006] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To report the mid-term results of 63 patients who received a new commercially-available retrievable vena cava filter, ALN. METHODS Between January 2001 and October 2005, 63 patients (mean age 65 +/- 15 years) underwent placement of ALN filters. Filter removal was performed when anti-thrombotic prophylaxis was considered unnecessary or when the patient could safely resume full anticoagulant therapy. RESULTS Thirty-five patients (55%) had ilio-femoral venous thrombosis and 28 patients (45%) had ilio-caval thrombosis. Overall, 49% had pulmonary embolism. Technical success for filter insertion was 100%, without any complications. None of the procedures aborted or was converted due to technical difficulties. After a median follow-up of 21-months (range 1-48, median 18), there were no cases of pulmonary embolism or vena cava thrombosis. Two patients died of a cause unrelated to deep venous thrombosis during the follow-up period, without clinical evidence of pulmonary embolism or filter-associated complications. No device migration was observed. There were 20 (31.7%) retrieval attempts: in 16 cases filters were retrieved successfully, but 4 cases were aborted. The mean implantation period of the retrieved filter was 179 days (range 53-370). CONCLUSION Our results confirm the clinical efficacy of the ALN filter for preventing potentially fatal pulmonary embolism whilst implanted and in absence of post-insertion complications, even when left in place indefinitely.
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Affiliation(s)
- R Caronno
- Vascular Surgery-Department of Surgery, University of Insubria, Varese, Italy
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Abstract
Venous thromboembolism is a major health problem that results in significant long-term complications and mortality. The management of venous thromboembolism is complex and can be particularly challenging when pharmacological therapy alone cannot be effectively utilized. Vena cava filters provide protection from pulmonary embolism for patients in whom therapeutic anticoagulation is contraindicated or inadequate. Recent innovations in caval interruption have included the use of alternative imaging modalities for filter insertion and the emergence of devices designed to allow temporary caval filtration. These developments have been accompanied by a controversial increase in the use of vena cava filters for prophylactic indications in the absence of venous thromboembolism. In addition to a brief historical perspective on caval filtration, this update reviews the indications for vena cava filter insertion, associated complications, methods of caval imaging and filter insertion and current FDA-approved devices.
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Affiliation(s)
- Matthew A Corriere
- Department of General Surgery, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - K Todd Piercy
- MidSouth Surgeons, 1220 Trotwood Avenue, Columbia, TN 38401, USA
| | - Matthew S Edwards
- Assistant Professor of Surgery and Public Health, Wake Forest University School of Medicine, Sciences, Department of General Surgery, Winston-Salem, NC 27157, USA
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Anderson RC, Bussey HI. Retrievable and Permanent Inferior Vena Cava Filters: Selected Considerations. Pharmacotherapy 2006; 26:1595-600. [PMID: 17064204 DOI: 10.1592/phco.26.11.1595] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The use of inferior vena cava (IVC) filters is increasing rapidly, and the recent availability of retrievable IVC filters is certain to accelerate this process. Unfortunately, because the risks and benefits of these devices have not been adequately studied, several important issues remain. Limitations of the quality of the data in the available literature make it virtually impossible to accurately quantify the specific rates of complications with various devices. Although many clinicians believe that the use of an IVC filter obviates anticoagulation, new data support the need for long-term anticoagulation in such patients. The recent introduction of retrievable IVC filters may eliminate the need for long-term anticoagulation if the filter can be removed, but further data are needed to ascertain the place of these devices in modern therapy. The increasing use of these devices increases the need for clinicians to be aware of the potential limitations and risks of IVC filters.
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Miyahara T, Miyata T, Shigematsu K, Deguchi J, Kimura H, Ishii S, Nagawa H. Clinical outcome and complications of temporary inferior vena cava filter placement. J Vasc Surg 2006; 44:620-4. [PMID: 16950444 DOI: 10.1016/j.jvs.2006.05.019] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2006] [Accepted: 05/05/2006] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We evaluated the current clinical experience of temporary inferior vena cava (IVC) filter placement and its related complications. METHODS From January 2000 to December 2005, we enrolled 33 patients (8 men and 25 women) who underwent percutaneous insertion of a temporary IVC filter in the Department of Vascular Surgery of Tokyo University Hospital. Deep vein thrombosis (DVT) was proven in 78.8% of the patients. The indications for filter insertion were contraindication to anticoagulation therapy (9.1%), thrombolytic therapy (12.1%), perioperative prophylactic implantation (84.8%), pregnancy with DVT (3.0%), and prophylactic implantation in the absence of DVT (15.2%). A Neuhaus Protect was used in 13 patients, and an Antheor was used in 20 patients. RESULTS The mean +/- SD duration of filter placement was 10.6 +/- 7.0 days. There was no case of pulmonary embolism during filter protection and retraction. Filter thrombosis (capture of thrombus) was observed in four patients (12.1%), who then received additional thrombolytic therapy. Thrombi were dissolved by thrombolysis in three, one of whom had replacement with a permanent filter. The thrombus was not dissolved in one patient and was removed under venotomy at the insertion site. Major filter-related complications occurred in nine patients (27.3%), including filter dislocation in four patients (12.1%), catheter fracture in three (9.1%), and catheter-related infection in one (3.0%). In a patient with giant ovarian cancer, the IVC was nearly occluded with massive thrombus around the filter 2 days after operation, and the vena cava was then ligated under open laparotomy. No patients died during filter protection and retraction. CONCLUSIONS Temporary IVC filters were effective for the prevention of fatal pulmonary embolism. However, our experience of a high incidence of complications related to temporary filters suggests that this device has limited indications and supports the need for innovative design of temporary filters.
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Affiliation(s)
- Takuya Miyahara
- Department of Surgery, Division of Vascular Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Bovyn G, Ricco JB, Reynaud P, Le Blanche AF. Long-duration temporary vena cava filter: A prospective 104-case multicenter study. J Vasc Surg 2006; 43:1222-9. [PMID: 16765244 DOI: 10.1016/j.jvs.2006.02.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2005] [Accepted: 02/05/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Nonpermanent caval filters are placed in critical thromboembolic situations in which anticoagulation therapy is transiently contraindicated, ineffective, or the source of complications. The purpose of this study was to assess the safety and effectiveness of a second-generation long-duration temporary caval filter in these situations and compare its utility with that of other temporary filters. METHODS This prospective study, including patients who underwent temporary caval filtration with the Tempofilter II, was conducted in nine European centers. All filters were successfully implanted. The filter was removed when the indication for caval filtration ceased. RESULTS A total of 104 filters were inserted in 103 patients with an average age of 60 +/- 15.5 years (range, 22-92 years). Most patients (85%) had pulmonary embolism, deep venous thrombosis, or both. The main indications for caval filter placement were complications of or contraindications to anticoagulation therapy (n = 85; 82.5%) or for ineffectiveness of anticoagulation therapy (n = 12; 11.7%). The average duration of implantation was 29.5 +/- 14.0 days (range, 2-86 days). One filter migrated in the right atrium, followed by pulmonary embolism. No other case of pulmonary embolism or of infectious or mechanical complications related to the filter was observed. Thrombus was trapped within the filter in 24 cases (23.3%). All filters but one were removed, regardless of whether thrombus had been trapped. Retrieval was always successful after implantation periods up to 12 weeks. In 16 cases (15.5%), the filter was replaced by a permanent filter. CONCLUSIONS The Tempofilter II is safe, effective, and useful in critical thromboembolic situations. It offers a valuable alternative to retrievable optional filters.
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Affiliation(s)
- Gilles Bovyn
- Vascular Surgery Department, Hospital Y. Le Foll, Saint Brieuc, France
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Hoppe H, Nutting CW, Smouse HR, Vesely TM, Pohl C, Bettmann MA, Kaufman JA. Günther Tulip Filter Retrievability Multicenter Study Including CT Follow-up: Final Report. J Vasc Interv Radiol 2006; 17:1017-23. [PMID: 16778236 DOI: 10.1097/01.rvi.90000223689.49091.76] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To evaluate the safety and effectiveness of retrieval of the Günther Tulip inferior vena cava (IVC) filter. MATERIALS AND METHODS This was a nonrandomized, single-armed, multicenter prospective investigation. Patients at temporary high risk for pulmonary embolism (PE) or deep vein thrombosis (DVT) who did not require a permanent filter were eligible. Forty-one patients received 42 Günther Tulip filters: 22 men and 19 women with a mean age of 47.7 years. Indications for filter placement included prophylaxis, PE, and DVT. Three months after filter retrieval, contrast agent-enhanced computed tomography of the abdomen, jugular vein ultrasonography, and clinical follow-up were performed. RESULTS The filter retrieval rate was 57% (23 of 41). Günther Tulip filters were removed at a mean of 11.1 days (range, 2-14 d). The technical and clinical success rates for filter retrieval were both 100%. One placement complication and two protocol deviations occurred. These patients were excluded in terms of retrieval-related outcomes. One case of PE occurred with a filter in place, and one filter migrated to the heart. There were no acute complications caused by filter retrieval. At 3-month follow-up, there was no recurrent PE, DVT, jugular vein occlusion, or IVC stenosis or occlusion. CONCLUSION In this multicenter study, retrieval of the Günther Tulip filter was safe and without recurrent thromboembolic events or evidence of IVC or jugular vein damage at 3-month follow-up.
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Affiliation(s)
- Hanno Hoppe
- Dotter Interventional Institute, Oregon Health Science University, Portland 97239-3098, USA
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42
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Saeed I, Garcia M, McNicholas K. Right Ventricular Migration of a Recovery IVC Filter’s Fractured Wire with Subsequent Pericardial Tamponade. Cardiovasc Intervent Radiol 2006; 29:685-6. [PMID: 16604409 DOI: 10.1007/s00270-005-0136-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A Recovery filter (C.R. Bard, Tempe, AZ, USA) is a device for pulmonary embolism prophylaxis. There have been few case reports involving the migration of this particular filter or of a broken wire migrating to the heart. We report a case of right ventricular migration of a fractured wire from this filter in a patient who subsequently developed pericardial tamponade and required open heart surgery to extract the fractured wire. We discuss the current US Food and Drug Administration (FDA)-approved nonpermanent inferior vena cava filters and their reported complications. These complications can be life-threatening and may require immediate surgical intervention.
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Affiliation(s)
- Imran Saeed
- MAP 2, Suite 2121, Christiana Hospital, 4745 Ogletown-Stanton Road, Newark, DE 19713, USA.
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43
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Kaufman JA, Kinney TB, Streiff MB, Sing RF, Proctor MC, Becker D, Cipolle M, Comerota AJ, Millward SF, Rogers FB, Sacks D, Venbrux AC. Guidelines for the Use of Retrievable and Convertible Vena Cava Filters: Report from the Society of Interventional Radiology Multidisciplinary Consensus Conference. J Vasc Interv Radiol 2006; 17:449-59. [PMID: 16567669 DOI: 10.1097/01.rvi.0000203418-39769.0d] [Citation(s) in RCA: 270] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- John A Kaufman
- Dotter Interventional Institute, Oregon Health & Science University, Portland, 97239, USA.
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44
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Cina A, Masselli G, Di Stasi C, Natale L, Cotroneo AR, Cina G, Bonomo L. Computed tomography imaging of vena cava filter complications: a pictorial review. Acta Radiol 2006; 47:135-44. [PMID: 16604959 DOI: 10.1080/02841850500447203] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Caval filters are widely used in the prevention of pulmonary embolism. Filters have proved to be effective, but the complication rate is not negligible. Computed tomography (CT) provides a complete evaluation of the filter, including both caval and extracaval complications. In this review, we describe the normal CT aspect of cava filters, the classification of complications and their CT findings. Technical considerations for adequate CT imaging are also highlighted.
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Affiliation(s)
- A Cina
- Department of Radiology, Università Cattolica del Sacro Cuore, Policlinico Agostino Gemelli, Rome, Italy.
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45
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Kaskarelis IS, Koukoulaki M, Chlapoutaki CE, Skarpalezos DE, Baltouka AD, Vagdatlis TK, Androutsopoulou VA, Bellenis I. Clinical experience with Günther temporary inferior vena cava filters. Clin Imaging 2006; 30:108-13. [PMID: 16500541 DOI: 10.1016/j.clinimag.2005.09.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2005] [Revised: 09/07/2005] [Accepted: 09/07/2005] [Indexed: 11/21/2022]
Abstract
This retrospective study was performed to evaluate the safety and effectiveness of Günther temporary inferior vena cava (IVC) filters. Fifteen Günther temporary filters were placed in 13 patients because of deep vein thrombosis (DVT) with pulmonary embolism (PE) despite DVT prophylaxis (9/13) or temporary contraindications for anticoagulants as well as recent or pending surgery (4/13). No clinical manifestation of PE was observed during the filtration or during the removal. Günther temporary IVC filters are easy and safe to use, and are effective in clot trapping, protecting patients at high risk for PE in whom anticoagulation treatment failed or is contraindicated.
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Affiliation(s)
- Ioannis S Kaskarelis
- "Evangelismos" General Hospital of Athens, 45-47 Ipsilantou Street, 10676 Athens, Greece
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46
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Antevil JL, Sise MJ, Sack DI, Sasadeusz KJ, Swanson SM, Rivera L, Lome BR, Weingarten KE, Kaminski SS. Retrievable Vena Cava Filters for Preventing Pulmonary Embolism in Trauma Patients: A Cautionary Tale. ACTA ACUST UNITED AC 2006; 60:35-40. [PMID: 16456434 DOI: 10.1097/01.ta.0000197607.23019.ab] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Retrievable vena cava filters (RFs) offer the appeal of short-term prophylaxis for trauma patients temporarily at risk for pulmonary embolism (PE) without the long-term risks of permanent vena cava filters (PFs). However, the evidence that RFs and PFs reduce the risks of PE and death in trauma patients is not conclusive. RFs were introduced at our trauma center in August 2002. The purpose of this study was to evaluate the effects of RFs on our strategy to prevent PE in trauma patients. METHODS We reviewed our trauma registry to compare rates of filter placement, filter-related complications (FRCs), and PE before (Group I: January 2000 to August 15, 2002) and after (Group II: August 16, 2002 through December 2004) RF introduction. Indication for filter placement, filter retrieval, FRCs, and incidence of PE were compared. RESULTS There were 5,042 patients in Group I and 5,038 patients in Group II. There was a threefold increase in filter placement in Group II compared with Group I (55 [1.1%] versus 161 [3.2%]; p < 0.001). There were no significant differences between the rates of PE (0.2% versus 0.2%, p = 0.636) or major FRCs (1.8% versus 2.5%, p = 0.777). Major FRCs included two filter infections with sepsis, one vena cava thrombotic occlusion, one filter lodged in the jugular vein during retrieval, and one PE after filter placement. RF removal was attempted in 43 (27%) patients and successful in 33 (21%). CONCLUSION The advent of RFs was associated with a threefold increase in vena cava filter placement in our trauma center. Major FRCs were encountered and a very low incidence of PE was not altered by their use. Successful removal could be verified in only 21% of RFs. The results of this study lead us to question the rationale for a more liberal use of vena cava filters in trauma patients.
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Affiliation(s)
- Jared L Antevil
- Division of Trauma, Scripps Mercy Hospital, 4077 5th Avenue, San Diego, CA 92103, USA
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47
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Kawamata K, Chiba Y, Tanaka R, Higashi M, Nishigami K. Experience of temporary inferior vena cava filters inserted in the perinatal period to prevent pulmonary embolism in pregnant women with deep vein thrombosis. J Vasc Surg 2005; 41:652-6. [DOI: 10.1016/j.jvs.2005.01.023] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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48
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Kerlan RK, LaBerge JM, Wilson MW, Gordon RL. Residual Thrombus within a Retrievable IVC Filter. J Vasc Interv Radiol 2005; 16:555-7. [PMID: 15802458 DOI: 10.1097/01.rvi.0000157045.92202.30] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Robert K Kerlan
- Department of Radiology, University of California, San Francisco, 505 Parnassus Avenue, M-361, Box 0628, San Francisco, CA 94143, USA.
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49
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Hoff WS, Hoey BA, Wainwright GA, Reed JF, Ball DS, Ringold M, Grossman MD. Early experience with retrievable inferior vena cava filters in high-risk trauma patients. J Am Coll Surg 2004; 199:869-74. [PMID: 15555969 DOI: 10.1016/j.jamcollsurg.2004.07.030] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2004] [Revised: 07/21/2004] [Accepted: 07/21/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND This study describes the use of retrievable IVC filters in a select group of trauma patients at high risk for deep vein thrombosis (DVT) and pulmonary embolism (PE). STUDY DESIGN Retrievable IVC filters were placed in selected trauma patients who met high-risk criteria for deep vein thrombosis and PE according to institutional clinical management guidelines. All filters were placed percutaneously in the interventional radiology suite. Indications for filter placement were based on injury complex, weight-bearing status, and contraindications to enoxaparin or pneumatic compression devices. IVC filters were either removed or maintained. RESULTS Retrievable IVC filters were placed in 35 patients after blunt trauma. Twenty-six patients (74%) sustained at least one orthopaedic injury; 17 patients (49%) were diagnosed with a pelvis fracture. Activity was limited to bed rest or spinal precautions in 18 patients (51%). Enoxaparin was contraindicated in 32 patients (91%) and injuries precluded the use of pneumatic compression devices in 11 (31%). IVC filters were removed in 18 patients (51%), with no reported complications. Patients with orthopaedic injuries and pelvis fractures were less likely to have their filters maintained (p = 0.040). CONCLUSIONS Retrievable IVC filters offer a versatile option for prophylaxis in trauma patients at high risk for PE. Filter retrieval potentially spares the longterm complications of permanent filters in younger trauma patients. Retrievable filters warrant consideration in patients who meet high-risk criteria for deep vein thrombosis or PE who cannot receive effective mechanical prophylaxis and in whom contraindications to anticoagulation are expected to be temporary.
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Affiliation(s)
- William S Hoff
- Division of Traumatology, St Luke's Hospital, Bethlehem, PA 18015, USA
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Terhaar OA, Lyon SM, Given MF, Foster AE, Mc Grath F, Lee MJ. Extended Interval for Retrieval of Günther Tulip Filters. J Vasc Interv Radiol 2004; 15:1257-62. [PMID: 15525745 DOI: 10.1097/01.rvi.0000134497.50590.e2] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To evaluate the Gunther Tulip vena cava filter with regard to ease of placement, complications, and retrieval over long time periods. MATERIALS AND METHODS In 53 patients (ratio of men to women, 24:29; mean age, 52.8 years) retrievable Gunther Tulip filters (Vena Cava M Reye Filter Set; William Cook Europe, Denmark) were inserted. Indications included planned major surgery with recent pulmonary embolus or high pulmonary embolus risk (n = 16), extensive ilio-femoral thrombus (n = 11), deep vein thrombosis with anticoagulant complications (n = 9), breakthrough pulmonary embolus despite anticoagulant therapy (n = 4), and contraindication to anticoagulant therapy (n = 13). All patients were followed-up for immediate and long-term complications. RESULTS Fifty-three filters were successfully placed in 52 of 53 patients, yielding a success rate of 98.1%. Nineteen patients underwent attempted retrieval of their filter. Sixteen of 19 retrieval procedures were successful (84%). In three patients, the filter could not be removed on attempted retrieval (extensive filter thrombus in two patients and attachment to the wall in one patient). One patient received two filters, which were both successfully retrieved at a later date. Median implantation time for retrievable filters was 34 days (range, 7-126 days). Mean follow-up for patients with permanent filters was 13 months. Two major complications (pneumothorax and break through pulmonary embolus) and three minor complications (right internal jugular vein thrombosis in two patients and transient Horner's Syndrome in one patient) were recorded. CONCLUSION Insertion and retrieval of filters is safe and feasible. Preliminary data suggest that Gunther Tulip filter retrieval is feasible over and above the manufacturer's recommended retrieval interval of 14 days.
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Affiliation(s)
- Olaf Alfons Terhaar
- Department of Academic Radiology, Beaumont Hospital and Royal College of Surgeons Medical School, Beaumont Road, Dublin 9, Ireland
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