Inferior vena cava filters: current best practices

Prophylactic Inferior Vena Cava Filters for Venous Thromboembolism in Adults With Trauma: An Updated Systematic Review and Meta-Analysis

Background: Trauma is an independent risk factor for venous thromboembolism (VTE). Due to contraindications or delay in starting pharmacological prophylaxis among trauma patients with a high risk of bleeding, the inferior vena cava (IVC) filter has been utilized as alternative prevention for pulmonary embolism (PE). Albeit, its clinical efficacy has remained uncertain. Therefore, we performed an updated systematic review and meta-analysis on the effectiveness and safety of prophylactic IVC filters in severely injured patients. Methods: Three databases (MEDLINE, EMBASE, and Cochrane) were searched from August 1, 2012, to October 27, 2021. Independent reviewers performed data extraction and quality assessment. Relative risk (RR) at 95% confidence interval (CI) pooled in a randomized meta-analysis. A parallel clinical practice guideline committee assessed the certainty of evidence using the GRADE approach. The outcomes of interest included VTE, PE, deep venous thrombosis, mortality, and IVC filter complications. Results: We included 10 controlled studies (47 140 patients), of which 3 studies (310 patients) were randomized controlled trials (RCTs) and 7 were observational studies (46 830 patients). IVC filters demonstrated no significant reduction in PE and fatal PE (RR, 0.27; 95% CI, 0.06-1.28 and RR, 0.32; 95% CI, 0.01-7.84, respectively) by pooling RCTs with low certainty. However, it demonstrated a significant reduction in the risk of PE and fatal PE (RR, 0.25; 95% CI, 0.12-0.55 and RR, 0.09; 95% CI, 0.011-0.81, respectively) by pooling observational studies with very low certainty. IVC filter did not improve mortality in both RCTs and observational studies (RR, 1.44; 95% CI, 0.86-2.43 and RR, 0.63; 95% CI, 0.3-1.31, respectively). Conclusion: In trauma patients, moderate risk reduction of PE and fatal PE was demonstrated among observational data but not RCTs. The desirable effect is not robust to outweigh the undesirable effects associated with IVC filter complications. Current evidence suggests against routinely using prophylactic IVC filters.

New method for ultrasound-guided inferior vena cava filter placement

OBJECTIVE

Transabdominal ultrasound (TAUS)-guided inferior vena cava filter (IVCF) placement currently uses an inferior vena cava (IVC) longitudinal plane with cross-section of the right renal artery or the transverse plane of the right renal vein (RRV)-IVC intersection. The goal of this study was to introduce a new method for TAUS-guided IVCF placement.

METHODS

The study enrolled patients who were at high risk for or had pulmonary embolism from October 22, 2010, to June 30, 2016. The probe was positioned on the right flank to centralize the RRV-IVC junction during imaging and to permit a straight line through the midpoint of the probe on the surface and a parallel line 1.0 cm below the straight line as a marker. The probe was subsequently placed on the abdominal wall with the upper edge at the marker line to show the long axis of the IVC during the process of filter placement. The upper edge of the probe was considered the filter tip position.

RESULTS

A total of 1029 patients were evaluated, and 98 patients (9.5%) were excluded because of poor IVC visualization (n = 14 [1.4%]), IVC or bilateral iliac vein thrombosis (n = 79 [7.7%]), and unsuitable anatomy (n = 5 [0.5%]). The remaining 931 patients (90.5%) were selected for TAUS-guided IVCF placement, and all filters (100%) were successfully placed. There were no procedure-related complications. Suprarenal IVCF was observed in 4 patients (0.4%) by computed tomography, and the filter tip exceeded the upper edge of L2 in 15 patients (1.6%) by plain film radiography; one of them had two RRVs. Severe filter tilting (20.8 degrees) occurred in one patient.

CONCLUSIONS

This new method of TAUS-guided IVCF placement was simple, safe, and effective. It may be widely applied for the bedside placement of vena cava filters.

Inferior vena cava filter use and patient safety: legacy or science?

There has been a dramatic increase in vena cava filter (VCF) use over the past 20 years in the absence of evidence that filters provide a net patient benefit or are required in most cases. This increase is largely attributable to the availability of retrievable filters and expanded indications, particularly as primary prophylaxis in patients thought to be at high risk of pulmonary embolism. Substantial variability in VCF use, unrelated to patient clinical factors, has been shown between hospitals, from region to region, and among various countries. Despite the lack of direct evidence for the benefit of VCFs for any indication, it is appropriate to insert a retrievable VCF in patients with a recent proximal deep vein thrombosis and an absolute contraindication to therapeutic anticoagulation and then to remove the filter once the bleeding risk decreases and the patient has been anticoagulated. Unfortunately, a high proportion of retrievable filters are not removed, even after the reason for their placement has long passed. Retrievable filters are associated with substantial rates of complications if they are not removed, including penetration of the vena caval wall, fracture and embolization of filter fragments, and caval occlusion. Patient safety priorities and medical-legal concerns mandate careful selection of patients for VCF placement and removal shortly after anticoagulation has been initiated.

Bedside implantation of a new temporary vena cava inferior filter - Safety and efficacy results of the European ANGEL-Registry

PURPOSE

Pulmonary embolism (PE) is a frequently occurring complication in critically ill patients. Simultaneous occurrence of PE and life-threatening bleeding, may render medical anticoagulation impossible. For these patients, inferior vena cava filters (IVCF) present a valuable therapeutic alternative. The Angel® catheter is a novel IVCF that provides temporary protection from PE and is implanted at bedside. The primary objective of the European Angel® catheter registry is to evaluate the safety and efficacy of this IVCF.

MATERIAL AND METHODS

The European Angel® catheter registry is an observational, multi-centre registry. Patients from four countries and eight sites that have undergone Angel® catheter implantation between March 2013 and February 2017 were enrolled.

RESULTS

A total of 114 critically ill patients were included. The main indication for implantation was a high-risk for PE in combination with contraindications for anticoagulation (69.3%). One clinically non-significant PE (0.9%) occurred in a patient with an indwelling Angel® catheter. No cases of catheter associated serious complications were observed.

CONCLUSION

Data shows that the Angel® catheter is a safe and effective approach to overcome the acute phase of critically ill patients with a high risk for the development of PE or an established PE, when an anticoagulation therapy is contraindicated.

[Bedside implantation of a new temporary vena cava inferior filter : German results from the European ANGEL registry]

BACKGROUND

Pulmonary embolism (PE) is a frequently occurring complication in critically ill patients, and the simultaneous occurrence of PE and life-threatening bleeding is a therapeutic dilemma. Inferior vena cava filters (IVCF) may represent an important therapeutic alternative in these cases. The Angel® catheter (Bio2 Medical Inc., San Antonio, TX, USA) is a novel IVCF that provides temporary protection from PE and is implanted at bedside without fluoroscopy.

MATERIAL AND METHODS

The European Angel® Catheter Registry is an observational, multicenter study. In our German substudy, we investigated patients from three German hospitals and four intensive care units, who underwent Angel® catheter implantation between February 2016 and December 2016.

RESULTS

A total of 23 critically ill patients (68 ± 9 years, 43% male) were included. The main indication for implantation was a high risk for or an established PE, combined with contraindications for prophylactic or therapeutic anticoagulation due to either an increased risk of bleeding (81%) or active bleeding (13%). The Angel® catheter was successfully inserted in all patients at bedside. No PE occurred in patients with an indwelling Angel® catheter. Clots with a diameter larger the 20 mm, indicating clot migration, were detected in 5% of the patients by cavography before filter retrieval. Filter retrieval was uneventful in all of our cases, while filter dislocation occurred in 3% of the patients.

CONCLUSION

The German data from the multicenter European Angel® Catheter Registry show that the Angel® catheter is a safe and effective approach for critically ill patients with a high risk for the development of PE or an established PE, when an anticoagulation therapy is contraindicated.

Retrievable inferior vena cava filters in geriatric trauma: Is there an age bias?

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%).

The short-term efficacy of vena cava filters for the prevention of pulmonary embolism in patients with venous thromboembolism receiving anticoagulation: Meta-analysis of randomized controlled trials

Objectives

To perform a meta-analysis of randomized controlled trials assessing the effectiveness of inferior vena cava filters in patients with deep vein thrombosis for preventing pulmonary embolism.

Method

Relevant randomized controlled trials of inferior vena cava filters for the prevention of pulmonary embolism were identified by searching electronic databases updated in February 2016. Relative risks of recurrent pulmonary embolism, recurrent deep vein thrombosis, and mortality at three months were analyzed.

Results

Three published randomized controlled trials were included involving a total of 863 deep vein thrombosis patients. No significant differences were detected with inferior vena cava filters placement with regard to the incidence of recurrent pulmonary embolism or fatal pulmonary embolism. There were also no significant differences in the incidence of recurrent deep vein thrombosis or mortality with inferior vena cava filters placement at three months.

Conclusions

Inferior vena cava filter in addition to anticoagulation was not associated with a reduction in the incidence of recurrent pulmonary embolism as compared with anticoagulation alone in patients with deep vein thrombosis in the short term.

Inferior vena cava filter thrombosis

Patients with inferior vena cava (IVC) filters – particularly permanent filters – are at increased risk for recurrent deep venous thrombosis (DVT). Judicious use of IVC filters, as well as the prompt retrieval of temporary IVC filters, substantially reduces the risk of IVC thrombosis.

Acute phase treatment of VTE: Anticoagulation, including non-vitamin K antagonist oral anticoagulants

The acute phase of venous thromboembolism (VTE) treatment focuses on the prompt and safe initiation of full-dose anticoagulation to decrease morbidity and mortality. Immediate management consists of resuscitation, supportive care, and thrombolysis for patients with haemodynamically significant pulmonary embolism (PE) or limb-threatening deep-vein thrombosis (DVT). Patients with contraindications to anticoagulants are considered for vena cava filters. Disposition for the acute treatment of VTE is then considered based on published risk scores and the patient's social status, as the first seven days carries the highest risk for VTE recurrence, extension and bleeding due to anticoagulation. Next, a review of: immediate and long-term bleeding risk, comorbidities (i. e. active cancer, renal failure, obesity, thrombophilia), medications, patient preference, VTE location and potential for pregnancy should be undertaken. This will help determine the most suitable anticoagulant for immediate treatment. The non-vitamin K antagonist oral anticoagulants (NOACs), including the factor Xa inhibitors apixaban, edoxaban and rivaroxaban as well as the direct-thrombin inhibitor dabigatran, are increasing the convenience of and options available for VTE treatment. Current options for immediate treatment include low-molecular-weight heparin (LMWH), unfractionated heparin (UFH), fondaparinux, apixaban, or rivaroxaban. LMWH or UFH may be continued as monotherapy or transitioned to treatment with a VKA, dabigatran or edoxaban. This review describes the upfront treatment of VTE and the evolving role of NOACs in the contemporary management of VTE.