A Review of Interventions to Increase Vena Cava Filter Retrieval Rates

The Impact of Implementation of a Commercial Inferior Vena Cava Filter Database Program on Filter Retrieval versus Physician Tracking over a 9-Year Period: A Retrospective, Observational Study

PURPOSE

To compare the impact of a commercial tracking database on inferior vena cava filter retrievals with that of physician tracking and no tracking.

MATERIALS AND METHODS

From January 2013 to December 2021, 532 filters were placed at a single institution and followed in 3 phases: (a) Phase 1, pretracking (January 1, 2013, to February 28, 2015); (b) Phase 2, commercial database tracking (March 1, 2015, to June 30, 2019); and (c) Phase 3, commercial database tracking with separate tracking by an interventional radiologist (July 1, 2019, to December 31, 2021). Patients excluded from the commercial database due to human error served as a control group. Outcomes of commercial database entry, 2-year filter retrieval rates, dwell times, and factors contributing to retrieval candidacy were collected.

RESULTS

Two-year retrieval rates in Phases 1, 2 and 3 were 20%, 31%, and 46%, respectively (Phase 1 vs 2, P = .04; Phase 2 vs 3, P = .009). Median dwell times across Phases 1, 2, and 3 were 168 days (4-1,313 days), 140 days (3-1,988 days), and 188 days (13-734 days) (P = .33), respectively. There was no difference in retrieval rates (P = .86) and dwell times (P = .50) between patients enrolled in the database group and those enrolled in the control group. Across all phases, 48% of patients enrolled in the database were not successfully contacted, and only 6% were categorized as "likely to consult" filter retrieval. During Phase 3, 100% of patients achieved a retrieval disposition.

CONCLUSIONS

A commercial tracking database had low success rates of contacting patients and did not increase filter retrieval rates relative to those in the control group; however, physician tracking increased retrieval rates.

Role of Inferior Vena Cava Filter Retrieval in Patients on Chronic Anticoagulation Therapy

Purpose of review

Describe the role of inferior vena cava filter (IVCF) retrieval in patients on chronic anticoagulation given the overlap of these treatment options in the management of patients with venous thromboembolic disease.

Recent findings

Despite the increase in IVCF retrievals since the Food and Drug Administration safety communications in 2010 and 2014, retrieval rates remain low. Previous studies have shown that longer filter dwell times are associated with greater risk for filter complications and more difficulty with filter retrievals. Recent findings suggest that complications are more frequent in the first 30 days after placement.

Summary

The decision to retrieve an optional IVCF is individualized and requires diligent follow-up with consistent re-evaluation of the need for the indwelling IVCF, particularly in those on long-term anticoagulation therapy.

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

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

Effect of a dedicated inferior vena cava filter retrieval program on retrieval rates and number of patients lost to follow-up

PURPOSE We aimed to assess the efficacy of a dedicated inferior vena cava (IVC) filter retrieval program on filter retrieval rates and number of patients lost to follow-up. METHODS A dedicated IVC filter retrieval program began in July 2016. This consisted of tracking all patients with retrievable filters placed by interventional radiology (IR). At the time of filter placement, patients were scheduled for a retrieval consult in the IR clinic. Any missed appointments were followed up by a physician assistant. The program was overseen by a single IR physician. To assess this program's efficacy, we reviewed the records of all patients who had retrievable IVC filters placed by IR nine months prior to and nine months after program initiation. Demographics and clinical factors were then collected and compared. A P value of < 0.05 was considered statistically significant. RESULTS Prior to the program, 76 patients (31 males, 45 females; mean age, 64.2 years) had retrievable filters placed; 75% were placed due to a contraindication to anticoagulation. From this group, five filters were removed (6.6%), 42 patients were lost to follow-up (55.3%), 22 patients died (29.0%), and seven filters were deemed permanent by a physician after placement (9.2%). All five retrievals were successful and no complications were reported. After program initiation, 106 patients (59 males, 47 females; mean age, 58.8 years) had retrievable filters placed; 75.5% were placed due to a contraindication to anticoagulation. In this group, 30 filters were retrieved (retrieval rate 28.3%), 17 patients were lost to follow-up (16%), 23 patients died (21.7%), 28 filters were deemed permanent by a physician after placement (26.4%), and decisions were still pending in eight patients (7.5%). One patient (3.3%) had a minor complication during filter retrieval. Initiation of a filter retrieval program increased our retrieval rate (6.6% vs. 28.3%; P < 0.001) and reduced the number of patients with filters that were lost to follow-up (55.3% vs. 16%; P < 0.001). CONCLUSION Dedicated filter retrieval program is effective in increasing filter retrieval rates and decreasing the number of patients lost to follow-up.

Spontaneous iliac vein rupture in the setting of a long dwelling intravenous vena cava filter

Venous thromboembolism impacts as many as 600,000 individuals each year in the United States, leading to significant morbidity and mortality. While typically treated with anticoagulants, retrievable inferior vena cava (IVC) filters may also be used for acute prevention of pulmonary embolism. The FDA recommends removing IVC filters within 29-54 days because long dwelling filters are associated with serious complications from the filter itself, such as perforation of adjacent structures and filter fracture. We report an unusual case in which a patient had an inferior venous cava filter in place for two years before experiencing spontaneous rupture of the left iliac vein. There was no evidence of filter migration or inferior venous cava perforation. Spontaneous iliac vein ruptures are rare, with fewer than 50 reported cases, and are not typically seen with a long-dwelling IVC. This case describes a unique complication of retrievable filters and highlights the importance of retrieving filters as soon as the acute danger of pulmonary embolism has resolved.

Changing trends in inferior vena cava filter indication for venous thromboembolism over the last two decades: a retrospective observational study

BACKGROUND

The present study aimed to evaluate changes in the incidence, patients' profile and indications of inferior vena cava filters at a single center over the past two decades.

METHODS

We retrospectively analyzed 187 consecutive patients with a venous thromboembolism requiring a filter at a tertiary hospital between 1999-2018. Within this period the availability of retrievable filters (since 2007) and the withdrawal of filter indication for recurrent venous thromboembolism from guidelines (since 2008) may have contributed to change practice patterns. Patients' profile, filter indication and survival were compared between decades (1999-2008 vs. 2009-2018).

RESULTS

The filter insertion rate doubled (60 vs. 127 cases) over 2009-2018. In this later period there was an unexpected rise (15 vs. 68 cases, P<0.001) of patients with isolated pulmonary embolism as baseline venous thromboembolism episode, without other relevant changes in patients' profile or survival. Regarding indications, there was an increase in filters for bleeding risk (23 vs. 45) and a reduction for venous thromboembolism recurrence (20 vs. 7), but also an unexpected increase of cases for bleeding (15 vs. 72). Among the 116 retrievable filters indicated for a temporary cause, 70 (60.3%) were finally not removed, being persistence of filter indication (n=33, 47.1%) the most common cause.

CONCLUSIONS

The number of filters inserted at our institution has raised over the last two decades. This increase was partly unexpected and perhaps related to the availability of retrievable filters. Unfortunately these devices remain frequently non-removed being persistence of the indication the most frequent cause.