Improving the retrieval rate of inferior vena cava filters with a multidisciplinary team approach

A change in strategy for filter choice leads to improved filter retrieval rates

OBJECTIVE

To assess whether a new strategy for the choice of inferior vena cava filter placed would improve filter retrieval rates at our institution.

METHODS

Consecutive patients who underwent retrievable filter placement for temporary embolic protection between January 2021 and January 2023 were considered for study inclusion. Risk factors for nonretrieval of short-term filters were identified in patients receiving filters between January 2021 and January 2022 (prestrategy group). For patients treated between February 2022 and January 2023 (poststrategy group), a long-term filter was recommended for those with these risk factors, and a short-term filter was recommended for those without these risk factors.

RESULTS

The study population included 303 patients (prestrategy group, n = 154; poststrategy group, n = 149). Long-term immobilization (odds ratio [OR] = 38.000; 95% confidence interval [CI]: 6.858-210.564), active cancer (OR = 17.643; 95% CI: 5.462-56.993), and venous thromboembolism detected in the intensive care unit (OR = 28.500; 95% CI: 7.419-109.477) were identified as independent risk factors for nonretrieval of short-term filters. The total retrieval rate was significantly higher in the poststrategy group (87.2%) than in the prestrategy group (72.7%; P = 0.002); the short-term filter retrieval rate was also significantly higher in the poststrategy group (84.5%) than in the prestrategy group (68.5%; P < 0.001).

CONCLUSION

The proposed strategy for filter choice based on risk factors for short-term filter nonretrieval can accurately identify patients who need long-term filter placement while also increasing the retrieval rates for both short-term filters retrieval rates and overall retrieval rates.

Utilization Practices of Inferior Vena Cava Filters at an Academic Medical Center

INTRODUCTION

 Anticoagulation is the mainstay of management for patients with venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). Inferior vena cava (IVC) filters are indicated in select patients who are not candidates for anticoagulation. There is a lack of quality evidence supporting other indications. In addition, long-term benefits and safety profiles of IVC filters have not been established. We investigated the utilization practice of IVC filters in a contemporary series of patients in a tertiary academic medical center.

METHODOLOGY

 A retrospective review of 200 patients who received IVC filters at Virginia Commonwealth University (VCU) Medical Center in the years 2017 and 2018 was conducted. Adult patients 18 years of age or older with or without cancer were included, and patients were selected consecutively until data on 200 patients were collected. Data on patient demographics, an indication of IVC filter placement, filter retrieval rate, and re-thrombosis events over a median follow-up period of nine months were extracted from the electronic medical record and analyzed.

RESULTS

A total of 200 patients (105 male and 95 female) were included with a median age of 61 years (range 17-92 years). Of the 200 patients, 97 (48.5%) had a DVT, 28 (14%) had a PE, 73 (36.5%) had both a PE and DVT, and 2 (1%) had thrombosis at other sites. A total of 130 (65%) patients had an IVC filter placed because of a contraindication to anticoagulation, while 70 (35%) had an IVC filter placed for other nonstandard indications, which included new or worsening VTE despite anticoagulation, recent VTE who must have anticoagulation held during surgery, primary prevention in high-risk patients, and extensive disease burden among other reasons. Seventy-two (36%) patients had active malignancy at the time of filter placement, and 64 (32%) were lost to follow-up. Of the 119 patients who were potentially eligible for filter retrieval, 55 (46%) patients had their IVC filters removed at a median of five months after insertion. Of the 55 patients who had IVC filters removed, 8 (14.5%) patients experienced a re-thrombosis event within a median follow-up of 39 months. Of the 145 patients who still had their filter in place at the time of death or last follow-up, 5 (3.4%) patients experienced a re-thrombosis event within a median follow-up of three months.

CONCLUSIONS

 One-third of the patients in this series had an IVC filter placed without a standard indication, and less than half of them had the IVC filters removed within one year of placement. Additionally, one-third of the patients were lost to follow-up, highlighting the need for improved structured follow-up programs and education among both patients and providers regarding the indications for placement and retrieval to minimize complications.

Reengaging patients with forgotten filters through an institutional multidisciplinary approach

OBJECTIVE

The aim of the present study was to evaluate the outcomes of a hospital-wide multidisciplinary initiative to reengage and manage patients with unretrieved chronic indwelling inferior vena cava (IVC) filters placed at a large tertiary care center, who had been lost to follow-up.

METHODS

We performed a retrospective review of outcomes from a completed multidisciplinary quality improvement project. The quality improvement project identified and contacted (via letter) patients with chronic indwelling IVC filters placed at a single tertiary care center from 2008 to 2016 who were alive and without evidence of filter retrieval in the medical records. A total of 316 eligible patients were mailed a letter regarding their chronic indwelling IVC filter and the updated recommendations regarding IVC filter removal. The letter included institutional contact information, and all the patients who responded were offered a clinic visit to discuss potential filter retrieval. In the retrospective review, we assessed the outcomes of the quality improvement project, including the patient response rate, follow-up clinic visits, new imaging studies generated, retrieval rate, procedural success, and complications. The patient demographics and filter characteristics were collected and evaluated for correlations with the response and retrieval rates.

RESULTS

The patient response rate to the letter was 32% (101 of 316). Of the 101 patients who responded, 72 (71%) were seen in clinic and 59 (82%) underwent new imaging studies. Using standard and advanced techniques, 34 of 36 filters after a median dwell time of 9.4 years (range, 3.3-13.3 years) were successfully retrieved (94% success rate). The patients with a documented IVC filter complication were more likely to respond to the letter (odds ratio, 4.34) and undergo IVC filter retrieval (odds ratio, 6.04). No moderate or severe procedural complications occurred during filter retrieval.

CONCLUSIONS

An institutional, multidisciplinary quality initiative successfully identified and reengaged patients with chronic indwelling IVC filters who had been lost to follow-up. The filter retrieval success rate was high and procedural morbidity low. Institution-wide efforts to identify and retrieve chronic indwelling filters are feasible.

The application of inferior vena cava filters in orthopaedics and current research advances

Deep vein thrombosis is a common clinical peripheral vascular disease that occurs frequently in orthopaedic patients and may lead to pulmonary embolism (PE) if the thrombus is dislodged. pulmonary embolism can be prevented by placing an inferior vena cava filter (IVCF) to intercept the dislodged thrombus. Thus, IVCFs play an important role in orthopaedics. However, the occurrence of complications after inferior vena cava filter placement, particularly recurrent thromboembolism, makes it necessary to carefully assess the risk-benefit of filter placement. There is no accepted statement as to whether IVCF should be placed in orthopaedic patients. Based on the problems currently displayed in the use of IVCFs, an ideal IVCF is proposed that does not affect the vessel wall and haemodynamics and intercepts thrombi well. The biodegradable filters that currently exist come close to the description of an ideal filter that can reduce the occurrence of various complications. Currently available biodegradable IVCFs consist of various organic polymeric materials. Biodegradable metals have shown good performance in making biodegradable IVCFs. However, among the available experimental studies on degradable filters, there are no experimental studies on filters made of degradable metals. This article reviews the use of IVCFs in orthopaedics, the current status of filters and the progress of research into biodegradable vena cava filters and suggests possible future developments based on the published literature by an electronic search of PubMed and Medline databases for articles related to IVCFs searchable by October 2022 and a manual search for citations to relevant studies.

Safety and efficacy of inferior vena cava filter retrieval: a 5-year single center retrospective review from a tertiary care center

Background

Inferior vena cava (IVC) filter retrieval is typically accomplished with standard snare technique. When this fails, more advanced techniques are necessary, especially when removal falls outside a 12-month window. Complications during filter retrieval depend heavily on technique, type of filter, and filter position. In this study we examined safety and efficacy of 536 filter retrievals at a tertiary care center and compared complication rates between standard snare and endobronchial forcep retrieval.

Method

We reviewed 536 cases between August 2015 and August 2020, recording retrieval success rates, patient comorbidities, and complication rates at the time of removal.

Results

Total overall retrieval success was 97.9% (525/536), and complications occurred in approximately 6.0% (32/536) of all cases. Success and complications with standard snare technique alone were 99.4% (345/347) and 1.7% (5 Grade I/II, 1 Grade III) and advanced forcep technique 98.8% (171/173) and 14.5% (22 Grade I/II, 2 Grade III, and 1 Grade IV), respectively. There was no significant difference between the technical success rates of the standard snare technique and forceps techniques (p = 0.60) despite a significantly longer dwell time in patients undergoing forceps retrieval (p < 0.001).

Conclusion

To our knowledge, this is the largest cohort of forceps directed IVC filter retrieval present in the literature. Rates of successful endobronchial forceps and standard snare retrievals in this study are similar to previous reports. Although use of endobronchial forceps may be associated with higher complication rates, this is likely due to prolonged dwell times, filter tilt, and attempted removal of non retrievable filters. Overall, forceps-directed retrieval offers a safe, effective means of removal in difficult cases.

Level of evidence

Level 3, Large Retrospective Study.

Vena Cava Filters: Toward Optimal Strategies for Filter Retrieval and Patients' Follow-Up

Mortality rates associated with venous thromboembolism (VTE) are high. Inferior vena cava filters (IVCFs) have been frequently placed for these patients as part of their treatment, albeit the paucity of data showing their ultimate efficacy and potential risk of complications. Issues regarding long-term filter dwell time are accounted for in society guidelines. This topic has led to an FDA mandate for filter retrieved as soon as protection from pulmonary embolism is no longer needed. However, even though most are retrievable, some were inadvertently left as permanent, which carries an incremental lifetime risk to the patient. In the past decade, attempts have aimed to determine the optimal time interval during which filter needs to be removed. In addition, distinct strategies have been implemented to boost retrieval rates. This review discusses current conflicts in indications, the not uncommon complications, the rationale and need for timely retrieval, and different quality improvement strategies to fulfill this aim.

An expert spotlight on inferior vena cava filters

Introduction: Inferior vena cava (IVC) filters are mechanical filtration devices designed as an alternative to surgical ligation/plication of the IVC. Their use has been controversial, especially with the introduction of retrievable filters and expanded/prophylactic indications.Areas covered: Authors discuss the types of available IVC filters, indications for placement, evidence on their effectiveness in general and specific patient populations, procedural considerations, off-label use, complications, and filter retrieval. This review is based on manuscripts/abstracts published from 1960 to 2021 on venous thromboembolism and IVC filters.Expert opinion: Despite the limited data on their effectiveness and survival benefit, IVC filters continue to play an important role in the treatment of patients with venous thromboembolism (VTE) who cannot receive standard anticoagulation. There is no role of IVC filters in patients without VTE. While retrievable filters are desirable for short-term use, a dedicated team-based approach, and advanced training are required for their successful removal. Newer devices are promising in improving patient safety . The device manufacturers and regulatory agencies should consider specific approaches to track device-related adverse events. Population-based studies are required to establish optimal patient population who would benefit from these devices. .

Single center experience of inferior vena cava filter retrieval in trauma patients: contrast-enhanced CT-based retrieval within hospital stay

PURPOSE

To assess the safety and retrieval rate of a predischarge inferior vena cava (IVC) filter retrieval strategy based on contrast computed tomography (CT).

METHODS

IVC filter insertion for trauma patients from 2010 to 2018 were reviewed. An active filter retrieval strategy was established in March 2017. The strategy sought early evaluation of venous thromboembolism (VTE) status and filter retrieval before a patient's discharge. The possibility of early IVC filter retrieval was evaluated by a multidisciplinary team based on pre-filter retrieval VTE-CT findings. Overall VTE-CT findings, retrieval rate, indwelling time, and recurrence of venous thromboembolic events were compared before and after the filter retrieval strategy setup.

RESULTS

177 IVC filters were inserted in trauma patients. All patients underwent pre-filter retrieval VTE-CT. VTE-CT findings were as follows: completely resolved VTE, n = 108 (61%); partially improved, n = 58 (33%); no change, n = 8 (5%); aggravated, n = 3 (2%). The overall retrieval rate was 84% with a mean indwelling time of 32 days. In subgroup analyses, 95 (53%) had filter retrieval with the before strategy (BS) setup and 82 (47%) with the after strategy (AS) setup. The retrieval rate was significantly higher in the AS group [81/82 (99%) vs. 68/95 (72%), (p < 0.001)]. No patients had recurrent VTE during the follow-up period.

CONCLUSIONS

The active strategy of VTE-CT-based filter retrieval during the hospital stay markedly improved the filter retrieval rate from 72% to 99% without evidence of recurrence of VTE. Hazards of low retrieval rate versus CT-related radiation exposure should be studied in the future.

Structured team-oriented program to follow patients after vena cava filter placement: a step forward in improving quality for filter retrieval

To reduce inferior vena cava filter (IVCF) related complications, retrieval is recommended whenever possible. Nevertheless, IVCF retrieval rates remain lower than expected, likely due to insufficient follow-up after placement. We evaluated the value of a structured program designed to follow patients by the interventional radiology team up to 5 months after IVCF placement. We prospectively enrolled 366 consecutive patients (mean age 64 ± 17 years; 201 men and 165 women) who benefited from IVCF between March 2015 and February 2020. The program consisted of advising the patient and clinicians to consider IVCF retrieval as soon as possible (standard workflow) and systematically planning an additional follow-up visit at 5-month. Clinical and technical eligibility, as well as technical success for retrieval (TSR) were evaluated. At 5-months, 38 (10.4%) patients were lost to follow-up, and 47 (12.8%) had died. Among survivors, the overall retrieval rate was 58%. The retrieval rates were 83% and 97% for the clinically eligible and technically eligible patients for retrieval, respectively. The 5-month visit enabled 89 additional retrievals (47.8%) compared to the standard workflow. No significant difference was seen in TSR before and after 5 months (p = 0.95). Improved patient tracking with a dedicated IVCF program results in an effective process to identify suitable patients for retrieval and drastically improves retrieval rates in eligible patients. Involving interventionalists in the process improved IVCF patient management.

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.

Inferior vena cava filter – comprehensive overview of current indications, techniques, complications and retrieval rates

Summary: Inferior vena cava (IVC) filter has been used to manage patients with pulmonary embolism and deep venous thrombosis. Its ease of use and the expansion of relative indications have led to a dramatic increase in IVC filter placement. However, IVC filters have been associated with a platitude of complications. Therefore, there exists a need to examine the current indications and identify the patient population at risk. In this paper, we comprehensively reviewed the current indications and techniques of IVC filter placement. Further, we examined the various complications associated with either permanent or retrievable IVC filters. Lastly, we examined the current data on filter retrieval.

Systems-based hematology: highlighting successes and next steps

Systems-based hematology is dedicated to improving care delivery for patients with blood disorders. First defined by the American Society of Hematology in 2015, the idea of a systems-based hematologist arose from evolving pressures in the health care system and increasing recognition of opportunities to optimize the quality and cost effectiveness of hematologic care. In this review, we begin with a proposed framework to formalize the discussion of the range of initiatives within systems-based hematology. Classification by 2 criteria, project scope and method of intervention, facilitates comparison between initiatives and supports dialogue for future efforts. Next, we present published examples of successful systems-based initiatives in the field of hematology, including efforts to improve stewardship in the diagnosis and management of complex hematologic disorders (eg, heparin-induced thrombocytopenia and thrombophilias), the development of programs to promote appropriate use of hematologic therapies (eg, blood products, inferior vena cava filters, and anticoagulation), changes in care delivery infrastructure to improve access to hematologic expertise (eg, electronic consultation and disorder-specific care pathways), and others. The range of projects illustrates the broad potential for interventions and highlights different metrics used to quantify improvements in care delivery. We conclude with a discussion about future directions for the field of systems-based hematology, including extension to malignant disorders and the need to define, expand, and support career pathways.

Society of Interventional Radiology Clinical Practice Guideline for Inferior Vena Cava Filters in the Treatment of Patients with Venous Thromboembolic Disease: Developed in collaboration with the American College of Cardiology, American College of Chest Physicians, American College of Surgeons Committee on Trauma, American Heart Association, Society for Vascular Surgery, and Society for Vascular Medicine

PURPOSE

To provide evidence-based recommendations on the use of inferior vena cava (IVC) filters in the treatment of patients with or at substantial risk of venous thromboembolic disease.

MATERIALS AND METHODS

A multidisciplinary expert panel developed key questions to address in the guideline, and a systematic review of the literature was conducted. Evidence was graded based on a standard methodology, which was used to inform the development of recommendations.

RESULTS

The systematic review identified a total of 34 studies that provided the evidence base for the guideline. The expert panel agreed on 18 recommendations.

CONCLUSIONS

Although the evidence on the use of IVC filters in patients with or at risk of venous thromboembolic disease varies in strength and quality, the panel provides recommendations for the use of IVC filters in a variety of clinical scenarios. Additional research is needed to optimize care for this patient population.

The role of an IVC filter retrieval clinic-A single center retrospective analysis

Background:

Inferior vena cava (IVC) filter placement still plays an essential role in preventing pulmonary embolism (PE) in patients with contraindications to anticoagulant therapy. However, IVC filter placement does have long-term risks which may be mitigated by retrieving them as soon as clinically acceptable. A dedicated IVC filter clinic provides a potential means of assuring adequate follow-up and retrieval.

Aim:

To assess the efficacy of our Inferior vena cava (IVC) filter retrieval clinic at improving the rate of patient follow-up, effective filter management, and retrieval rates.

Materials and Methods:

During the period of August 2017 through July 2018, 70 IVC filters were placed at our institution, and these patients were automatically enrolled into our IVC filter retrieval clinic for quarterly follow-up. We retrospectively reviewed data including appropriateness for removal at 3 months, overall retrieval rates, removal technique(s) employed, and technical success.

Results:

62.9% of the potentially retrievable filters were removed during the study period. The technical success of extraction, using a combination of standard and advanced techniques, was 91.7%. Overall, 15% of the patients were lost to follow-up.

Conclusion:

Our findings add to the growing body of literature to support the need for a robust IVC filter retrieval clinic to ensure adequate follow-up and timely retrieval of IVC filters.

Phlegmasia cerulea dolens: a rare cause of shock

Phelgmasia cerulea dolens (PCD) is a rare cause of shock that can complicate deep venous thrombosis and carries a high risk of mortality. We present a case of extensive bilateral lower extremity deep vein thrombosis associated with an inferior vena cava filter which rapidly progressed to PCD and refractory shock.

Usefulness of a Computerized Reminder System to Improve Inferior Vena Cava Filter Retrieval and Complications

Inferior vena cava filters (IVCF) are associated with complications which may be due to delayed retrieval. Initiation of an automated reminder system may improve retrieval rates and reduce complications. A computerized reminder system, which provides interactive email reminders after implantation while collecting IVCF use data, was implemented. IVCF retrieval was compared before ("reminder not provided" group) and after ("reminder provided" group) implementation. Data regarding implantation, retrieval, and complications were collected. The primary efficacy outcome was retrieval rate, and the primary safety outcome was indwelling complication rate. Secondary outcomes were time to retrieval and a composite adverse outcome defined as IVCF thrombosis, deep venous thrombosis (DVT), pulmonary embolism, and death. A total of 1,070 IVCF insertions were included, 715 in the "reminder not provided" group and 355 in the "reminder provided" group. Patient age (61 vs 64 years, p = 0.95) and gender (42% vs 40% female, p = 0.55) were similar in the "reminder not provided" and "reminder provided" groups, respectively. In the "reminder provided" group, the retrieval rate was higher (148/297 [49.8%] vs 223/715 [31.2%], p = 0.0001), the indwelling complication rate was lower (30/319 [9.4%] vs 115/715 [16.1%], p = 0.005), and the time to retrieval was shorter (112 days vs 146 days, p = 0.02). The composite adverse outcome occurred less frequently in the "reminder provided" group: (85/355 [23.9%] vs 297/715 [41.5%], p = 0.0001). The system was associated with increased odds of IVCF retrieval (odds ratio 2.56; 95% confidence interval: 1.82 to 3.59; p <0.0001) and reduced odds of the composite adverse outcome (odds ratio 0.72; 95% confidence interval: 0.60 to 0.80; p <0.0001). In conclusion, implementing a computerized email reminder system was associated with higher IVCF retrieval rates, fewer indwelling complications, and shorter dwell times.

Factors Affecting Inferior Vena Cava Filter Retrieval: A Review

Objective:

Over the last 2 decades, there has been an exponential rise in placement of retrievable inferior vena cava (IVC) filters, while the retrieval rate has remained steadily low. Approaches to increasing filter retrieval rates have been extensively studied.

Conclusion:

This review presents an up-to-date review of reported data-driven variables that affect retrieval rates of IVC filters, with a focus on clinical, technical, and process factors.

Persistently low inferior vena cava filter retrieval rates in a population-based cohort

BACKGROUND

Practice patterns associated with inferior vena cava (IVC) filter placement have seen considerable variation in the last decade. We used a statewide administrative database to examine trends in IVC filter placement and retrieval in the general population.

METHODS

We reviewed Florida state inpatient and ambulatory surgery databases from 2004 to 2014. International Classification of Diseases, Ninth Revision diagnosis and procedure codes and Current Procedural Terminology codes were searched for patients undergoing inpatient or outpatient IVC filter placement, and each patient was longitudinally tracked to the time of inpatient or outpatient filter retrieval. For inpatient filter placements, associated diagnoses were reviewed to identify indications for placement. Univariate and multivariate logistic regression models were constructed to identify factors associated with improved retrieval rates.

RESULTS

During the 11-year period, 131,791 IVC filter placements were identified, with a 50% increase from 2004 to 2010 and a 24% decline from 2010 to 2014. Median age at filter placement was 71 years (interquartile range, 57-81 years). Mean follow-up after filter placement was 17.3 ± 25.5 months. Only 8637 filters (6.6%) were retrieved. The annual retrieval rate trended upward, from 3.4% in 2004 to 8.5% in 2013 (P < .001). Median filter dwell time was 96.5 days (interquartile range, 44-178 days). Diagnoses associated with filter placement included venous thromboembolism (75.9%), trauma (35.0%), hemorrhage (29.9%), malignant disease (29.4%), and stroke (5.1%). Retrieval rates were highest in younger patients (34.0% in patients younger than 20 years) and lowest in Medicare patients (2.5%). In a multivariate logistic regression model, Medicare was associated with decreased retrieval rates (odds ratio, 0.33; 95% confidence interval, 0.31-0.35; P < .001) after adjusting for age and associated diagnoses. Weaker risk factors included increased age, white race, and diagnoses of deep venous thrombosis, pulmonary embolism, and malignant disease. A trauma diagnosis was associated with improved retrieval. To further investigate the Medicare effect, a propensity score-matched model was created to better account for confounding effects. In this model, Medicare persisted as a risk factor for decreased filter retrieval (odds ratio, 0.43; 95% confidence interval, 0.40-0.46; P < .001).

CONCLUSIONS

IVC filter placements, after a substantial increase between 2004 and 2010, have been declining since 2010. Retrieval rates in the general population are steadily improving but continue to lag behind those described in center-specific literature. Increased age and Medicare as the primary payer are the strongest risk factors for lack of filter retrieval. Widespread improvements on a national scale are needed to improve the appropriateness of filter placements and to enhance filter retrieval rates.

Practice Patterns of Inferior Vena Cava Filter Placement and Factors That Predict Retrieval Rates: A Single-Center Institution and Review of the Literature

Background

There is a wide variability in practice patterns on the use of inferior vena cava filters (IVCFs) among institutions, which is likely due to contrasting indication guidelines published by different professional societies. The aim of the present study is to report our healthcare system use of IVCF to: 1) determine practice patterns, 2) determine factors that may predict IVCF retrieval and 3) identify areas for improvement.

Methods

A retrospective review of 180 consecutive IVCF placement performed between July 2014 and December 2015 was conducted.

Results

One hundred nine (60.6%) IVCFs were placed for absolute indications, 27 (15.0%) for relative indications, 26 (14.4%) prophylactically and 18 (10.0%) for unknown indications. Average age was 59.3 years. Ninety-five had active cancer. Surgical and medical services requested filter placement in 112 (62.2%) and 68 (37.8%) patients, respectively. Thirteen (7.2%) patients had a hematology consult prior to IVCF placement. Documentation of the presence of an IVCF was present in 118/127 (92.9%) discharge summaries, and outlined instructions for filter retrieval post-discharge were present in 20/124 (16.1%) cases. Only 33 (25.0%) IVCF were retrieved at a median interval of 162 days (range: 4 - 1,053 days). None of the factors of interest was found to be significantly associated with IVCF retrieval.

Conclusion

A root cause analysis identified that the lack of a structured system for IVCF tracking resulted in poor IVCF retrieval rates. This study resulted in the development of a hospital-initiated multidisciplinary team to address these issues.

An Informatics Approach to Facilitate Clinical Management of Patients With Retrievable Inferior Vena Cava Filters

OBJECTIVE

Long indwelling times for inferior vena cava (IVC) filters that are used to prevent venous thromboembolism can result in complications. To improve care for patients receiving retrievable IVC filters, we developed and evaluated an informatics-based initiative to facilitate patient tracking, clinical decision-making, and care coordination.

MATERIALS AND METHODS

A semiautomated filter-tracking application was custom-built to query our radiology information system to extract and transfer key data elements related to IVC filter insertion procedures into a database. A web-based interface displayed key information and facilitated communication between the interventional radiology clinical team and referring physicians. A set of filter management options was provided depending on each patient's clinical condition. The system was launched in April 2016. Using retrospective observational cohort methods, we compared filter retrieval rates during a test period from July through December 2016 with a control period of the same 6 months in 2015.

RESULTS

System development required approximately 100 hours of development time. Two hundred ninety-three IVC filter placements and 83 filter retrievals were tracked during the study periods. The overall filter retrieval rate was 23% in the control period and 34% in the test period. Mean times from filter placement to retrieval in the control and test periods were not significantly different (88.9 and 102.7 days, respectively; p = 0.32).

CONCLUSION

A semiautomated approach to tracking patients with IVC filters can facilitate care coordination and clinical decision-making for a device with known potential complications. Similar applications designed to improve provider communication and documentation of filter management plans, including appropriateness for retrieval, can be replicated.

Non-retrieval of inferior vena cava filters as a patient safety concern: evaluation of a new process improvement project to increase retrieval rates in a vascular and interventional radiology clinic

Background

Retrieval of inferior vena cava filters (IVCFs) is important to decrease the long-term risk of complications associated with indwelling devices. Our hospital experienced low retrieval rates and implemented a low-cost intervention and evaluation for quality improvement. The working hypothesis was that a simple, mailed letter intervention could increase retrieval rates by increasing patient and primary care provider knowledge of the need for retrieval.

Methods

For all prospective patients who received a retrievable IVCF during the intervention period from January 1, 2014 to February 29, 2016, patients and their primary care providers were mailed letters encouraging contact with the clinic for evaluation of eligibility for retrieval. The main outcome was retrieval of the IVCF if clinically indicated with a secondary outcome of time-to-retrieval. A pre-intervention control group from October 1, 2011 to December 31, 2013 was used to evaluate the impact of the intervention. Competing risks, time-to-event analysis was used to compare the pre- and post-intervention period retrieval rates correcting for patients who died during follow-up.

Results

Between the pre- and post-intervention periods, crude retrieval rates increased from 4.4% to 8.1% with a 12-fold change at comparable time points. The time-to-retrieval in the pre-intervention period was a mean (SD) of 503 (207) days with a median (IQR) of 505 (301–742). In the post-intervention period, time-to-retrieval was a mean (SD) of 119 (83) days and with median (IQR) of 128 (38–164) days.

Conclusions

This low-cost intervention significantly increased retrieval rates in a single clinic. However, retrieval rates remain low and can be further improved. Ongoing interventions, including improved patient follow-up and physician education, are being implemented to further improve retrieval and use of inferior vena cava filters. Implanting clinics should implement quality improvement initiatives to improve patient care and follow-up with IVCFs to ensure retrievals occur once clinically relevant in order to minimize long-term complications.

Prophylactic Inferior Vena Cava Filter Utilization and Risk Factors for Nonretrieval

PURPOSE

Inferior vena cava filters (IVCFs) are often placed for prophylactic indications. We sought to better define the range of practice indications for placement of prophylactic IVCFs, as well as the specific retrieval rate and risk factors for nonretrieval.

METHODS

A retrospective, single-institution review of patients undergoing IVCF placement over a 2-year period was performed. Patients undergoing prophylactic IVCF placement were selected from a prospectively collected database. Risk factors for nonretrieval were identified using a multivariate logistic regression model.

RESULTS

Of 615 IVCFs placed, 256 were retrievable filters placed for prophylactic indications and comprised the study cohort. The most common indications were a history of venous thromboembolic disease (43.7%), malignancy (35.1%), bleeding risk precluding anticoagulation (33.9%), and trauma (22.6%). One hundred sixty-three (63.6%) were placed preoperatively. Placement was performed in 70.3% by interventional radiology, 21.4% by vascular surgery, and 8.2% by cardiology. The most common requesting services were orthopedics (67%), general surgery (11%), neurosurgery (9%), and bariatric surgery (7%). Of all, 67.6% were placed in the inpatient setting and 32.4% in outpatients. Seventy-one (27.7%) of the 256 prophylactic filters were retrieved, with a mean indwelling time of 92 ± 74 days. Inpatients were significantly less likely to have their IVCF removed (32.4% vs 57.8%; P < .001), as were preoperative patients.

CONCLUSIONS

This study helps define current practice trends for the placement of prophylactic IVCFs. Importantly, the specific retrieval rate for prophylactic filters is low. This suggests that prophylactic IVCF usage is suboptimal and efforts should be taken to increase retrieval, especially among inpatients and perioperative patients.