Predicting the Safety and Effectiveness of Inferior Vena Cava Filters Study: Design of a unique safety and effectiveness study of inferior vena cava filters in clinical practice

Updated Trends in Inferior Vena Cava Filter Use by Indication in the United States After Food and Drug Administration Safety Warnings: A Decade Analysis From 2010 to 2019

BACKGROUND

Overall inferior vena cava filter (IVCF) utilization has decreased in the United States since the 2010 US Food and Drug Administration (FDA) safety communication. The FDA renewed this safety warning in 2014 with additional mandates on reporting IVCF-related adverse events. We evaluated the impact of the FDA recommendations on IVCF placements for different indications from 2010 to 2019 and further assessed utilization trends by region and hospital teaching status.

METHODS

Inferior vena cava filter placements between 2010 and 2019 were identified in the Nationwide Inpatient Sample database using the associated International Classification of Diseases, Ninth Revision, Clinical Modification, and Tenth Revision codes. Inferior vena cava filter placements were categorized by indication for venous thromboembolism (VTE) "treatment" in patients with VTE diagnosis and contraindication to anticoagulation and "prophylaxis" in patients without VTE. Generalized linear regression was used to analyze utilization trends.

RESULTS

A total of 823 717 IVCFs were placed over the study period, of which 644 663 (78.3%) were for VTE treatment and 179 054 (21.7%) were for prophylaxis indications. The median age for both categories of patients was 68 years. The total number of IVCFs placed for all indications decreased from 129 616 in 2010 to 58 465 in 2019, with an aggregate decline rate of -8.4%. The decline rate was higher between 2014 and 2019 than between 2010 and 2014 (-11.6% vs -7.2%). From 2010 to 2019, IVCF placement for VTE treatment and prophylaxis trended downward at rates of -7.9% and -10.2%, respectively. Urban nonteaching hospitals saw the highest decline for both VTE treatment (-17.2%) and prophylactic indications (-18.0%). Hospitals located in the Northeast region had the highest decline rates for VTE treatment (-10.3%) and prophylactic indications (-12.5%).

CONCLUSION

The higher decline rate in IVCF placements between 2014 and 2019 compared with 2010 and 2014 suggests an additional impact of the renewed 2014 FDA safety indications on national IVCF utilization. Variations in IVCF use for VTE treatment and prophylactic indications existed across hospital teaching types, locations, and regions.

CLINICAL IMPACT

Inferior vena cava filters (IVCF) are associated with medical complications. The 2010 and 2014 FDA safety warnings appeared to have synergistically contributed to a significant decline in IVCF utilization rates from 2010 - 2019 in the US. IVC filter placements in patients without venous thromboembolism (VTE) declined at a higher rate than VTE. However, IVCF utilization varied across hospitals and geographical locations, likely due to the absence of universally accepted clinical guidelines on IVCF indications and use. Harmonization of IVCF placement guidelines is needed to standardize clinical practice, thereby reducing the observed regional and hospital variations and potential IVC filter overutilization.

Developmental or Procedural Vena Cava Interruption and Venous Thromboembolism: A Review

The inferior vena cava (IVC) and superior vena cava are the main conduits of the systemic venous circulation into the right atrium. Developmental or procedural interruptions of vena cava might predispose to stasis and deep vein thrombosis (DVT) distal to the anomaly and may impact the subsequent rate of pulmonary embolism (PE). This study aimed to review the various etiologies of developmental or procedural vena cava interruption and their impact on venous thromboembolism. A systematic search was performed in PubMed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines per each clinical question. For management questions with no high-quality evidence and no mutual agreements between authors, Delphi methods were used. IVC agenesis is the most common form of congenital vena cava interruption, is associated with an increased risk of DVT, and should be suspected in young patients with unexpected extensive bilateral DVT. Surgical techniques for vena cava interruption (ligation, clipping, and plication) to prevent PE have been largely abandoned due to short-term procedural risks and long-term complications, although survivors of prior procedures are occasionally encountered. Vena cava filters are now the most commonly used method of procedural interruption, frequently placed in the infrarenal IVC. The most agreed-upon indication for vena cava filters is for patients with acute venous thromboembolism and coexisting contraindications to anticoagulation. Familiarity with different forms of vena cava interruption and their local and systemic adverse effects is important to minimize complications and thrombotic events.

Effect of inferior vena cava filter placement position on device complications

BACKGROUND

Indwelling inferior vena cava (IVC) filters can cause complications, including penetration into surrounding structures, migration, and thrombosis of the vena cava. Computational fluid dynamics suggests juxtarenal placement of IVC filters decreases the risk of thrombosis; however, this has not been explored clinically. The present study examines the effect of filter placement position on long-term device complications with an emphasis on IVC thrombosis. We hypothesized that IVC filters placed further caudal to the renal veins were more likely to develop long-term thrombosis.

METHODS

A retrospective review of the medical records of patients receiving IVC filters at a single tertiary center between 2008 and 2016 was performed. Patients missing follow-up or procedural imaging data were excluded. The placement procedure venograms were reviewed, and the distance from the filter apex to the more inferior renal vein was measured using reported IVC filter lengths for calibration. The patients were divided into three groups according to the tip position relative to the more inferior renal vein: at or superior (group A), 1 to 20 mm inferior (group B), and >20 mm inferior (group C). The patient and procedural characteristics and outcomes were compared between the three groups. The primary end points were IVC thrombosis and device-related mortality.

RESULTS

Of 1497 eligible patients, 267 (17.8%) were excluded. The most common placement position was group B (64.0%). The mean age was lowest in group C, followed by groups A and B (age, 59.5 years, 64.6 years, and 62.2 years, respectively; P = .003). No statistically significant differences were found in the distribution of sex or the measured comorbidities. Group C was the most likely to receive jugular access (group C, 71.7%; group A, 48.3%; group B, 62.4%; P < .001) and received more first-generation filters (group C, 58.5%; group A, 46.6%; group B, 52.5%; P = .045). The short-term (<30-day) and long-term (≥30-day) outcomes, including access site hematoma, deep vein thrombosis, and pulmonary embolism, were uncommon, with no differences between the groups. Cases of symptomatic filter penetration, migration, and fracture were rare (one, one, and three cases, respectively). Although a pattern of increasing thrombosis with more inferior placement was found, the difference between groups was not statistically significant (group A, 1.5%; group B, 1.8%; group C, 2.5%; P = .638). No cases of device-related mortality occurred. All-cause mortality after a mean follow-up of 2.6 ± 2.3 years was 41.3% and did not vary significantly between the groups (P = .051). Multivariate logistic regression revealed that placement position did not predict for short- or long-term deep vein thrombosis, pulmonary embolism, IVC thrombosis, or all-cause mortality after adjustment for the baseline patient characteristics.

CONCLUSIONS

IVC filters have low rates of short- and long-term complications, including IVC thrombosis. The placement position did not affect the occurrence of device complications in this study.

Open retrieval management of inferior vena cava filter erosion resulting in symptomatic hydroureteronephrosis

Inferior vena cava filters are effective for the management of thromboembolic disease but can erode into adjacent organ systems in rare instances. Endovascular retrieval of eroded filters has been the preferred management for this complication. We present a case for which endovascular retrieval was not appropriate because of filter orientation and erosion into the ureter and describe successful management using open retrieval of a permanent filter with erosion into the renal collecting system requiring reconstruction. Although minimally invasive retrieval is preferred over open repair, this approach should be considered when filter erosion is not amenable to endovascular retrieval.

An Internal Hernia With Small Bowel Volvulus From an Inferior Vena Cava Filter Wire Strut: A Rare Cause of Acute Abdomen

The use of inferior vena cava (IVC) filters has been increasingly prevalent. Although they are relatively safe with clear indications, they are not without complications. Late-onset complications include IVC filter migration, IVC wire fracture, wire strut penetration, and perforation of organs in its vicinity. In this report, we present the case of a patient with small bowel volvulus secondary to an IVC wire strut migration, causing tethering of the mesentery and vascular compromise to the small bowel.

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.

Predicting the Safety and Effectiveness of Inferior Vena Cava Filters (PRESERVE): Outcomes at 12 months

OBJECTIVE

To determine the safety and effectiveness of vena cava filters (VCFs).

METHODS

A total of 1429 participants (62.7 ± 14.7 years old; 762 [53.3% male]) consented to enroll in this prospective, nonrandomized study at 54 sites in the United States between October 10, 2015, and March 31, 2019. They were evaluated at baseline and at 3, 6, 12, 18, and 24 months following VCF implantation. Participants whose VCFs were removed were followed for 1 month after retrieval. Follow-up was performed at 3, 12, and 24 months. Predetermined composite primary safety (freedom from perioperative serious adverse events [AEs] and from clinically significant perforation, VCF embolization, caval thrombotic occlusion, and/or new deep vein thrombosis [DVT] within 12-months) and effectiveness (composite comprising procedural and technical success and freedom from new symptomatic pulmonary embolism [PE] confirmed by imaging at 12-months in situ or 1 month postretrieval) end points were assessed.

RESULTS

VCFs were implanted in 1421 patients. Of these, 1019 (71.7%) had current DVT and/or PE. Anticoagulation therapy was contraindicated or had failed in 1159 (81.6%). One hundred twenty-six (8.9%) VCFs were prophylactic. Mean and median follow-up for the entire population and for those whose VCFs were not removed was 243.5 ± 243.3 days and 138 days and 332.6 ± 290 days and 235 days, respectively. VCFs were removed from 632 (44.5%) patients at a mean of 101.5 ± 72.2 days and median 86.3 days following implantation. The primary safety end point and primary effectiveness end point were both achieved. Procedural AEs were uncommon and usually minor, but one patient died during attempted VCF removal. Excluding strut perforation greater than 5 mm, which was demonstrated on 31 of 201 (15.4%) patients' computed tomography scans available to the core laboratory, and of which only 3 (0.2%) were deemed clinically significant by the site investigators, VCF-related AEs were rare (7 of 1421, 0.5%). Postfilter, venous thromboembolic events (none fatal) occurred in 93 patients (6.5%), including DVT (80 events in 74 patients [5.2%]), PE (23 events in 23 patients [1.6%]), and/or caval thrombotic occlusions (15 events in 15 patients [1.1%]). No PE occurred in patients following prophylactic placement.

CONCLUSIONS

Implantation of VCFs in patients with venous thromboembolism was associated with few AEs and with a low incidence of clinically significant PEs.

Predicting the Safety and Effectiveness of Inferior Vena Cava Filters (PRESERVE): Outcomes at 12 months

OBJECTIVE

To determine the safety and effectiveness of vena cava filters (VCFs).

METHODS

A total of 1429 participants (62.7 ± 14.7 years old; 762 [53.3% male]) consented to enroll in this prospective, nonrandomized study at 54 sites in the United States between October 10, 2015, and March 31, 2019. They were evaluated at baseline and at 3, 6, 12, 18, and 24 months following VCF implantation. Participants whose VCFs were removed were followed for 1 month after retrieval. Follow-up was performed at 3, 12, and 24 months. Predetermined composite primary safety (freedom from perioperative serious adverse events [AEs] and from clinically significant perforation, VCF embolization, caval thrombotic occlusion, and/or new deep vein thrombosis [DVT] within 12-months) and effectiveness (composite comprising procedural and technical success and freedom from new symptomatic pulmonary embolism [PE] confirmed by imaging at 12-months in situ or 1 month postretrieval) end points were assessed.

RESULTS

VCFs were implanted in 1421 patients. Of these, 1019 (71.7%) had current DVT and/or PE. Anticoagulation therapy was contraindicated or had failed in 1159 (81.6%). One hundred twenty-six (8.9%) VCFs were prophylactic. Mean and median follow-up for the entire population and for those whose VCFs were not removed was 243.5 ± 243.3 days and 138 days and 332.6 ± 290 days and 235 days, respectively. VCFs were removed from 632 (44.5%) patients at a mean of 101.5 ± 72.2 days and median 86.3 days following implantation. The primary safety end point and primary effectiveness end point were both achieved. Procedural AEs were uncommon and usually minor, but one patient died during attempted VCF removal. Excluding strut perforation greater than 5 mm, which was demonstrated on 31 of 201 (15.4%) patients' computed tomography scans available to the core laboratory, and of which only 3 (0.2%) were deemed clinically significant by the site investigators, VCF-related AEs were rare (7 of 1421, 0.5%). Postfilter, venous thromboembolic events (none fatal) occurred in 93 patients (6.5%), including DVT (80 events in 74 patients [5.2%]), PE (23 events in 23 patients [1.6%]), and/or caval thrombotic occlusions (15 events in 15 patients [1.1%]). No PE occurred in patients following prophylactic placement.

CONCLUSIONS

Implantation of VCFs in patients with venous thromboembolism was associated with few AEs and with a low incidence of clinically significant PEs.

A review of inferior vena cava filters

The care of patients with venous thromboembolism (VTE) is delivered via a multidisciplinary team. The primary treatment for VTE is anticoagulation; however, placement of filter devices in the inferior vena cava (IVC) to prevent embolisation of deep venous thrombosis (DVT) is a well-established secondary treatment option. Many controversies remain regarding utilisation and management of filters.

Changes in perfusion angiography after IVC filter placement and retrieval

Inferior vena cava (IVC) filters are posited to effect flow dynamics, causing turbulence, vascular remodeling and eventual thrombosis; however, minimal data exists evaluating hemodynamic effects of IVC filters in vivo. The purpose of this study was to determine differences in hemodynamic flow parameters acquired with two-dimension (2D)-perfusion angiography before and after IVC filter placement or retrieval. 2D-perfusion images were reconstructed retrospectively from digital subtraction angiography from a cohort of 37 patients (13F/24M) before and after filter placement (n = 18) or retrieval (n = 23). Average dwell time was 239.5 ± 132.1 days. Changes in the density per pixel per second within a region of interest (ROI) were used to calculate contrast arrival time (AT), time-to-peak (TTP), wash-in-rate (WIR), and mean transit time (MTT). Measurements were obtained superior to, inferior to, and within the filter. Differences in hemodynamic parameters before and after intervention were compared, as well as correlation between parameters versus filter dwell time. A P value with Bonferroni correction of <.004 was considered statistically significant. After placement, there was no difference in any 2D-perfusion variable. After retrieval, ROIs within and inferior to the filter showed a significantly shorter TTP (1.7 vs 1.4 s, P = .004; 1.5 vs 1.3 s, P = .001, respectively) and MTT (1.7 vs 1.4 s, P = .003; 1.5 vs 1.2 s, P = .002, respectively). Difference in variables showed no significant correlation when compared to dwell time. 2D-perfusion angiography is feasible to evaluate hemodynamic effects of IVC filters in vivo. TTP and MTT within and below the filter after retrieval were significantly changed, without apparent correlation to dwell time, suggesting a functional hemodynamic delay secondary to filter presence.

Back to the Basics: Inferior Vena Cava Filters

Inferior vena cava filters are an important therapeutic option for patients with venous thromboembolism and contraindication to anticoagulation. Indications for filter placement have varied over the previous decades. This article discusses the history of inferior vena cava filter use, with a basic overview of technology and specific devices. Finally, this article reviews emerging filter design and technology. Understanding the basics of inferior vena cava filters is critical to building more robust clinical data for the purpose of improving patient outcomes.

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.

Right Ventricle Embolization of IVC Filter Fragments: An Incidental Finding

This case report describes a 52-year-old male patient, with the incidental finding of inferior vena cava filter (IVCF) fragments impacted into the right ventricle, secondary to IVCF fragmentation and subsequent embolization. While IVCFs are prescribed to prevent pulmonary embolizations when anticoagulation is either contraindicated, or has failed, IVCF embolizations to the heart represent an extremely rare, but potentially life-threatening complication. Of note, at the time of writing, the utility and effectiveness of IVCF are not fully established. Intracardiac embolizations of IVCF typically present with complications such as hypotension, cardiac tamponade, arrhythmias, ventricle perforation, bleeding, cardiac arrest, and death. To our knowledge, this is the first case report of an asymptomatic kidney transplant recipient found to have right ventricle embolizations of IVCF fragments through routine assessment. Additionally, this is also the first report of an asymptomatic patient who presented IVCF fragments embolized to the right ventricle and left gonadal vein in the same clinical setting.

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.