Predictors of attempted inferior vena cava filters retrieval in a tertiary care centre

Comparison of inferior vena cava filter use and outcomes between cancer and non-cancer patients in a tertiary hospital

BACKGROUND

While accepted indications for the use of inferior vena cava filter (IVCF) in patients with a venous thromboembolism (VTE) have remained stable, their use continues to be frequent. Retrieval rates are still low, being particularly notable in the population with cancer. This study aims to review the rate of adherence to guidelines recommendation and to compare retrieval rates and complications in both cancer and non-cancer patients.

METHODS

A retrospective study was performed including 185 patients in whom an IVCF was placed in Hospital Clinic of Barcelona. Baseline characteristics, clinical outcomes, and IVCF-related outcomes were analyzed. A strongly recommended indication (SRI) was considered if it was included in all the revised clinical guidelines and non-strongly if it was included in only some.

RESULTS

Overall, 47 % of the patients had a SRI, without differences between groups. IVCF placement after 29 days from the VTE event was more frequent in the cancer group (46.1 vs. 17.7 %). Patients with cancer (48.1 % of the cohort) were older, with higher co-morbidity and bleeding risk. Anticoagulation resumption (75.3 % vs. 92.7 %) and IVCF retrieval (50.6 % vs. 66.7 %) were significantly less frequent in cancer patients. No significant differences were found regarding IVCF-related complications, hemorrhagic events and VTE recurrence.

CONCLUSIONS

SRI of IVCF placement was found in less than half of the patients. Cancer patients had higher rates of IVCF placement without indication and lower anticoagulation resumption and IVCF retrieval ratios, despite complications were similar in both groups.

Temporary inferior vena cava filters factors associated with non-removal

OBJECTIVES

Inferior vena cava filter (IVCF) placement is indicated when there is a deep vein thrombosis and/or a pulmonary embolism and a contraindication of anticoagulation. Due to the increased risk of recurrent deep venous thrombosis when left in place, IVCF removal is indicated once anticoagulant treatment can be reintroduced. However, many temporary IVCF are not removed. We aimed to analyze the removal rate and predictors of filter non-removal in a university hospital setting.

METHODS

We collected all the data of consecutive patients who had a retrievable IVCF inserted at the Saint-Etienne University Hospital (France) between April 2012 and November 2019. Rates of filter removal were calculated. We analyzed patient characteristics to assess factors associated with filter non-removal, particularly in patients without a definitive filter indication. The exclusion of this last category of patients allowed us to calculate an adjusted removal rate.

RESULTS

The overall removal rate of IVCF was 40.5% (IC 95% 35.6-45.6), and the adjusted removal rate was 62.9 % (IC 95% 56.6-69.2%). No major complications were noted. Advanced age (p < 0.0001) and cancer presence (p < 0.003) were statistically significant predictors of patients not being requested to make a removal attempt.

CONCLUSIONS

Although most of the filters placed are for therapeutic indications validated by scientific societies, the removal rate in this setting remains suboptimal. The major factors influencing IVCF removal rate are advanced age and cancer presence.

KEY POINTS

• Most vena cava filters are placed for therapeutic indications validated by scientific societies. • Vena cava filter removal rates in this setting remain suboptimal. • Major factors influencing IVCF removal rate are advanced age and cancer presence.

Long-Term Outcomes in Patients with Not-Retrieval Inferior Vena Cava Filter Under Anticoagulation

Since permanent inferior vena cava (IVC) filters increase deep vein thrombosis (DVT), filter retrieval should be performed as possible. Despite the guideline recommendation, IVC filters are not always retrieved in clinical practice. To date, many patients with not-retrieval IVC filters have been prescribed anticoagulant therapy, but the long-term prognosis, including venous thromboembolism (VTE) and bleeding events, remains unknown. In this study, 195 patients who underwent IVC filter implantation between 2006 and 2017 at 3 institutions in Niigata City have been investigated about their deaths, VTE recurrence, and bleeding events. After peaking 2009, the number of IVC filter implantation gradually decreased. During observational period, there were 158 patients with not-retrieval IVC filters (the overall retrieval rate of 19.0%). The not-retrieval group included significantly older and more patients with cancer compared to the retrieval group. Anticoagulation therapy was continued in 88% of the not-retrieval group. During a mean follow-up of 5.0 years, 6 symptomatic DVT events associated with inadequate control of anticoagulation and 13 bleeding events were observed. A total of 52 patients died and only the presence of cancer was prognostic risk factor. Although long-term anticoagulation therapy may be associated with bleeding events, there were few recurrent VTE under optimal anticoagulation. It is anticipated that even if the IVC filter cannot be retrieved, appropriate anticoagulation is useful for prevention of DVT recurrence despite the risk of bleeding.

Retrievable Inferior Vena Cava Filters: A Tertiary Centre Perspective and Quality Assurance Study

Purpose

To conduct a retrospective review and quality assurance study of inferior vena cava (IVC) filter retrieval over a two-year period at a tertiary care centre.

Methods

Patients who underwent IVC filter placement or retrieval over a two-year period were identified. Medical records were reviewed for patient characteristics, filter indication, time to filter retrieval, and complications.

Results

IVC filters were placed in 229 patients between January 1, 2015 and December 31, 2016. 113 retrievals were attempted and 101 filters were successfully retrieved (89.4%). Median time to first retrieval attempt was 48 days (range of 5–728). Seventy-one patients died in the interval after filter insertion before a retrieval attempt at a median time of 27 days (range of 3–430). In 17 patients, retrieval was complicated by or delayed because of penetration of IVC wall (n = 6), large thrombus burden trapped by filter (n = 5), filter tilt or migration (n = 3), and unclear reasons (n = 3). Time-to-first unsuccessful retrieval attempt was 141 days (median). Of all filters placed, 55.9% were never retrieved. Excluding deceased patients with in-situ filters (n = 71) and unsuccessful retrievals left in-situ as permanent filters (n = 5), there remains 52 patients (33%), with a median filter in-situ time of 488 days.

Conclusion

Our study indicates that as many as 33% of patients may have been lost to follow-up of their in-situ IVC filter. Considering widespread reports of long-term complications and the recent safety alert issued by Health Canada, it is evident that a unified strategy is needed to track patients post filter insertion.

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.

Retrospective analysis of outcomes following inferior vena cava (IVC) filter placement in a managed care population

The role of inferior vena cava filter (IVC) filters for prevention of pulmonary embolism (PE) is controversial. This study evaluated outcomes of IVC filter placement in a managed care population. This retrospective cohort study evaluated data for individuals with Humana healthcare coverage 2013-2014. The study population included 435 recipients of prophylactic IVC filters, 4376 recipients of therapeutic filters, and two control groups, each matched to filter recipients. Patients were followed for up to 2 years. Post-index anticoagulant use, mortality, filter removal, device-related complications, and all-cause utilization. Adjusted regression analyses showed a positive association between filter placement and anticoagulant use at 3 months: odds ratio (ORs) 3.403 (95% CI 1.912-6.059), prophylactic; OR, 1.356 (95% CI 1.164-1.58), therapeutic. Filters were removed in 15.67% of prophylactic and 5.69% of therapeutic filter cases. Complication rates were higher with prophylactic procedures than with therapeutic procedures and typically exceeded 2% in the prophylactic group. Each form of filter placement was associated with increases in all-cause hospitalization (regression coefficient 0.295 [95% CI 0.093-0.498], prophylactic; 0.673 [95% CI 0.547-0.798], therapeutic) and readmissions (OR 2.444 [95% CI 1.298-4.602], prophylactic; 2.074 [95% CI 1.644-2.616], therapeutic). IVC filter placement in this managed care population was associated with increased use of anticoagulants and greater healthcare utilization compared to controls, low rates of retrieval, and notable rates of device-related complications, with effects especially pronounced in assessments of prophylactic filters. These findings underscore the need for appropriate use of IVC filters.

Utility of Retrievable Inferior Vena Cava Filters: A Systematic Literature Review and Analysis of the Reasons for Nonretrieval of Filters with Temporary Indications

OBJECTIVE

To investigate the use of retrievable inferior vena cava (IVC) filters in the current practice and analyze the causes of filter left in situ despite initial plans for retrieval.

METHODS

A systematic search of all English-language studies of retrievable IVC filters was conducted, including clinical trials and observational studies published between January 1984 and March 2016.

RESULTS

A total of 103 studies were identified, including 10 filter models in 20,319 patients. Placement indications were reported for 11,128 (54.8%) patients, including therapeutic (n = 6270; 56.3%) and prophylactic (n = 4858; 43.7%) indications. A total of 13,224 (65.1%) filters were left as permanent devices; 7095 (34.9%) filters were removed. The reasons for filter nonretrieval among the 5308 (40.1%) reported cases were primary permanent indication (21.2%; 1127/5308), death (19.4%; 1031/5308), ongoing pulmonary embolism (PE) protection (19.0%; 1011/5308), failed retrieval (13.7%; 725/5308), loss to follow-up (13.0%; 689/5308), discontinued care (4.4%; 235/5308), physician oversight (4.0%; 213/5308), patient morbidity (2.8%; 149/5308), and patient refusal (2.4%; 128/5308). A total of 7820 patients presented for filter retrieval, and 7095 filters (90.7%) were successfully removed, with a mean indwelling time of 106.6 ± 47.3 days. Breakthrough PE was reported in 2.1% (191/9169) of patients. Filter tilt, recurrent deep vein thrombosis, penetration, IVC thrombosis, migration, and fracture occurred in 7.7% (798/10,348), 7.1% (362/5092), 5.4% (379/7001), 3.9% (345/8788), 1.4% (160/11,679), and 0.5% (50/9509) of patients, respectively.

CONCLUSIONS

Approximately two-thirds of retrievable filters were not retrieved even though more than 85% of the filters were initially intended for temporary use. The major reasons for filter left in situ despite initial plans for retrieval were death, need for ongoing PE protection, failed retrieval, loss to follow-up, discontinued care, and physician oversight.

Ten-year experience of retrievable inferior vena cava filters in a tertiary referral center

PURPOSE

A significant proportion of patients undergoing surgery have an increased incidence of acute pulmonary embolus (PE). We analyzed all patients who had a retrievable inferior vena cava (IVC) filter placed preoperatively for PE prophylaxis and investigated the long-term outcomes of the patients who did not have their filter removed.

METHODS

Patients who underwent retrievable IVC filter insertion and attempted removal were identified from the radiology information systems database in a large tertiary referral university teaching hospital. Results of all clinical investigations (including computed tomography, magnetic resonance imaging, ultrasonography, and plain radiography) while the IVC filters were in situ were reviewed.

RESULTS

In total, 393 retrievable IVC filters were inserted, 254 with the indication of preoperative thromboembolic prophylaxis. Recurrent PE was reported in five patients (1.9%) despite the IVC filter. Of the 254 retrievable filters inserted prior to surgery, an attempt at retrieval was made in 168 filters (66.1%). Successful retrieval at the first attempt occurred in 143 cases (85.1%), while 25 cases failed or were aborted (14.9%). No attempt at retrieval was made in 86 (33.9%) patients and a significant proportion of these patients had undergone cancer surgery (P < 0.0107). In those patients where there was no attempt at retrieval, there was an association between cancer surgery and a shorter absolute survival time (P < 0.0001).

CONCLUSION

The majority of attempted filter retrievals were successful, and a proportion of nonretrieved IVC filters are accounted for in patients who underwent cancer surgery and ultimately died with the filter in situ. A departmental protocol is recommended to ensure the filter is removed where appropriate and possible.

Practice patterns of retrievable inferior vena cava filters and predictors of filter retrieval in patients with pulmonary embolism

Retrievable inferior vena cava (IVC) filters are increasingly used in patients with venous thromboembolism (VTE) who have contraindications to anticoagulant therapy. However, previous studies have shown that many retrievable filters are left permanently in patients. This study aimed to identify the common indications for IVC filter insertion, the filter retrieval rate, and the predictive factors for filter retrieval attempts. To this end, a retrospective cohort study was performed at a tertiary care center in South Korea between January 2010 and May 2016. Electronic medical charts were reviewed for patients with pulmonary embolism (PE) who underwent IVC filter insertion. A total of 439 cases were reviewed. The most common indication for filter insertion was a preoperative/procedural aim, followed by extensive iliofemoral deep vein thrombosis (DVT). Retrieval of the IVC filter was attempted in 44.9% of patients. The retrieval success rate was 93.9%. History of cerebral hemorrhage, malignancy, and admission to a nonsurgical department were the significant predictive factors of a lower retrieval attempt rate in multivariate analysis. With the increased use of IVC filters, more issues should be addressed before placing a filter and physicians should attempt to improve the filter retrieval rate.

The Role of Inferior Vena Cava Filters in Cancer Patients

Cancer induces a hypercoagulable state and renders patients susceptible to venous thromboembolism. While anticoagulation remains the mainstay of treatment, many of these patients require placement of an inferior vena cava (IVC) filter, often due to a contraindication to or failure of anticoagulation. In this article, the available data on IVC filter usage in cancer patients will be reviewed.

Outcomes After Vena Cava Filter Use in Noncancer Patients With Acute Venous Thromboembolism: A Population-Based Study

BACKGROUND

Evidence that vena cava filters (VCFs) are beneficial is limited.

METHODS AND RESULTS

We retrospectively analyzed all noncancer patients admitted to nonfederal California hospitals for acute venous thromboembolism from 2005 to 2010. Analysis was stratified by the presence/absence of a contraindication to anticoagulation (active bleeding, major surgery). Outcomes were death within 30 or 90 days of admission and the 1-year incidence of recurrent venous thromboembolism manifested as pulmonary embolism or deep vein thrombosis. Propensity score methods were used to account for observed systematic differences in baseline characteristics between patients treated and those not treated with a VCF. Among 80 697 patients with no contraindication to anticoagulation, VCF use (n=7762, 9.6%) did not significantly reduce the 30-day risk of death (hazard ratio [HR], 1.12; 95% confidence interval [CI], 0.98-1.28). Among 3017 patients with active bleeding, VCF use (n=1095, 36.3%) reduced the 30-day risk of death by 32% (HR, 0.68; 95% CI, 0.52-0.88) and the 90-day risk by 27% (HR, 0.73; 95% CI, 0.59-0.90). VCF use (n=489, 33.8%) did not reduce mortality among 1445 patients who underwent major surgery (HR, 1.1; 95% CI, 0.71-1.77). In all subgroups, filter use did not reduce the risk of subsequent pulmonary embolism. However, the risk of subsequent deep vein thrombosis increased by 50% among VCF patients with no contraindication (HR, 1.53; 95% CI, 1.34-1.74) and by 135% among VCF patients with active bleeding (HR, 2.35; 95% CI, 1.56-3.52).

CONCLUSIONS

VCF use significantly reduced the short-term risk of death only among patients with acute venous thromboembolism who had a contraindication to anticoagulation because of active bleeding. These results support the findings of a randomized clinical trial and current guidelines that recommend VCF use only in patients who cannot receive anticoagulation treatment.

Inferior Vena Cava Filters: Indications, Outcomes, and Evidence

OPINION STATEMENT

Filter technology seems relatively stable, although absorbable devices are an area of investigational interest. The indications for filter placement remain controversial, with wide variations in adherence to guidelines, and relatively poor quality of data about the specific prophylactic indications of trauma or bariatric surgery. The outcomes of filters are not well-defined despite widespread clinical use, and good data remains difficult to obtain. Several larger database and institutional retrospective studies support the notions that while filters prevent pulmonary embolism, they may be associated with venous thrombotic complications. Some subsets of cancer patients may be at increased risk of these complications, but whether the filter or the underlying hypercoagulable state is the cause is not clear. Lastly, although the benefits of filter retrieval are widely assumed (but not proven), filter retrieval rates remain lower than expected. The single most influential factor in improving filter retrieval rates is dedicated follow-up with intent to retrieve the filter.

Retrievable inferior vena cava filters in patients with cancer are safe but are they beneficial?

The availability and insertion of permanent and retrievable inferior vena cava filter devices have increased substantially over the past decade. Our retrospective study provides the first detailed assessment of the safety and efficacy of retrievable inferior vena cava filters in a large cohort of cancer patients with predominantly advanced malignancies. We retrospectively reviewed the medical records of consecutive patients with the diagnosis of cancer who underwent inferior vena cava filter placement at a single academic medical center from 2007 to 2012 with special attention to safety, recurrent venous thromboembolism, and survival data. Three hundred thirty-seven cancer patients were included in the analysis. Gastrointestinal, lung, and genitourinary malignancies were the most commonly represented malignancies [94 (27.8 %), 70 (20.8 %), and 37 (10.9 %) patients, respectively]. Immediate complications were diagnosed in one of 258 (1 %) evaluable patients following placement of a retrievable filter. Delayed complications occurred in 23 of 258 (8 %) patients. The 7, 14, 30, 90, and 365 day post-filter survival rates for patients with stage IV cancer were 0.91, 0.86, 0.71, 0.52, and 0.29, respectively. Patients with lung and gastrointestinal tumors demonstrated a significantly reduced post-filter survival rate compared with those with genitourinary, brain, and breast cancers. Retrievable and non-retrievable inferior vena cava filters are associated with an overall low rate of complications in patients with cancer. However, survival rates following filter placement are poor in this patient population.