Inferior vena cava filters in patients with cancer and venous thromboembolism (VTE): patterns of use and outcomes

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.

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.

Pulmonary Embolism in the Cancer Associated Thrombosis Landscape

In cancer patients, pulmonary embolism (PE) is the second leading cause of death after the cancer itself, most likely because of difficulties in diagnosing the disease due to its nonclassical presentation. The risk of PE recurrence and possibly the case-fatality rate depends on whether the patient presents a symptomatic PE, an unsuspected PE, a subsegmental PE, or a catheter-related PE. Choosing the best therapeutic option is challenging and should consider the risk of both the recurrence of thrombosis and the occurrence of bleeding. The purpose of this review is to provide an overview of the clinical characteristics and the treatment of cancer-associated PE, which could benefit clinicians to better manage the deadliest form of thrombosis associated with cancer. After a brief presentation of the epidemiological data, we will present the current attitude towards the diagnosis and the management of cancer patients with PE. Finally, we will discuss the perspectives of how the medical community can improve the management of this severe medical condition.

Factors Associated With Inferior Vena Cava Filter Placement and Retrieval for Patients With Cancer-Associated Thrombosis

BACKGROUND

Venous thromboembolism is a leading cause of death in patients with cancer. Inferior vena cava filters are utilized to mitigate the risk of pulmonary embolism for patients who have contraindication to, or failure of, anticoagulation.

METHODS

We reviewed an insurance claims database to identify adults receiving cancer-directed therapy and had a new diagnosis of venous thromboembolism. We then evaluated clinical and sociodemographic characteristics in patients with and without filter placement and retrieval.

RESULTS

There were 25,788 patients (mean [SD] age: 68.3 [12.7] years) who met the study inclusion criteria, with 2111 individuals (8.2%) undergoing filter placement. Filter placement was associated with the type of thrombosis, malignancy, recent surgery, comorbidities, and income. A total of 137 patients (6.5%) newly started anticoagulation within 3 days of filter placement, and 612 (29%) patients received anticoagulation within 30 days after filter placement. Despite this, only 159 (7.5%) patients had their filters retrieved during the study period. Patients with income of $75-99K (odds ratio 2.13, P = .012) or above $100K (odds ratio 1.8, P = .038) were more likely to have filter retrieval compared with those with income <$50K. Filter retrieval was also more likely in younger patients and those with fewer comorbidities or without central nervous system or lung malignancies.

CONCLUSIONS

Inferior vena cava filter placement and retrieval are associated with several sociodemographic factors. Filter retrieval rates are low despite re-initiation of anticoagulation in many patients. Efforts are needed to address disparities in filter use and improve retrieval rates.

Effect of inferior vena cava filters on pulmonary embolism-related mortality and major complications: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Inferior vena cava (IVC) filters are often used. However, no clear consensus has been reached regarding the benefits and risks from randomized, controlled trials. Therefore, we investigated benefits and risks of IVC filter use.

METHODS

The PubMed and Cochrane Library databases were searched from inception to October 31, 2019 to identify randomized, controlled trials for inclusion in our meta-analysis. The primary outcome was mortality related to pulmonary embolism (PE). The secondary outcomes were overall mortality, PE, deep vein thrombosis, and major bleeding. Risk ratios were pooled using the Mantel-Haenszel method with the fixed effects model for low heterogeneity. Otherwise, the random effects model was used. Risk differences were considered candidates of effect size if some of the data could not be pooled in the calculations.

RESULTS

Seven articles with 1274 patients were included. We found no significant difference in mortality related to PE between the IVC filter and control groups within 3 months (risk difference, -0.01; 95% confidence interval, -0.03 to 0.00; P = .11) nor during the entire follow-up period with low heterogeneity (I² = 0%). The new occurrence of PE within 3 months and during the whole follow-up period was lower in the IVC filter group than in the control group (0.81% vs 5.98%; risk ratio, 0.17; 95% CI, 0.04-0.65; P = .01; and 3.2% vs 7.79%; risk ratio, 0.42; 95% CI, 0.25-0.71; P = .001, respectively). No significant differences were found in the rates of the new occurrence of deep vein thrombosis, major bleeding, and mortality during the whole follow-up period between the two groups (P > .05).

CONCLUSIONS

We found insufficient evidence to conclude that the use of IVC filters can reduce mortality. However, the use of IVC filters decreased the new occurrence of PE without increasing deep vein thrombosis or major bleeding.

Inferior Vena Cava Filters: Past, Present, and Future

Inferior vena cava (IVC) filters have existed as a treatment option for VTE for decades. Advances in medical technology have provided physicians with several options for devices that can be placed on either a permanent or temporary basis; however, there are limited data from randomized, controlled trials on the appropriate use of IVC filters. This contemporary review summarizes the history of IVC filters and the types that are available in clinical practice. It reviews the literature on the use of IVC filters and discusses the indications that professional societies have endorsed for their use. In addition, it outlines the complications of IVC filter placement and future research directions.

Association of Inferior Vena Cava Filter Placement With Rates of Pulmonary Embolism in Patients With Cancer and Acute Lower Extremity Deep Venous Thrombosis

IMPORTANCE

Venous thromboembolism is the second overall leading cause of death for patients with cancer, and there is an approximately 2-fold increase in fatal pulmonary embolism (PE) in patients with cancer. Inferior vena cava (IVC) filters are designed to prevent PE, but defining the appropriate use of IVC filters in patients with cancer remains a substantial unmet clinical need.

OBJECTIVE

To evaluate the association of IVC filters with the development of PE in patients with cancer and deep venous thrombosis (DVT).

DESIGN, SETTING, AND PARTICIPANTS

A population-based cohort study was conducted using administrative data on 88 585 patients from the state inpatient databases for California (2005-2011) and Florida (2005-2014). Based on diagnostic and procedure codes, patients with cancer and acute lower extremity DVT were identified. All subsequent hospital visits for these patients were evaluated for the placement of an IVC filter, the development of new PE, the development of new DVT, and in-hospital mortality. Data analysis was performed from September 1 to December 1, 2019.

EXPOSURES

Placement of an IVC filter.

MAIN OUTCOMES AND MEASURES

The association of IVC filter placement with rates of new PE and DVT was estimated using a propensity score matching algorithm and competing risk analysis.

RESULTS

The study cohort comprised 88 585 patients (45 074 male; median age, 71.0 years [range, 1.0-104.0 years]) with malignant neoplasms who presented to a health care institution with a diagnosis of acute lower extremity DVT. Of these patients, 33 740 (38.1%) underwent IVC filter placement; patients with risk factors such as upper gastrointestinal bleeding (odds ratio, 1.32; 95% CI, 1.29-1.37), intracranial hemorrhage (odds ratio, 1.21; 95% CI, 1.19-1.24), and coagulopathy (odds ratio, 1.09; 95% CI, 1.08-1.10) were more likely to receive an IVC filter. A total of 4492 patients (5.1%) developed a new PE after their initial DVT diagnosis. There was a significant improvement in PE-free survival for these patients compared with those who did not receive IVC filters across the full, unbalanced study cohort as well as after propensity score matching and competing risk analysis (hazard ratio, 0.69; 95% CI, 0.64-0.75; P < .001). Furthermore, IVC filter placement reduced the development of PE in patients with very high-risk malignant neoplasms (eg, pancreaticobiliary cancer), high-risk malignant neoplasms (eg, lung cancer), and low-risk malignant neoplasms (eg, prostate cancer). After accounting for anticoagulation use and imbalanced risk factors, IVC filter placement did not increase the risk of new DVT development.

CONCLUSIONS AND RELEVANCE

This study suggests that, for patients with cancer and DVT and bleeding risk factors, IVC filter placement is associated with an increased rate of PE-free survival.

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.

Role of vena cava filters for the management of cancer-related venous thromboembolism: Systematic review and meta-analysis

BACKGROUND

Results from cohort studies evaluating the benefit in prevention of recurrent Venous Thromboembolism in cancer population are heterogeneous and controversial.

OBJECTIVE

To determine the effectiveness and harms of vena cava filters alone or combined with anticoagulation to prevent the risk of recurrent venous thromboembolism in patients with cancer-related venous thromboembolism.

MATERIALS AND METHODS

A search strategy was conducted in the MEDLINE, CENTRAL, EMBASE and LILACS databases. Searches were also conducted in other databases and unpublished literature. Clinical trials were included without language restrictions. The risk of bias was evaluated with the Cochrane Collaboration's tool and a modified version for cohort studies. An analysis of fixed effects was conducted. The primary outcome was recurrent venous thromboembolism. The secondary outcomes were overall survival and adverse effects. The measure of the effect was the risk ratio with a 95% confidence interval.

RESULTS

Seven studies were included in the qualitative and quantitative analysis. 35,333 patients were found among the seven studies. A low risk of bias was shown for most of the study items. The overall risk ratio (RR) for recurrent venous thromboembolism was 2.53 95%CI (1.35-4.75) favoring anticoagulation compared with vena cava filter.

CONCLUSION

Vena cava filter did not show benefits for recurrent venous thromboembolism prevention in the cancer-patients population.

Managing thrombosis in cancer patients

Venous thromboembolism is a major complication in cancer patients. The basis for the strong association between cancer and thrombosis remains incompletely understood, and the optimal approaches to both the treatment and the prevention of cancer-associated thrombosis are evolving. Here we review several important topics related to cancer-associated thromboembolism, including the pathogenesis, prevention, and management of this disease. Wherever possible, we include evidence from clinical trials, including the results of recently published trials that compared direct oral anticoagulants to low-molecular-weight heparin for the treatment of cancer-associated thrombosis.

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

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

Inferior vena cava filters

Use of inferior vena cava (IVC) filters has increased dramatically in recent decades, despite a lack of evidence that their use has impacted venous thromboembolism (VTE)-related mortality. This increased use appears to be primarily driven by the insertion of retrievable filters for prophylactic indications. A growing body of evidence, however, suggests that IVC filters are frequently associated with clinically important adverse events, prompting a closer look at their role. We sought to narratively review the current evidence on the efficacy and safety of IVC filter placements. Inferior vena cava filters remain the only treatment option for patients with an acute (within 2-4 weeks) proximal deep vein thrombosis (DVT) or pulmonary embolism and an absolute contraindication to anticoagulation. In such patients, anticoagulation should be resumed and IVC filters removed as soon as the contraindication has passed. For all other indications, there is insufficient evidence to support the use of IVC filters and high-quality trials are required. In patients where an IVC filter remains, regular follow-up to reassess removal and screen for filter-related complications should occur.