Inferior vena cava filters in children: our experience and suggested guidelines

Contemporary Management of Pulmonary Embolism: Review of the Inferior Vena Cava filter and Other Endovascular Devices

Inferior vena cava (IVC) filters and endovascular devices are used to mitigate the risk of pulmonary embolism in patients presenting with lower extremity venous thromboembolism in whom long-term anticoagulation is not a good option. However, the efficacy and benefit of these devices remain uncertain, and controversies exist. This review focuses on the current use of IVC filters and other endovascular therapies in clinical practice. The indications, risks, and benefits are discussed based on current data. Further research and randomized controlled trials are needed to characterize the patient population that would benefit most from these interventional therapies.

Intravascular Tumor Extension and Pulmonary Tumor Embolism in Children With Solid Malignancies: Is There a Role for Inferior Vena Cava Filters?

Intravascular tumor extension is an uncommon complication of solid malignancies that, when present in the inferior vena cava (IVC), can result in fatal pulmonary tumor embolism. Currently, neoadjuvant chemotherapy and surgery are the mainstays of treatment; however, there are no consensus guidelines for management. We describe three cases of pediatric solid malignancies with associated IVC extension and pulmonary tumor embolism. We hypothesize that there is scope for IVC filter placement in such cases to mitigate the risk of fatal pulmonary tumor embolism.

Off-label use of a vena caval filter in the SVC in an adolescent with upper deep vein thrombosis

Vena caval filters remain as a useful tool in patients with deep vein thrombosis and contraindications to anticoagulation. Although they are rarely used in paediatric patients, they have been shown to be safe and effective when used in the inferior vena cava.In this case report, we describe the off-label use of a retrievable vena caval filter in the superior vena cava in an adolescent with acute lymphoblastic leukaemia with extensive thrombosis of the right upper neck veins as a means to reduce the risk of pulmonary embolism.

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. .

Pulmonary Embolism in Children

Pulmonary embolism is an uncommon but potentially life-threatening event in children. There has been increasing awareness of pulmonary embolism in children with improved survival in children with systemic disease and advancements in diagnostic modalities. However, literature regarding pulmonary embolism in children is sparse, and thus current guidelines for management of pulmonary embolism in children are extrapolated from adult literature and remain controversial. This article reviews the background and pathophysiology of venous thromboembolism, as well as current diagnostic approach and recommended management of pulmonary embolism in children.

IVC filter placements in children: nationwide comparison of practice patterns at adult and children's hospitals using the Kids' Inpatient Database

BACKGROUND

Inferior vena cava (IVC) filter placement in children has been described in literature, but there is variability with regard to their indications. No nationally representative study has been done to compare practice patterns of filter placements at adult and children's hospitals.

OBJECTIVE

To perform a nationally representative comparison of IVC filter placement practices in children at adult and children's hospitals.

MATERIALS AND METHODS

The 2012 Kids' Inpatient Database was searched for IVC filter placements in children <18 years of age. Using the International Classification of Diseases, 9th Revision (ICD-9) code for filter insertion (38.7), IVC filter placements were identified. A small number of children with congenital cardiovascular anomalies codes were excluded to improve specificity of the code used to identify filter placement. Filter placements were further classified by patient demographics, hospital type (children's and adult), United States geographic region, urban/rural location, and teaching status. Statistical significance of differences between children's or adult hospitals was determined using the Wilcoxon rank sum test.

RESULTS

A total of 618 IVC filter placements were identified in children <18 years (367 males, 251 females, age range: 5-18 years) during 2012. The majority of placements occurred in adult hospitals (573/618, 92.7%). Significantly more filters were placed in the setting of venous thromboembolism in children's hospitals (40/44, 90%) compared to adult hospitals (246/573, 43%) (P<0.001). Prophylactic filters comprised 327/573 (57%) at adult hospitals, with trauma being the most common indication (301/327, 92%). The mean length of stay for patients receiving filters was 24.5 days in children's hospitals and 18.4 days in adult hospitals.

CONCLUSION

The majority of IVC filters in children are placed in adult hospital settings. Children's hospitals are more likely to place therapeutic filters for venous thromboembolism, compared to adult hospitals where the prophylactic setting of trauma predominates.

Pediatric Thrombolysis: A Practical Approach

The incidence of pediatric venous thromboembolic disease is increasing in hospitalized children. While the mainstay of treatment of pediatric thrombosis is anticoagulation, reports on the use of systemic thrombolysis, endovascular thrombolysis, and mechanical thrombectomy have steadily been increasing in this population. Thrombolysis is indicated in the setting of life- or limb-threatening thrombosis. Thrombolysis can rapidly improve venous patency thereby quickly ameliorating acute signs and symptoms of thrombosis and may improve long-term outcomes such as postthrombotic syndrome. Systemic and endovascular thrombolysis can result in an increase in minor bleeding in pediatric patients, compared with anticoagulation alone, and major bleeding events are a continued concern. Also, endovascular treatment is invasive and requires technical expertise by interventional radiology or vascular surgery, and such expertise may be lacking at many pediatric centers. The goal of this mini-review is to summarize the current state of knowledge of thrombolysis/thrombectomy techniques, benefits, and challenges in pediatric thrombosis.

IVC filter retrieval in adolescents: experience in a tertiary pediatric center

BACKGROUND

Inferior vena cava (IVC) filters are commonly implanted with the intent to prevent life-threatening pulmonary embolism in at-risk patients with contraindications to anticoagulation. Various studies have reported increases in the rate of venous thromboembolism within the pediatric population. The utility and safety of IVC filters in children has not yet been fully defined.

OBJECTIVE

To describe the technique and adjunctive maneuvers of IVC filter removal in children, demonstrate its technical success and identify complications.

MATERIALS AND METHODS

A retrospective 10-year review was performed of 20 children (13 male, 7 female), mean age: 15.1 years (range: 12-19 years), who underwent IVC filter retrieval. Eleven of 20 (55%) were placed in our institution. Electronic medical records were reviewed for filter characteristics, retrieval technique, technical success and complications.

RESULTS

The technical success rate was 100%. Placement indications included: deep venous thrombosis with a contraindication to anticoagulation (10/20, 50%), free-floating thrombus (4/20, 20%), post-trauma pulmonary embolism prophylaxis (3/20, 15%) and pre-thrombolysis pulmonary patient (1/20, 5%). The mean implantation period was 63 days (range: 20-270 days). Standard retrieval was performed in 17/20 patients (85%). Adjunctive techniques were performed in 3/20 patients (15%) and included the double-snare technique, balloon assistance and endobronchial forceps retrieval. Median procedure time was 60 min (range: 45-240 min). Pre-retrieval cavogram demonstrated filter tilt in 5/20 patients (25%) with a mean angle of 17° (range: 8-40). Pre-retrieval CT demonstrated strut wall penetration and tip embedment in one patient each. There were two procedure-related complications: IVC mural dissection noted on venography in one patient and snare catheter fracture requiring retrieval in one patient. There were no early or late complications.

CONCLUSION

In children, IVC filter retrieval can be performed safely but may be challenging, especially in cases of filter tilt or embedding. Adjunctive techniques may increase filter retrieval rates.

A Multicenter Cohort Study of Inferior Vena Cava Filter Use in Children

BACKGROUND

To describe inferior vena cava (IVC) filter use in pediatric patients admitted to U.S. children's hospitals and to determine factors associated with prophylactic placement.

PROCEDURE

This retrospective multicenter cohort study utilized data from the Pediatric Health Information Systems (PHIS) administrative database, with 44 participating children's hospitals. Subjects included for analysis were less than 21 years of age, admitted to a PHIS hospital between January 1, 2004 and December 31, 2012 and had a procedure code for IVC filter placement. ICD-9-CM discharge codes were used to identify subjects with a venous thromboembolism (VTE). Pharmaceutical billing codes were used to identify anticoagulation use.

RESULTS

During this 9-year-study period, 276 subjects met the inclusion criteria. The median age of subjects was 15 years (range 1 month-20 years). Subjects had an ICD-9-CM code for VTE 76% of the time and were started on anticoagulation after IVC filter placement 77% of the time. The mean number of IVC filters placed per year was 6 per 100,000 admissions (SD-1.4), which was constant throughout the study period (P = 0.12). The median number of filters placed by center was 4.5 (range 0-32). In multivariate analysis, subjects undergoing orthopedic surgery were more likely to have prophylactic placement of an IVC filter (OR 4.5; 95%CI 1.8-11).

CONCLUSIONS

IVC filter placement in pediatric patients remains a rare event and is most common in adolescents. Unlike in adults, pediatric IVC filter placement does not appear to be increasing over time and is predominantly used in the setting of a venous thrombotic event.

Inferior vena cava (IVC) filters in children: A 10-year single center experience

BACKGROUND

Venous thromboembolism (VTE) is an increasingly recognized problem among children and adolescents. Although inferior vena cava (IVC) filter placement for pulmonary embolism prevention is well reported in adults, data regarding safety and efficacy in the pediatric age group are lacking.

PROCEDURE

At a large university hospital with a level I trauma center, medical records of children and adolescents who underwent IVC filter insertion were reviewed. Appropriateness of referral for retrieval was assessed in each case.

RESULTS

Fifty-nine children and adolescents (mean age 16 years) successfully underwent IVC filter insertion. All filters placed were retrievable. In 47 patients (79.7%), prophylactic filters were placed in the absence of acute VTE in the setting of trauma. In eight patients (13.5%), filters were placed due to contraindication to anticoagulation therapy with concomitant lower extremity deep vein thrombosis or pulmonary embolism. Filters were successfully retrieved in only 12 patients (20.3%), although an attempt at removal was appropriate and feasible in over 90% of cases. Mean duration of follow-up was 2.1 (range 0.4-7.3) years. A significantly higher retrieval rate was found in patients followed at our thrombosis clinic (P < 0.01). Ten patients (17%) experienced at least one filter-related complication.

CONCLUSIONS

Although in most cases, IVC filters were placed for prophylactic indications, the evidence to support their role in this setting is limited. Their low retrieval rate and high filter-related complication rate question their extensive utilization in children. Dedicated follow-up is necessary to detect complications and to ensure that an attempt at retrieval is made when feasible.

Management of venous thrombosis in the pediatric patient

The incidence of venous thromboembolism in children has increased significantly over the past decade. The evaluation and management of the child with venous thromboembolism, while based on the adult experience, has its own particularities dictated by the differences in the hemostatic system of the newborn and child. The current review addresses the evaluation of pediatric patient with thrombosis as well as the established and emerging treatment interventions.

Extensive thrombotic complications after inferior vena cava filter placement in 2 adolescents with spinal cord injury: a cautionary tale and review

We report extensive thrombotic complications of inferior vena cava (IVC) filters that were placed for primary prophylaxis in 2 pediatric trauma patients with spinal cord injuries. Although thrombosis is a known common complication in adults with IVC filters, we were unable to find any reports in the literature of this complication in children. These cases highlight a significant problem with the use of prophylactic IVC filters that are not subsequently retrieved, particularly in young trauma patients with decades to live. The overall reported complications of IVC filters in the pediatric literature are also reviewed.

Retrievable inferior vena cava filters for venous thromboembolism

Inferior vena cava (IVC) filters are used as an alternative to anticoagulants for prevention of fatal pulmonary embolism (PE) in venous thromboembolic disorders. Retrievable IVC filters have become an increasingly attractive option due to the long-term risks of permanent filter placement. These devices are shown to be technically feasible in insertion and retrieval percutaneously while providing protection from PE. Nevertheless, there are complications and failed retrievals with these retrievable filters. The aim of the paper is to review the retrievable filters and their efficacy, safety, and retrievability.