A systematic method for follow-up improves removal rates for retrievable inferior vena cava filters in a trauma patient population

Ibero-American Society of Interventionism (SIDI) and the Spanish Society of Vascular and Interventional Radiology (SERVEI) Standard of Practice (SOP) for the Management of Inferior Vena Cava Filters in the Treatment of Acute Venous Thromboembolism

Objectives: to present an interventional radiology standard of practice on the use of inferior vena cava filters (IVCFs) in patients with or at risk to develop venous thromboembolism (VTE) from the Iberoamerican Interventional Society (SIDI) and Spanish Vascular and Interventional Radiology Society (SERVEI). Methods: a group of twenty-two interventional radiologist experts, from the SIDI and SERVEI societies, attended online meetings to develop a current clinical practice guideline on the proper indication for the placement and retrieval of IVCFs. A broad review was undertaken to determine the participation of interventional radiologists in the current guidelines and a consensus on inferior vena cava filters. Twenty-two experts from both societies worked on a common draft and received a questionnaire where they had to assess, for IVCF placement, the absolute, relative, and prophylactic indications. The experts voted on the different indications and reasoned their decision. Results: a total of two-hundred-thirty-three articles were reviewed. Interventional radiologists participated in the development of just two of the eight guidelines. The threshold for inclusion was 100% agreement. Three absolute and four relative indications for the IVCF placement were identified. No indications for the prophylactic filter placement reached the threshold. Conclusion: interventional radiologists are highly involved in the management of IVCFs but have limited participation in the development of multidisciplinary clinical practice guidelines.

Changing trends in inferior vena cava filter indication for venous thromboembolism over the last two decades: a retrospective observational study

BACKGROUND

The present study aimed to evaluate changes in the incidence, patients' profile and indications of inferior vena cava filters at a single center over the past two decades.

METHODS

We retrospectively analyzed 187 consecutive patients with a venous thromboembolism requiring a filter at a tertiary hospital between 1999-2018. Within this period the availability of retrievable filters (since 2007) and the withdrawal of filter indication for recurrent venous thromboembolism from guidelines (since 2008) may have contributed to change practice patterns. Patients' profile, filter indication and survival were compared between decades (1999-2008 vs. 2009-2018).

RESULTS

The filter insertion rate doubled (60 vs. 127 cases) over 2009-2018. In this later period there was an unexpected rise (15 vs. 68 cases, P<0.001) of patients with isolated pulmonary embolism as baseline venous thromboembolism episode, without other relevant changes in patients' profile or survival. Regarding indications, there was an increase in filters for bleeding risk (23 vs. 45) and a reduction for venous thromboembolism recurrence (20 vs. 7), but also an unexpected increase of cases for bleeding (15 vs. 72). Among the 116 retrievable filters indicated for a temporary cause, 70 (60.3%) were finally not removed, being persistence of filter indication (n=33, 47.1%) the most common cause.

CONCLUSIONS

The number of filters inserted at our institution has raised over the last two decades. This increase was partly unexpected and perhaps related to the availability of retrievable filters. Unfortunately these devices remain frequently non-removed being persistence of the indication the most frequent cause.

Removal of retrievable inferior vena cava filters before discharge: Is it associated with increased incidence of pulmonary embolism?

BACKGROUND

Severely injured trauma patients are at high risk of developing deep venous thrombosis and pulmonary emboli (PE), and may have contraindications to prophylactic or therapeutic anticoagulation. Retrievable inferior vena cava filters (rIVCFs) are used to act as a mechanical obstruction to prevent PE in high risk populations and those with deep venous thrombosis who cannot be anticoagulated. The removal rate of rIVCFs is variable in trauma centers, including our previous published rate of 50% to 89%/year. Indwelling filters carry a risk of significant morbidity and the success of retrieval decreases as the dwell time increases. We hypothesized that once patients could receive appropriate prophylactic or therapeutic anticoagulation, rIVCF could be removed before hospital discharge without impact on occurrence or recurrence of PE.

METHODS

All trauma patients with rIVCF placed and removed between January 2006 and August 2018 were reviewed. We collected data from record review from admission to 6 months postfilter removal, including demographics, filter indication, filter type, dwell time, placement and removal complications, antithrombosis medications, location of venous thromboembolism, complications, and discharge disposition. Exposure of interest was timing of filter removal: before (BEF) or after hospital discharge (AFT). The outcome of interest was whether the patient had a documented PE within 6 months of filter removal.

RESULTS

A total of 281 rIVCFs were placed, 218 were eligible for removal, 72.4% (158/218) were retrieved with 63% (100/158) removed before discharge. Mean filter duration was 26 days and 103 days for the before and after groups, respectively. No differences (p > 0.05) were noted in the distribution of demographic and clinical factors except for filter indication (venous thromboembolism indication, 95% in AFT vs. 74% in BEF, p = 0.0043). Postremoval PE rates were 0% BEF and 1% AFT (Fisher's exact test, p = 1.000).

CONCLUSION

Our results suggest that removal of rIVCFs before discharge once patients are appropriately anticoagulated is a safe strategy to improve retrieval rates.

LEVEL OF EVIDENCE

Therapeutic, level V.

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.

Vena Cava Filter Retrieval Rates and Factors Associated With Retrieval in a Large US Cohort

Background

Retrieval of vena cava filters (VCFs) is important for safety as complications increase with longer dwell times. This study assessed VCF retrieval rates and factors associated with retrieval in a national cohort.

Methods and Results

VCFs were identified by procedural codes from an administrative claims database. Patients were identified who had a VCF placement during a hospitalization from a national commercial administrative claims database. Indications for VCF placement were identified as pulmonary embolism with or without deep vein thrombosis, deep vein thrombosis only, or prophylactic. Patient demographic and clinical characteristics were included in proportional hazard regression models to find associations with early (90‐day) and 1‐year VCF retrieval. Initiation of anticoagulation and the correlation between time‐to‐retrieval and time‐to‐initiation of anticoagulation were observed. Of 54 766 patients receiving a VCF, 36.9% had pulmonary embolism, 43.9% had deep vein thrombosis only, and 19.2% had no apparent venous thromboembolism present. Over the 1 year of follow‐up, the cumulative incidence of VCF retrieval was 18.4%. Retrieval increased over time from a low of 14.0% in 2010 up to ≈24% in 2014. In adjusted time‐to‐event models, increasing age, differing regions, and some comorbidities were associated with poorer retrieval rates. Initiation of anticoagulation was poorly correlated with retrieval, with anticoagulation preceding retrieval by a median of 51 days while those without retrieval had a median of 278 days of exposure to anticoagulation.

Conclusions

VCF retrieval increased over the study period but remained suboptimal and was weakly correlated with anticoagulation initiation.

Indications, complications and outcomes of elderly patients undergoing retrievable inferior vena cava filter placement

AIM

The utilization of inferior vena cava filter placement for pulmonary embolism prevention in elderly patients has not been well characterized. The present study aimed to review indications, complications and follow-up data of elderly patients undergoing inferior vena cava filter placement.

METHODS

A retrospective review was carried out of consecutive admitted patients who underwent inferior vena cava filter insertion at a large university hospital with a level I trauma center.

RESULTS

Overall, 455 retrievable filters were inserted between 2009 and 2014. A total of 133 patients (29.2%) were aged ≥70 years. Elderly patients were less likely to have their filter retrieved compared with non-elderly patients (5.3% vs 21.4%, P < 0.001). Filter-related complications occurred in 13% of non-elderly patients and 14.3% of elderly patients (P = 0.72), most of them occurring in the first 3 months after filter placement. Survival among elderly patients with no evidence of active malignancy was similar to the non-elderly patients with a 1-year survival rate of 76.3% versus 82% in non-elderly patients (P = 0.22), and a 2-year survival rate of 73.1% versus 78.6% in non-elderly patients (P = 0.27). Although decreased, survival rates among elderly patients with active cancer were still substantial, with a 1-year survival rate of 45% and 2-year survival rate of 40%.

CONCLUSIONS

Elderly patients had significantly lower rates of filter retrieval with similar complication rate. Survival rates among elderly patients were substantial, and in elderly patients with no active cancer were even comparable with non-elderly patients. When feasible, filter retrieval should be attempted in all elderly patients in order to prevent filter-related complications. Geriatr Gerontol Int 2017; 17: 1508-1514.

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

OBJECTIVE

The option to retrieve inferior vena cava (IVC) filters has resulted in an increase in the utilization of these devices as stopgap measures in patients with relative contraindications to anticoagulation. These retrievable IVC filters, however, are often not retrieved and become permanent. Recent data from our institution confirmed a historically low retrieval rate. Therefore, we hypothesized that the implementation of a new IVC filter retrieval protocol would increase the retrieval rate of appropriate IVC filters at our institution.

METHODS

All consecutive patients who underwent an IVC filter placement at our institution between September 2003 and July 2012 were retrospectively reviewed. In August 2012, a multidisciplinary task force was established, and a new IVC filter retrieval protocol was implemented. Prospective data were collected using a centralized interdepartmental IVC filter registry for all consecutive patients who underwent an IVC filter placement between August 2012 and September 2014. Patients were chronologically categorized into preimplementation (PRE) and postimplementation (POST) groups. Comparisons of outcome measures, including the retrieval rate of IVC filters along with rates of retrieval attempt and technical failure, were made between the two groups.

RESULTS

In the PRE and POST groups, a total of 720 and 74 retrievable IVC filters were implanted, respectively. In the POST group, 40 of 74 filters (54%) were successfully retrieved compared with 82 of 720 filters (11%) in the PRE group (P < .001). Furthermore, a greater number of IVC filter retrievals were attempted in the POST group than in the PRE group (66% vs 14%; P < .001). No significant difference was observed between the PRE and POST groups for technical failure (17% vs 18%; P = .9).

CONCLUSIONS

The retrieval rate of retrievable IVC filters at our institution was significantly increased with the implementation of a new IVC filter retrieval protocol with a multidisciplinary team approach. This improved retrieval rate is possible with minimal dedication of resources and can potentially lead to a decrease in IVC filter-related complications in the future.

Inferior vena cava filters: current best practices

Venous thromboembolism (VTE) is a common cause of inpatient and outpatient morbidity and mortality. While anticoagulant therapy is considered the primary means of prevention and treatment of VTE, inferior vena cava filters (IVCFs) are often used as an alternative or adjunct to anticoagulation. With the advent of retrievable filters indications have liberalized, to include placement for primary prophylaxis in high-risk patients. However, this practice is based on limited evidence supporting their efficacy in preventing clinically relevant outcomes. Since indiscriminate use of IVCFs can be associated with net patient harm and increased health care costs, knowledge of the literature surrounding IVCF utilization is critical for providers to adopt best practices. In this review, we will provide an overview of the literature as it relates to specific clinical questions that arise when considering IVCF utilization in the prevention and treatment of VTE. Practice-based recommendations will be reviewed to provide the clinician with guidance on challenging clinical scenarios.

Evaluation of nonpermanent inferior vena cava filter placement in patients with deep venous thrombosis after lower extremity fracture: A single-center retrospective study

OBJECTIVE

To investigate nonpermanent inferior vena cava (IVC) filter in the prevention of perioperative pulmonary embolism (PE) in patients of lower extremity and/or pelvic bone fracture with deep vein thrombosis (DVT).

METHODS

Lower extremity or pelvic bone fracture patients with lower extremity DVT hospitalized in our hospital from January 2003 to October 2014 were retrospectively analyzed. Data was analyzed for age, gender, position of fracture, position of proximal of thrombosis, indications of placement, complications, retrieval rate, and rate of entrapped filter clot. Patients who underwent IVC filter placement were selected as the filter group. The patients who did not perform IVC filter placement after 2008 and the cases between January 2003 and December 2007 were selected as control group 1 and control group 2, respectively. The incidence of perioperative symptomatic PE and mortality were analyzed.

RESULTS

A total of 2763 cases complicated with DVT underwent orthopedic surgery between January 2003 and October 2014. 823 nonpermanent filters were inserted. All filters were successfully deployed with no major complications. After a mean 14.2 days indwelling time, all of temporary filters were removed. Retrieval was attempted in 556 patients with retrievable filters and was successful in 545 (98%); mean indwelling time was 16.3 days. The total retrieval rate was 90%. The incidence of PE in the filter group was significantly lower compared with the two control groups. Among the patients who received chemical anticoagulant therapy, the incidence of PE in filter group, control group 1 and control group 2 were 0.14%, 1.60% and 2.10%, respectively. The incidence of PE in filter group was also significant lower compared with control groups.

CONCLUSION

Nonpermanent IVC filter placement seems like to be a safe and effective method for preventing perioperative symptomatic and fatal PE in bone fracture patients with DVT in the present retrospective study.

Current Status of the Retrieval Rate of Retrievable Vena Cava Filters in a Tertiary Referral Center in Korea

PURPOSE

The purpose of this study was to review the daily practice of inferior vena cava filters (IVCFs) in a tertiary referral center in Korea and to reveal the retrieval rate and the methods for improving it.

MATERIALS AND METHODS

Through the electronic medical record system, a retrospective review was performed on 115 consecutive patients who underwent placement of retrievable IVCFs between February 2000 and January 2011 in Seoul National University Hospital.

RESULTS

IVCF placement was done in 115 cases (113 patients). There were 68 men (59.1%), and the mean age was 58.5±15.5 years (range, 10-96 years). The affiliated departments were Vascular Surgery (57 cases, 49.6%), and Internal Medicine (20 cases, 17.4%). Advanced malignancy was the most commonly associated disease (n=30, 26%). The indications for IVCF placement were categorized; absolute indications in 36 cases (31.3%), relative indications in 78 cases (67.8%), and prophylactic use in 1 case (0.9%). The most common indications were thrombolysis/thrombectomy for iliocaval deep vein thrombosis (DVT) (n=55, 47.8). Of the 115 filters, 68 were retrieved (retrieval rate, 59%). The most common cause of non-retrieval was chronic high risk of venous thromboembolism in 24 patients (51%), followed by residual proximal DVT (n=7, 15%), and negligence by unknown reasons (n=6, 13%).

CONCLUSION

To improve the retrieval rate, the number of follow-up losses to vascular specialists must be decreased, which can be achieved by establishment of a dedicated IVC filter clinic, implementation of a filter registry, and regular education for medical teams and patients along with their families.

Thromboprophylaxis in patients with pelvic and acetabular fractures: A short review and recommendations

The management of thromboprophylaxis in patients with pelvic and acetabular fractures remains a highly controversial topic within the trauma community. Despite anticoagulation, venous thromboembolism (VTE) remains the most common cause of surgical morbidity and mortality in this high-risk patient group. Although various thromboprophylactic regimes are employed, evidence relating to the most effective method remains unclear. Controversies surrounding screening, the use of prophylactic inferior vena cava filters (IVCF) and chemothromboprophylaxis in polytraumatised patients, particularly those with pelvic and acetabular fractures, form the basis of considerable debate. With the absence of a well-designed clinical trial and the presence of ongoing controversies within the literature, this review will explore current treatment options available to trauma surgeons and highlight differing scientific opinions, providing an update on the role of screening and current available preventative measures. We cover existing as well as recent advances in chemical thromboprophylactic agents and discuss external mechanical compression devices, the usefulness of serial duplex ultrasonography and the role of extended chemothromboprophylaxis on discharge. The evidence behind prophylactic IVCF is also considered, along with reported complication profiles. We conclude with a proposed protocol for use in major trauma centres, which can form the basis of local policy for the prevention of VTE in trauma patients with pelvic and acetabular fractures.

Clinical review: inferior vena cava filters in the age of patient-centered outcomes

Inferior vena cava filter (IVCF) use continues to increase in the United States (US) despite questionable clinical benefit and increasing concerns over long-term complications. For this review we comprehensively examine the randomized, prospective data on IVC filter efficacy, compare relative rates of IVCF placement in the US and Europe, compare commonly considered guidelines for IVCF indications, and the current data on IVCF complications. Searches of MEDLINE and Cochrane databases were conducted for randomized prospective IVCF studies. Only three randomized prospective studies for IVCFs were identified. Commonly cited IVCF guidelines were reviewed with attention to their evolution over time. No evidence has shown a survival benefit with IVCF use. Despite this, continued rising utilization, especially for primary prophylactic indications, is concerning, given increasing evidence of long-term filter-related complications. This is particularly noted in the US where IVCF placements for 2012 are projected to be 25 times that of an equivalent population in Europe (224,700 versus 9,070). Pending much-needed randomized controlled trials that also evaluate long-term safety, we support the more stringent American College of Chest Physicians (ACCP) guidelines for IVCF placement indications and advocate a close, structured follow-up of retrievable IVCFs to improve filter retrieval rates.

Improving retrieval rates for retrievable inferior vena cava filters

The introduction of retrievable inferior vena cava (IVC) filters was an important step in the evolution of deep vein thrombosis/pulmonary embolism management. Their removability makes them preferred to permanent filters in many cases. IVC filter retrieval often occurs at a suboptimal rate, leading to complications associated with long-term placement. Improving retrievability includes solutions for patients being lost to follow-up, filter malpositioning, need arising for permanent IVC filtration, filtration requiring longer than the filter's window of retrievability, and filter compromise by the presence of a large trapped clot. This review explores these strategies for retrieval in detail in hopes of improving IVC filter retrieval rates.

The use of prophylactic inferior vena cava filters in trauma patients: a systematic review

INTRODUCTION

Pulmonary embolisms (PE) are an often preventable cause of late morbidity and mortality after trauma. Although there is evidence for the use of therapeutic inferior vena cava (IVC) filters (defined as IVC filters implanted in those with proven deep venous thrombosis [DVT] in order to prevent PE), there is not as much evidence to support the use of prophylactic IVC filters. Thus, we undertook a systematic review of the literature to assess the following in prophylactic IVC filters: efficacy in PE reduction, prevalence of filter-related complications and the indications for use.

MATERIALS AND METHODS

After screening 249 studies, 24 studies met inclusion criteria for qualitative synthesis.

RESULTS

Overall, the literature is supportive of the use of prophylactic IVC filters in high-risk poly-trauma patients who may have contraindications to DVT prophylaxis. Filter-associated complications are uncommon and, when they do occur, tend to be of limited clinical significance. Limited data, mostly in the form of case series, supports a reduction in PE and PE-related mortality. There has been increasing use of retrievable filters as well as the ability to safely retrieve them at longer intervals.

CONCLUSION

Despite the addition of a few matched-control studies, the literature is still plagued by a lack of high quality data, and therefore the true efficacy of prophylactic IVC filters for prevention of PE in trauma patients remains unclear. Further studies are required to determine the true role of prophylactic IVC filters in trauma patient.

Retrievable inferior vena cava filter use in major trauma

Venous thromboembolism (VTE) remains a devastating complication among trauma patients. However, conventional VTE prophylaxis is often contraindicated in major trauma patients due to concurrent injuries. This article discusses the use of retrievable inferior vena cava filters as a method for VTE prophylaxis in major trauma patients.