Retrievable Gunther Tulip inferior vena cava filter: Experience in 317 patients

Inferior Vena Cava Filters and Complications: A Systematic Review

Inferior vena cava (IVC) filters have been used since the 1960s to treat patients with acute risk of pulmonary embolism (PE) to prevent migration of thrombus by trapping it within the filter. Traditional usage has been in patients with contraindication to anticoagulation that carry a significant mortality risk. In this systematic review, we sought to evaluate complications associated with placement of inferior vena cava filters based on published data from the past 20 years. A search was performed on October 6th, 2022, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews, using three databases (ProQuest, PubMed and ScienceDirect) for articles published between the dates of February 1, 2002 and October 1, 2022. Results were filtered to include full-text, clinical studies, and randomized trials written in English pertaining to keywords "IVC filter AND complications", "Inferior Vena Cava Filter AND complications", "IVC filter AND thrombosis" and "Inferior Vena Cava Filter AND thrombosis". Articles identified by the three databases were pooled and further screened for relevance based on inclusion and exclusion criteria. Initial search results yielded 33,265 hits from all three databases combined. Screening criteria were applied, with 7721 results remaining. After further manual screening, including removal of duplicate hits, a total of 117 articles were selected for review. While there are no consensus guidelines for best practice, there is compelling evidence that IVC filters can provide significant protection against PE with minimal complications if the treatment window is appropriate. Increase in the variety of filter models has led to broader availability, but skepticism remains about their efficacy and safety, with ongoing controversy surrounding appropriate indications. Further research is needed to establish clear guidelines on appropriate indications for IVC placement and to determine time course of complications versus benefits for indwelling filters.

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.

Clinical outcomes of retrievable inferior vena cava filters for venous thromboembolic diseases

Aim: To identify literature evidence assessing retrievable inferior vena cava filter (rIVCF) for venous thromboembolic diseases. Methods: A systematic literature search was conducted to identify relevant references from the mainstay English and Chinese bibliographic databases (search period: January 2003 to October 2019). Results: 80 original studies with 11,413 patients were included in this review. The success rates of deploying the six types of rIVCFs ranged from 98.4 to 100.0%. Denali had the highest retrieval success rate (95.4-97.6%). The incidence rates of fracture and perforation associated with retrieving the six rIVCFs were less than 2%. Conclusion: The approved rIVCF had comparable clinical profiles, except that Denali was easier to be retrieved than other rIVCF.

Endovascular treatment of thrombosed inferior vena cava filters: Techniques and short-term outcomes

PURPOSE

To present the techniques for endovascular treatment of thrombosed filter-bearing inferior vena cavae (IVCs), along with short-term clinical and imaging follow-up.

MATERIALS AND METHODS

A total of 45 consecutive patients (17 females and 28 males), aged 19-79 years (mean age of 49 years), who had IVC filter placement complicated by symptomatic acute or chronic iliocaval thrombosis and underwent endovascular therapy were studied. All patients presented with lower extremity swelling and/or pain. One patient also had bilateral lower extremity swelling and chronic gastrointestinal (GI) bleeding which was secondary to chronic systemic to portal venous collaterals. Patients underwent one or more of the following endovascular treatments depending on the chronicity and extent of thrombosis: (a) catheter-directed thrombolysis (CDT) (n = 25), (b) pharmacomechanical thrombolysis (PMT) (n = 15), (c) balloon angioplasty (n = 45), and/or (d) stent placement across the filter (n = 42). In addition, 16 patients underwent groin arteriovenous fistula (AVF) creation (36%) and 3 (7%) had femoral venous thrombectomy to improve flow in the recanalized iliac veins and IVCs.

RESULTS

Anatomical success was achieved in all patients. Follow-up was not available in 10 patients (lost to follow-up, n = 4; expired due to comorbidities, n = 2; lost to follow-up after re-intervention, n = 4). At a mean follow-up time of 13.3 months (range 1-48 months), clinical success was achieved in 27 patients (60%), i.e. in 21 patients without re-intervention and in 6 patients with re-intervention. Clinical success was not achieved despite re-intervention in eight patients. Higher clinical success was noted in patients who did not require repeat interventions (P = 0.03) and the time to re-intervention was significantly shorter in patients who had clinical failure (P = 0.01). AVF creation did not improve the clinical success rate (P = 1). There was no significant difference in clinical success between patients who had acute or subacute thrombosis compared to those who had chronically occluded filter-bearing IVCs (P = 1).

CONCLUSION

This study suggests that endovascular therapy for thrombosed filter-bearing IVCs is safe and technically feasible.

A single center experience with retrievable IVC filters

Objective

To evaluate retrievable IVC filters in our institution and assess their retrieval following a well-structured follow up program.

Design

Retrospective cohort study.

Materials

The medical records of patients implanted with retrievable IVC filters were reviewed.

Methods

All retrievable filter insertions between July 2007 and August 2011 at our institution were reviewed. Data was analyzed for age, gender, indication, complications, retrieval rate, and brand of filter inserted. Statistical analysis was done using SPSS software v19. Chi-square was used to compare discrete data and t-test for continuous data. P < 0.05 was significant.

Results

A total of 484 patients were reviewed of which 258 (53.1%) had a complete medical record. And 96 (37.2%) filters were placed as permanent at the time of insertion. An additional 40 (15.5%) filters were converted to permanent (total permanent filters 136; 52.7%). Death was reported in 26 (10%) patients and 96 (37.2%) out of the remaining 232 patients presented for potential retrieval. Also, 73 (28.2%) had an attempt to retrieve the filters, 69 (94.5%) were successful and 4 (5.4%) failed to retrieve. The remaining 23 (8.9%) patients declined retrieval. Filters studied include Celect (38%), Bard (31.4%), Option (26.2%), Tulip (4.1%), and Recovery (0.2%). Bard was more commonly used as a retrievable filter (80.9%). Retrieval on the first attempt was 90.4% ( n = 66) successful. Of the remaining seven filters, three were successfully retrieved on a second attempt, and four failed to retrieve due to filter tilt. The success rates of retrieval for Celect and Tulip were significantly lower than for Bard ( p = 0.04 and 0.023, respectively).

Conclusion

Our study showed that a variety of IVC filters can be retrieved successfully with minimal complication rates. In more than half of our patients, IVC filters were used as permanent. Failure of retrieval was most frequently due to filter tilting.

Clinical outcomes and causes of death in Japanese patients with long-term inferior vena cava filter implants and deep vein thrombosis

BACKGROUND AND PURPOSE

We assessed the causes of death and efficacy of permanent inferior vena cava (IVC) filters for preventing new pulmonary embolisms (PE) in Japanese deep vein thrombosis (DVT) patients with or without PE.

METHODS AND SUBJECTS

We studied the clinical outcomes during the follow-up period of 1 day to 9 years (median: 18 months; mean: 28 months) in 66 of 72 consecutive patients (44 with acute PE, 27 with intrapelvic DVT, and 1 with floating femoral vein thrombosis). Fifty of 66 patients received anticoagulant therapy after the filter placement.

RESULTS

Five patients died within 1 month (median 9 days) after the filter placement: three from recurrence of PE, one from cancer, and one from sepsis. Two of the three patients with recurrence of PE had preexisting intracardiac thrombi in the right atrium or main pulmonary artery before filter implantation. Ten patients died from the underlying disease (cancer: 7; brain hemorrhage: 1; amyotrophic lateral sclerosis: 1; pneumonia: 1) over 1 month after the filter placement (median follow-up period: 21 months). No new symptomatic PE recurrence was observed over 1 month after the filter placement. The 61 patients with long-term follow-up had no deterioration of DVT, and all the 31 patients who underwent multi-slice computed tomography showed no PE recurrence or filter thrombus occlusion, fracture, or migration.

CONCLUSIONS

Underlying diseases and preexisting intracardiac thrombi may be the determining factors for the prognosis of DVT patients. Permanent IVC filters with anticoagulant therapy may be effective for preventing death from new PE in Japanese DVT patients.

Three-year experience of prophylactic placement of inferior vena cava filters in women with gynecological cancer

Objective

To evaluate the outcomes of prophylactic placement of inferior vena cava (IVC) filters to prevent pulmonary embolism (PE) in women undergoing surgery and chemotherapy for gynecological cancer.

Methods and materials

Thirty-eight IVC filters were placed in 38 women between January 2008 and January 2010; 25 of these were placed in gynecological cancer patients for prevention of PE during surgery and the postoperative period. The patients’ electronic medical records, follow-up computed tomography scans, and outpatient follow-up notes were retrospectively reviewed for incidence of PE and adverse events.

Results

After 6 months of follow-up, no PE was observed and there was no mortality. Nine filters were retrieved uneventfully, and there were no clinical complications associated with any indwelling filter.

Conclusion

IVC filters are safe and beneficial towards preventing PE in women undergoing surgery and chemotherapy for gynecological cancer.

Dedicated Tracking of Patients with Retrievable Inferior Vena Cava Filters Improves Retrieval Rates

Retrievable IVC filters (R-IVCF) are associated with multiple complications, including filter migration and deep venous thrombosis. Unfortunately, most series of R-IVCF show low retrieval rates, often due to loss to follow-up. This study demonstrates that actively tracking R-IVCF improves retrieval. Trauma patients at one institution with R-IVCF placed between January 2007 and January 2011 were tracked in a registry with a goal of retrieval. These were compared to a control group who had R-IVCF placed previously (December 2005 to December 2006). Outcome measures include filter retrieval, retrieval attempts, loss to follow-up, and time to filter retrieval. We compared 93 tracked patients with R-IVCF with 20 controls. The baseline characteristics of the groups were similar. Tracked patients had significantly higher rates of filter retrieval (60% vs 30%, P = 0.02) and filter retrieval attempts (70% vs 30%, P = 0.002) and were significantly less likely to be lost to follow-up (5% vs 65%, P < 0.0001). Time to retrieval attempt was 84 days in the registry versus 210 days in the control group, which trended towards significance ( P = 0.23). Tracking patients with R-IVCF leads to improved retrieval rates, more retrieval attempts, and decreased loss to follow up. Institutions should consider tracking R-IVCF to maximize retrieval rates.

Improved recovery of prophylactic inferior vena cava filters in trauma patients: the results of a dedicated filter registry and critical pathway for filter removal

BACKGROUND

Temporary inferior vena cava filters (IVCF) are uniquely suited for trauma patients in whom the high risk of venous thromboembolism is transient. Currently, few "retrievable filters" are actually retrieved, with most published series documenting a retrieval rate between 20% and 50%. We sought to determine whether we could achieve a higher rate of retrieval with an improved process of care.

METHODS

All permanent and temporary filters were entered prospectively into a dedicated filter registry. Within 60 days of filter placement, all temporary filter patients were contacted by a trauma case manager to evaluate ongoing venous thromboembolism risk. Low-risk patients were then evaluated by radiology for removal of the IVCF. If appropriate, removal of the IVCF was scheduled. Initial contacts with patients were made by telephone. If unsuccessful with phone contact, family members, rehabilitation facility, and social work were all contacted to obtain the most recent phone number and address. A follow-up letter was sent to the patient with follow-up visit instructions. Finally, if prior contact measures did not work, a certified letter was sent to the last known address.

RESULTS

Between 2006 and 2009, of 7,949 trauma admissions, 420 (5.2%) met indications for filter placement. Of those, 160 were available for removal and 94 were successfully removed (59%).

CONCLUSIONS

A retrieval rate of 59% can be achieved with an explicit process of care emphasizing disciplined follow-up.

LEVEL OF EVIDENCE

III.

Systematic review of the use of retrievable inferior vena cava filters

PURPOSE

To review the available literature on retrievable inferior vena cava (IVC) filters to examine the effectiveness and risks of these devices.

MATERIALS AND METHODS

Investigators searched MEDLINE for clinical trials evaluating retrievable filters and reviewed the complications reported to the Manufacturer and User Facility Device Experience (MAUDE) database of the U.S. Food and Drug Administration (FDA).

RESULTS

Eligibility criteria were met by 37 studies comprising 6,834 patients. All of the trials had limitations, and no studies were randomized. There were 11 prospective clinical trials; the rest were retrospective studies. Despite the limitations of the evidence, the IVC filters seemed to be effective in preventing pulmonary embolism (PE); the rate of PE after IVC placement was 1.7%. The mean retrieval rate was 34%. Most of the filters became permanent devices. Multiple complications associated with the use of IVC filters were described in the reviewed literature or were reported to the MAUDE database; most of these were associated with long-term use (> 30 days). At the present time, the objective comparison data of different filter designs do not support superiority of any particular design.

CONCLUSIONS

In high-risk patients for whom anticoagulation is not feasible, retrievable IVC filters seem to be effective in preventing PE. Long-term complications are a serious concern with the use of these filters. The evidence of the effectiveness and the risks was limited by the small number of prospective studies.

Clinical review of pulmonary embolism: diagnosis, prognosis, and treatment

Pulmonary embolism (PE) is a common disease causing significant morbidity, mortality, and substantial socioeconomic costs. The correct diagnosis and management of PE, however, offers many challenges. As a result, ongoing research continues to develop and refine new and existing diagnostic and prognostic tools, as well as therapeutic interventions, leading to significant improvements in the care of PE over the past 2 decades. This article summarizes the current literature to aid the clinician in the correct integration and implementation of these advances in the treatment of PE.

Permanent or temporary IVC filtration with a novel double-ring anchoring technology optional nitinol filter

Permanent or temporary implantation of inferior vena cava filters for protection against pulmonary embolism is well established. There have been numerous devices developed for this purpose, each of which has proprietary design considerations that affect performance and potentially impose limitations with regard to positioning, efficacy and risk profile. This article describes a recently developed, unique inferior vena cava filter design that employs a separated filtration component and a novel double-ring anchoring system that allows intraprocedural capture and repositioning for optimized placement. In addition, early experience suggests easy removal when desired, a high rate of filtration success and excellent caval patency.