Vena Cava Filters

Guidelines and the use of inferior vena cava filters: a review of an institutional experience

BACKGROUND AND OBJECTIVES

Based on the American College of Chest Physicians 2004 antithrombotic therapy for venous thromboembolism (VTE) and the Eastern Association for the Surgery of Trauma 2002 guidelines, placement of an inferior vena cava (IVC) filter is indicated in patients who either have, or are at high risk for, VTE, but have a contraindication or failure of anticoagulation. Our aim is to compare clinical characteristics and outcomes of patients receiving IVC filters within-guidelines (WG) and outside-of-guidelines (OOG).

METHODS

The 558 patients who received an IVC filter were divided into two groups called WG or OOG. The WG group met the criteria described above and the OOG group did not have a contraindication to or a failure of anticoagulation.

RESULTS

The WG group had 362 patients and the OOG group had 196 patients. The OOG group had one (0.5%) patient with post-filter pulmonary embolism (PE), two (1%) with IVC thrombosis, and seven (3.6%) with deep vein thrombosis (DVT). The WG group had five (1.4%) patients with post-filter PE, 13 (3.6%) with IVC thrombosis, and 34 (9.4%) with DVT. All patients who developed post-filter PE had a DVT before filter placement, and patients who did not have a prior VTE event were at a significantly lower risk of developing post-filter IVC thrombosis and PE.

CONCLUSION

Our data do not support the use of an IVC filter outside of guidelines in patients without prior VTE who can tolerate anticoagulation because of the low risk of developing PE.

Real-time 3-D ultrasound guidance of interventional devices

We have previously developed 2-D array transducers for many real-time volumetric imaging applications. These applications include transducers operating up to 7 MHz for transthoracic imaging, up to 15 MHz for intracardiac echocardiography (ICE), 5 MHz for transesophageal echocardiography (TEE) and intracranial imaging, and 7 MHz for laparoscopic ultrasound imaging (LUS). Now we have developed a new generation of miniature ring-array transducers integrated into the catheter deployment kits of interventional devices to enable real-time 3-D ultrasound scanning for improved guidance of minimally invasive procedures. We have constructed 3 new ring transducers. The first consists of 54 elements operating at 5 MHz. Typical measured transducer element bandwidth was 25%, and the 50 Ohm round trip insertion loss was -65 dB. Average nearest neighbor cross talk was -23.8 dB. The second is a prototype 108-element transducer operating at 5 MHz. The third is a prototype 108-element ring array with a transducer center frequency of 8.9 MHz and a -6 dB bandwidth of 25%. All transducers were integrated with an 8.5 French catheter sheath of a Cook Medical, Inc. vena cava filter deployment device.

Current treatment of acute lower extremity deep venous thrombosis

The long-term complications of acute deep venous thrombosis (DVT) include recurrence, increased mortality, and the development of the postthrombotic syndrome. Rates of recurrent venous thromboembolism (VTE) are elevated in patients with cancer and thrombophilia. Heparin, administered either as unfractionated or low-molecular weight, is indicated for at least five days for acute DVT. Long-term treatment is currently a vitamin K antagonist with a variable duration depending on the etiology of the DVT and risk of bleeding. Novel anticoagulant agents that target factor Xa and directly inhibit thrombin are being studied in clinical trials and may one day replace vitamin K antagonists for the long-term treatment of VTE. Interventional approaches such as percutaneous mechanical thrombectomy have the potential to reduce clot burden in acute DVT with lower bleeding risks and help prevent development of the postthrombotic syndrome, a common and potentially debilitating complication of DVT.

Efficacy of inferior vena cava filters in anticoagulated patients

BACKGROUND AND OBJECTIVES

The benefit of an inferior vena cava (IVC) filter in addition to standard anticoagulation regimens is unknown.

METHODS

We examined data for patients who received IVC filters with anticoagulation (AC-Filter) after an episode of venous thromboembolism (VTE) and compared them with data for those who received anticoagulation only (AC-Only). Outcome measures were new pulmonary embolism (PE), recurrent deep vein thrombosis (DVT), and mortality at 90 days and at 5 years. Demographic data included age, gender, and ethnicity/race, prior thromboembolic history, cancer, serum albumin, and time in therapeutic range. In addition, subsets matched for age, gender and race/ethnicity were examined in detail.

RESULTS

AC-Filter patients (n = 251), when compared to AC-Only patients (n = 1377), did not differ significantly with regard to gender or cancer status, but white males in general had better outcomes. AC-Filter patients were more likely to have had a previous history of PE or VTE (P < 0.001). In comparison to AC-Only patients, AC-Filter patients had lower mean serum albumin levels (3.1 +/- 0.8 vs. 3.6 +/-0.8 mg dL(-1), P < 0.001) and were older (65 +/- 16.1 years vs. 60 +/- 17.5 years, P < 0.001). After stratification according to previous history of PE or VTE prior to the index VTE event, no differences in the outcome measures of new PE, recurrent DVT or mortality were identified between groups, but patients with a prior history of PE from either group were more likely to have a new PE (hazard ratio 1.9, P < 0.001).

CONCLUSIONS

These data suggest that IVC filters may not provide any substantial additional benefit for patients who can tolerate anticoagulant therapy.