Experience with vena cava filters at a large community hospital and level-I trauma center: indications, complications, and compliance barriers

Inferior vena cava filter use at a large community hospital: a retrospective cohort study

Inferior vena cava (IVC) filters are considered when patients with venous thromboembolism (VTE) develop a contraindication to anticoagulation. Use of IVC filters is increasing, despite associated complications and lack of data on efficacy in reducing VTE-related mortality. We characterized the pattern of IVC filter use at a large community hospital between 2018 and 2022. Specifically, we assessed the indications for IVC filter insertion, filter removal rates, and filter-associated complications. Indications for IVC filters were compared to those outlined by current clinical practice guidelines. We reviewed 120 consecutive filter placement events. The most common indications included recent VTE and active bleeding (40.0%) or need for anticoagulation interruption for surgery (25.8%). Approximately one-third (30.0%) of IVC filters were inserted for indications either not supported or addressed by guidelines. Half (50.0%) of patients had successful removal of their IVC filter. At least 13 patients (10.8%) experienced a filter-related complication. In a large community-based practice, nearly one-third of IVC filters were inserted for indications not universally supported by current practice guidelines. Moreover, most IVC filters were not removed, raising the risk of filter-associated complications, and supporting the need for development of comprehensive guidelines addressing use of IVC filters, and post-insertion monitoring practices.

Guideline Compliance and Indications for Inferior Vena Cava Filter Placement at a Quaternary Care Medical Center

PURPOSE

This study investigated physician compliance with indications for inferior vena cava (IVC) filter placement according to the 2012 American College of Chest Physicians (ACCP) and the 2011 Society of Interventional Radiology (SIR) guidelines.

MATERIALS AND METHODS

A retrospective medical record review of 231 retrievable IVC filters placed between August 15, 2016, and December 28, 2017, at a large urban academic medical center. Guideline compliance to the 2012 ACCP and the 2011 SIR guidelines, and indications for IVC filter placements were assessed through an adjudication protocol. Filter retrieval and complication rates were also examined.

RESULTS

Compliance to guidelines was low (60.2% for ACCP; 74.0% for SIR), especially for non-intensive care unit (ICU) patients (ICU 74.6% vs non-ICU 54.8%, p=0.007 for ACCP; ICU 82.5% vs non-ICU 70.8%, p=0.092 for SIR). After adjudication, 8.2% (19/231) of filters were considered non-indicated but reasonable, 17.7% (41/231) non-indicated and unreasonable, and 13.9% (32/231) SIR-indicated but not ACCP-indicated. The most common indication was venous thromboembolism with contraindication to anticoagulation. The most common reasons for non-compliance were distal deep venous thrombosis with contraindication to anticoagulation (19/60, 31.6%) and clot burden (19/60, 31.6%). One-year filter retrieval and 90-day complication rates were 32.0% (74/231) and 6.1% (14/231), respectively.

CONCLUSION

Compliance to established guidelines was low. Reasons for non-compliance included limitations or discrepancies in guidelines, as well as non-evidence-based filter placements.

CLINICAL IMPACT

Despite increasing utilization of inferior vena cava (IVC) filters, guideline compliance for IVC filter placement among providers is unclear. The results of this study indicate that physician compliance to established guidelines is poor, especially in non-intensive-care-unit patients. Noncompliance stems from non-evidence-based filter placement as well as differences and limitations in guidelines. Avoiding non-indicated IVC filter placement and consolidation of guidelines may significantly improve guideline compliance. The critical insights gained from this study can help promote judicious use of IVC filters and highlight the role of venous thromboembolism experts in navigating complex cases and nuances of guidelines.

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.

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.

Inferior Vena Cava Filter Migration to the Left Internal Iliac Vein

Inferior vena cava filter placement is an important method for managing deep venous thrombosis of the lower extremities and has a high risk of pulmonary embolism. Filter migration is rare but potentially fatal. We describe a case of migration of an inferior vena cava filter to the left internal iliac vein. The filter perforated the internal iliac vein, resulting in hemorrhagic shock, and was removed with open surgery. To our knowledge, this is the first reported case of migration of an inferior vena cava filter to an internal iliac vein.

Are retrievable vena cava filters placed in trauma patients really retrievable?

PURPOSE

Concerns have arisen regarding the use of retrievable inferior vena cava filters (rIVCFs) in trauma patients due to increasing reports of low retrieval rates. We hypothesized that complete follow-up with a dedicated trauma nurse practitioner would be associated with a higher rate of retrievability. This study was undertaken to determine the rate of retrievability of rIVCFs placed in a Canadian Lead Trauma Centre, and to compare the rate of retrievability in our trauma population to our non-trauma patients.

METHODS

We performed a retrospective cohort study of all patients with rIVCF placed between Jan 1 2000 and June 30 2014. Data were collected on demographics, indication for filter placement, retrieval status, and reasons for non-retrieval. Comparison was made between trauma patients and non-trauma patients.

RESULTS

A total of 374 rIVCFs were placed (61 in trauma patients and 313 in non-trauma patients) and follow-up was complete for the entire cohort. Filter retrieval was achieved in 86.9 % of trauma patients. Reasons for non-retrieval were technical in two patients, and death before retrieval in six patients. Retrieval was successful in 48.9 % of non-trauma patients.

CONCLUSIONS

This study demonstrates that rIVCFs can be successfully retrieved amongst trauma patients. We demonstrated a higher rate of successful retrieval amongst trauma patients than non-trauma patients in our institution. Careful patient follow-up may play a role in successful retrieval of rIVCFs.