Review of indications and practices of vena caval filters at a large university hospital

Effect of access site choice on inferior vena cava filter angulation and outcomes

BACKGROUND

In the present study, we compared the outcomes of inferior vena cava (IVC) filter placement between the femoral vein (FV) and internal jugular (IJ) vein access sites.

METHODS

We performed a retrospective study using the Vascular Quality Initiative database to assess patients who had undergone IVC filter placement from 2013 to 2019. The patients were placed into two groups according to the access site location: FV and IJ vein. The FV group included patients with access via the right and left FVs and other leg veins, and the IJ group included patients with access via the right or left IJ vein. The primary outcome was the rate of filter angulation. The secondary outcomes included access site complications such as deep vein thrombosis, hematoma, and bleeding requiring transfusion.

RESULTS

Of 13,221 patients, 8214 (63%) had undergone IVC filter placement via FV access and 4789 (37%) via IJ access. The remaining 218 patients had had an unknown access site or were excluded. Within the IJ group, 4696 (98.0%) had undergone access via the right IJ and 93 (2%) via the left IJ. Within the FV (common femoral, femoral, or other infrainguinal veins) group, 7007 (85.3%) had undergone access via the right FV and 1207 (14.6%) via the left FV. The mean patient age was 63 ± 15.9 years, the mean body mass index was 30.9 ± 9.60 kg/m², and 6788 of the patients were men (52.0%). The most common indication for filter placement was a contraindication to anticoagulation because of a recent or active bleeding episode (30%), followed by planned surgery (22%), new deep vein thrombosis/pulmonary embolism (7%), fall risk (5%), and trauma (4%). Infrarenal filters had been placed in 97.9% of the patients. Univariate analysis identified body mass index and suprarenal placement as independent risk factors for angulation. The final multivariate analysis showed a significant increase in angulation (0.9% vs 0.34%; odds ratio, 1.46; 95% confidence interval, 1.02-2.11; P = .04) and increased access site complications (0.25% vs 0.07%; odds ratio, 2.068; 95% confidence interval, 1.01-4.23; P = .048) in the FV access group. No significant correlation between the access site and retrieval rate was found (P = .9270).

CONCLUSIONS

Placement of IVC filters via IJ access showed a lower rate of filter angulation in the IVC and fewer access site complications compared with FV access.

Retrospective analysis of outcomes following inferior vena cava (IVC) filter placement in a managed care population

The role of inferior vena cava filter (IVC) filters for prevention of pulmonary embolism (PE) is controversial. This study evaluated outcomes of IVC filter placement in a managed care population. This retrospective cohort study evaluated data for individuals with Humana healthcare coverage 2013-2014. The study population included 435 recipients of prophylactic IVC filters, 4376 recipients of therapeutic filters, and two control groups, each matched to filter recipients. Patients were followed for up to 2 years. Post-index anticoagulant use, mortality, filter removal, device-related complications, and all-cause utilization. Adjusted regression analyses showed a positive association between filter placement and anticoagulant use at 3 months: odds ratio (ORs) 3.403 (95% CI 1.912-6.059), prophylactic; OR, 1.356 (95% CI 1.164-1.58), therapeutic. Filters were removed in 15.67% of prophylactic and 5.69% of therapeutic filter cases. Complication rates were higher with prophylactic procedures than with therapeutic procedures and typically exceeded 2% in the prophylactic group. Each form of filter placement was associated with increases in all-cause hospitalization (regression coefficient 0.295 [95% CI 0.093-0.498], prophylactic; 0.673 [95% CI 0.547-0.798], therapeutic) and readmissions (OR 2.444 [95% CI 1.298-4.602], prophylactic; 2.074 [95% CI 1.644-2.616], therapeutic). IVC filter placement in this managed care population was associated with increased use of anticoagulants and greater healthcare utilization compared to controls, low rates of retrieval, and notable rates of device-related complications, with effects especially pronounced in assessments of prophylactic filters. These findings underscore the need for appropriate use of IVC filters.

Impact of Physician Education and a Dedicated Inferior Vena Cava Filter Tracking System on Inferior Vena Cava Filter Use and Retrieval Rates Across a Large US Health Care Region

PURPOSE

To evaluate the effects of physician familiarity with current evidence and guidelines on inferior vena cava (IVC) filter use and the availability of IVC filter tracking infrastructure on retrieval rates.

MATERIALS AND METHODS

Fourteen continuing medical education-approved in-hospital grand rounds covering evidence-based review of the literature on IVC filter efficacy, patient-centered outcomes, guidelines for IVC filter indications, and complications were performed across a large United States (US) health care region serving more than 3.5 million members. A computer-based IVC filter tracking system was deployed simultaneously. IVC filter use, rates of attempted retrieval, and fulfillment of guidelines for IVC filter indications were retrospectively evaluated at each facility for 12 months before intervention (n = 427) and for 12 months after intervention (n = 347).

RESULTS

After education, IVC filter use decreased 18.7%, with a member enrollment-adjusted decrease of 22.2%, despite an increasing IVC filter use trend for 4 years. Reduction in IVC filter use at each facility strongly correlated with physician attendance at grand rounds (r = -0.69; P = .007). Rates of attempted retrieval increased from 38.9% to 54.0% (P = .0006), with similar rates of successful retrieval (82.3% before education and 85.8% after education on first attempt). Improvement in IVC filter retrieval attempts correlated with physician attendance at grand rounds (r = 0.51; P = .051). IVC filter dwell times at first retrieval attempt were similar (10.2 wk before and 10.8 wk after).

CONCLUSIONS

Physician education dramatically reduced IVC filter use across a large US health care region, and represents a learning opportunity for physicians who request and place them. Education and a novel tracking system improved rates of retrieval for IVC filter devices.

Changes in the rate of prophylactic vena cava filter insertion at a university hospital

OBJECTIVE

We previously demonstrated a high rate of prophylactic vena cava filter (VCF) insertion at our institution. We have since attempted to restrict the use of VCF to indications supported by Level-I evidence. This study was designed to evaluate the success of our interventions.

METHODS

All patients receiving VCF between 2007-2009 and 2012-2014 at a university hospital were reviewed. After assessing the use of VCF in the first period, a meeting was convened among the Departments of Radiology, Vascular Surgery and Trauma. Policy was implemented to avoid the inappropriate use of VCF. Data were prospectively collected in the second period to assess the effect of our intervention.

RESULTS

There were 156 VCF placed from 2012 to 2014. VCF was absolutely indicated in 84% of cases, relatively indicated in 9% and prophylactic in 7%. These data contrast our previous experience from 2007 to 2009. In the earlier series, a total of 244 filters were placed, in which 54% of patients had an absolute indication, 14% relative, and 32% prophylactic. There was a significant decrease in filters placed for pure prophylaxis: whereas 76 prophylactic filters were placed between 2007 and 2009, only 11 were placed between 2012 and 2014 (p < 0.0001). No significant differences existed for relatively indicated filters. The department of trauma and surgical critical care (TSCC) observed the most dramatic change in practice. TSCC placed 61 prophylactic VCF between 2007 and 2009 (57% of all filters placed by the department), and 4 prophylactic VCF from 2012 to 2014 (15% of filters placed by TSCC) (p < 0.0001).

CONCLUSION

These findings demonstrate a significant change in the attitudes regarding prophylactic VCF insertion between the two periods of study. Further investigations must be performed to assess changes in clinical outcomes that may result from the altered practice at our university.

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.