Inferior vena cava filter use and patient safety: legacy or science?

Population-Based Disparities in Inferior Vena Cava Filter Procedures Among Medicare Enrollees With Acute Venous Thromboembolism

PURPOSE

Venous thromboembolism (VTE) imposes a significant clinical and financial burden on patients and society. Inferior vena cava filters (IVCFs) are considered for patients with absolute contraindications or failures of anticoagulation. However, studies examining the population-based disparities of IVCF placement and retrieval are limited. The association between patient and clinical characteristics in the likelihood of and time to IVCF placement and retrievals in a nationally representative cohort was examined.

METHODS

Medicare patients aged ≥65 years with index VTE claims between 2015 and 2018 were followed through 2019 to identify IVCF placements and retrievals. Rates were compared using survival analysis methods.

RESULTS

Of the 516,978 patients with VTE diagnoses, 5,864 (1.1%) had IVCFs placed, and 1,884 (32.1%) of those underwent retrieval procedures. Placement and retrieval rates varied significantly by demographics, comorbidity burden, and geographic region. From Cox regression, older age (hazard ratio [HR], 1.26; P < .0001), higher baseline comorbidity (Elixhauser) score (HR, 1.07; P < .0001), and outpatient (vs inpatient) site of VTE service (HR, 2.11; P < .0001) were associated with increased frequency of IVCF placement. The rate of retrieval was significantly lower for men (HR, 0.83; P = .0393), patients with higher comorbidity scores (HR, 0.95; P = .0037), and those with outpatient (vs inpatient) VTE sites of service (HR, 0.77; P = .0173). Neither facility- nor county-level characteristics were significantly associated with placements or retrievals.

CONCLUSIONS

This large cohort of Medicare beneficiaries with newly diagnosed VTE demonstrated inequities in IVCF placement and retrieval.

Risk factors associated with complex inferior vena cava filter retrievals and complications: A 7-year retrieval database analysis and the impact on retrieval rates at an Australian tertiary centre

INTRODUCTION

Venous thromboembolism (VTE) affects approximately 17,000 Australians annually. While anticoagulation is the mainstay of treatment, inferior vena cava filters (IVCFs) are used in patients where this is contraindicated. The primary aim was to identify risk factors for complex retrievals and IVCF-related complications following the establishment of a database at a single tertiary centre. The secondary aim was to evaluate the IVCF retrieval rate and patients lost to follow-up.

METHODS

A retrospective study at a single tertiary centre was conducted on IVCFs inserted from 2012 to 2018. Logistic regression models were used to evaluate potential risk factors for filter-related complications and complex retrievals.

RESULTS

In total, 402 patients had an IVCF inserted. Of these, 308 patients (77%) had a retrieval attempted, 10 (3%) of which required more than one retrieval attempt (complex retrieval). Factors associated with filter-related complications included dwell time (OR 1.02, 95% CI: 1.01-1.04) and select indications for insertion, namely VTE requiring thrombolysis/thrombectomy (OR 2.29, 95% CI: 1.02-5.16) and iliocaval/free-floating iliofemoral DVT without thrombectomy/thrombolysis (OR 5.89, 95% CI: 1.53-22.71). After mutual adjustment for all variables, only dwell time remained a significant factor for filter-related complications (adjusted OR 1.03, 95% CI: 1.01-1.05) and complex retrieval (AOR 1.05, 95% CI: 1.02-1.08). The annual retrieval rate increased from 73% (2012) to 83% (2018), with an overall retrieval rate of 75%.

CONCLUSION

Dwell time is a potential risk factor for filter-related complications and complex retrievals. The annual IVCF retrieval rate was 75% since an Interventional Radiology-led database was established.

Retrievable inferior vena cava filter to prevent pulmonary embolism in patients with fractures and deep venous thrombosis of lower extremities: a single-center experience

Objective

To evaluate the effectiveness of inserting a retrievable inferior vena cava filter (IVCF) to prevent pulmonary embolism (PE) in patients with bone fractures and acute deep venous thrombosis (DVT) before major orthopedic surgery.

Methods

Clinical data of patients with fractures and acute DVT who underwent IVCF insertion were analyzed. The patients were divided into above-knee DVT (AKDVT), popliteal vein thrombosis (PVT), and below-knee DVT (BKDVT) groups.

Results

An IVCF was successfully implanted in 964 patients, among whom 929 were followed up (335, 470, and 124 in AKDVT, PVT, and BKDVT groups, respectively). There was no significant difference in the incidence of filter thrombosis among the groups (11.04%, 11.70%, and 8.06%, respectively). No symptomatic PE occurred during follow-up. The mean filter indwelling time was 18.4 ± 4.3 days, and the total filter removal rate was 76.87%. There was no significant difference in the rate of filter implantation, retrieval, complications, or mortality among the groups.

Conclusions

Retrievable filters can effectively prevent PE before orthopedic surgery in patients with fractures and acute DVT of the lower limbs. AKDVT more readily forms a ≥1-cm thrombus in the IVCF than does BKDVT, and PVT more readily forms a <1-cm thrombus than does AKDVT.

Occult deep vein thrombosis in lower limb trauma requiring microsurgical reconstruction-A retrospective cohort study

BACKGROUND

Delayed microsurgical reconstruction of lower extremity trauma is associated with increased risk of free flap loss, frequently following failure of the venous anastomosis. This has been attributed to thrombocytosis, but occult deep vein thrombosis (DVT) may contribute to this risk.

METHODS

We performed a retrospective cohort study of consecutive patients presenting to our service with lower limb injuries requiring microsurgical reconstruction between 2013 and 2017, and examined venous Duplex ultrasound reports, operation notes and free flap outcomes.

RESULTS

A total of 165 free flap reconstructions for lower limb trauma were performed for 162 limbs in 158 patients. Seventy-two limbs (44.4%) underwent preoperative venous Duplex ultrasound identifying occult DVT in 14 (19.4%) patients. Occult DVT was identified intraoperatively in a further 7 cases. Bilateral lower limb injuries (p = 0.0002), the level of injury at or above the knee (p < 0.0001), multiple levels of injury within the affected limb (p = 0.0008) and critical care admission (p = 0.0008) were significant risk factors for DVT. All 7 cases of DVT diagnosed intraoperatively prompted a change in the surgical plan for the recipient vein; however, preoperative identification of occult DVT also lead to an adjustment in the microsurgical plan in 4 out of 14 cases.

CONCLUSIONS

Prevalence of DVT is high in severe lower limb injury, potentially increasing the risk of free flap loss. Preoperative identification of occult DVT may influence the microsurgical plan and mitigate for this risk.

Inferior Vena Cava Filter Evaluation and Management for the Diagnostic Radiologist: A Comprehensive Review Including Inferior Vena Cava Filter-Related Complications and PRESERVE Trial Filters

Inferior vena cava filters are commonly encountered devices on diagnostic imaging that were highlighted in a 2010 Food and Drug Administration safety advisory regarding their complications from long-term implantation. The Predicting the Safety and Effectiveness of Inferior Vena Cava Filters (PRESERVE) trial is an ongoing after-market study investigating the safety and utility of commonly utilized filters in practice today. While most of these filters are safe, prompt recognition and management of any filter-associated complication is imperative to prevent or reduce the morbidity and mortality associated with them. This review is aimed at discussing the appropriate utilization and placement of inferior vena cava filters in addition to the recognition of filter-associated complications on cross-sectional imaging. An overview of the PRESRVE trial filters is also provided to understand each filter's propensity for specific complications.