Safety of Inferior Vena Cava Filter Retrieval in Anticoagulated Patients

Acute venous problems: Integrating medical, surgical, and interventional treatments

"Acute venous problems" refers to a group of disorders that affect the veins and result in sudden and severe symptoms. They can be classified based on the pathological triggering mechanisms, such as thrombosis and/or mechanical compression, and their consequences, including symptoms, signs, and complications. The management and therapeutic approach depend on the severity of the disease, the location, and the involvement of the vein segment. Although summarizing these conditions can be challenging, the objective of this narrative review was to provide an overview of the most common acute venous problems. This will include an exhaustive yet concise and practical description of each condition. The multidisciplinary approach remains one of the major advantages in dealing with these conditions, maximizing the results and the prevention of complications.

Role of Inferior Vena Cava Filter Retrieval in Patients on Chronic Anticoagulation Therapy

Purpose of review

Describe the role of inferior vena cava filter (IVCF) retrieval in patients on chronic anticoagulation given the overlap of these treatment options in the management of patients with venous thromboembolic disease.

Recent findings

Despite the increase in IVCF retrievals since the Food and Drug Administration safety communications in 2010 and 2014, retrieval rates remain low. Previous studies have shown that longer filter dwell times are associated with greater risk for filter complications and more difficulty with filter retrievals. Recent findings suggest that complications are more frequent in the first 30 days after placement.

Summary

The decision to retrieve an optional IVCF is individualized and requires diligent follow-up with consistent re-evaluation of the need for the indwelling IVCF, particularly in those on long-term anticoagulation therapy.

Optional Vena Cava Filters: What, Why, and When

Optional vena cava filters can used to provide either short-term or permanent protection from pulmonary embolism. These devices have recently become available for clinical use in the United States. However, there remains a paucity of data about these devices and their outcomes. This article reviews current and future devices, the rationale behind non-permanent caval filtration, and the generally accepted guidelines for their clinical application.

Caval filters in intensive care: a retrospective study

AIM

To evaluate the effectiveness of a caval vein filter (CVF) peri-implant monitoring protocol in order to reduce pulmonary embolism (PE) mortality and CVF-related morbidity.

BACKGROUND

The reduction in mortality from PE associated with the use of CVF is affected by the risk of increase in morbidity. Therefore, CVF implant is a challenging prophylactic or therapeutic option. Nowadays, we have many different devices whose rational use, by applying a strict peri-implant monitoring protocol, could be safe and effective.

MATERIALS AND METHODS

We retrospectively studied 62 patients of a general Intensive Care Unit (ICU) scheduled for definitive, temporary, or optional bedside CVF implant. A peri-implant monitoring protocol including a phlebocavography, an echo-Doppler examination, and coagulation tests was adopted.

RESULTS

In our study, no thromboembolic recurrence was registered. We implanted 48 retrievable and only 20 definitive CVFs. Endothelial adhesion (18%), residual clot (5%), cranial or caudal migration (6%), microbial colonization of the filter in the absence of clinical signs of infection (1%), caval thrombosis (1%), and pneumothorax (1%) were reported. Deep-vein thrombosis (DVT) was reported (8%) as early complication. All patients with DVT had a temporary or optional filter implanted. However, in our cohort, definitive CVFs were reserved only to 32% of patients and they were not associated with DVT as complication.

CONCLUSION

CVF significantly reduces iatrogenic PE without affecting mortality. Generally, ICU patients have a transitory thromboembolic risk, and so the temporary CVF has been proved to be a first-line option to our cohort. A careful monitoring may contribute to a satisfactory outcome in order to promote CVF implant as a safe prophylaxis option.

Inferior vena cava filtration in the management of venous thromboembolism: filtering the data

Venous thromboembolism (VTE) is a common cause of morbidity and mortality. This is especially true for hospitalized patients. Pulmonary embolism (PE) is the leading preventable cause of in-hospital mortality. The preferred method of both treatment and prophylaxis for VTE is anticoagulation. However, in a subset of patients, anticoagulation therapy is contraindicated or ineffective, and these patients often receive an inferior vena cava (IVC) filter. The sole purpose of an IVC filter is prevention of clinically significant PE. IVC filter usage has increased every year, most recently due to the availability of retrievable devices and a relaxation of thresholds for placement. Much of this recent growth has occurred in the trauma patient population given the high potential for VTE and frequent contraindication to anticoagulation. Retrievable filters, which strive to offer the benefits of permanent filters without time-sensitive complications, come with a new set of challenges including methods for filter follow-up and retrieval.

Improving the tracking and removal of retrievable inferior vena cava filters

Therapeutic and prophylactic inferior vena cava (IVC) filters should be placed based on currently accepted indications to prevent a fatal pulmonary embolism (PE). The protective effect of filters is offset by the potential for lower extremity deep venous thrombosis (DVT), caval thrombosis, and possible otherwise unnecessary life-long anticoagulation (AC). The duration of treatment for most DVTs or PEs is 3 to 6 months of AC/filter. Filters should be retrieved when duration of treatment for a DVT/PE has been met, the risk of a PE is no longer high, and/or there is no longer a contraindication to AC. An effective system that leads to improving the retrieval rate of filters must include education of the patient, a tracking system to minimize patient lost to follow-up, and dedicated personnel to oversee the process. If these goals are accomplished, interventionalists can help decrease the incidence of a fatal PE during the high-risk period, and also decrease the risk of a DVT or the use of otherwise unnecessary life-long AC in subsequent years. Currently, there is much room for improvement in the frequency that IVCF patients are systematically followed and filters are retrieved. The principles discussed in this report will be helpful in this process.

Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

BACKGROUND

Neonates and children differ from adults in physiology, pharmacologic responses to drugs, epidemiology, and long-term consequences of thrombosis. This guideline addresses optimal strategies for the management of thrombosis in neonates and children.

METHODS

The methods of this guideline follow those described in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.

RESULTS

We suggest that where possible, pediatric hematologists with experience in thromboembolism manage pediatric patients with thromboembolism (Grade 2C). When this is not possible, we suggest a combination of a neonatologist/pediatrician and adult hematologist supported by consultation with an experienced pediatric hematologist (Grade 2C). We suggest that therapeutic unfractionated heparin in children is titrated to achieve a target anti-Xa range of 0.35 to 0.7 units/mL or an activated partial thromboplastin time range that correlates to this anti-Xa range or to a protamine titration range of 0.2 to 0.4 units/mL (Grade 2C). For neonates and children receiving either daily or bid therapeutic low-molecular-weight heparin, we suggest that the drug be monitored to a target range of 0.5 to 1.0 units/mL in a sample taken 4 to 6 h after subcutaneous injection or, alternatively, 0.5 to 0.8 units/mL in a sample taken 2 to 6 h after subcutaneous injection (Grade 2C).

CONCLUSIONS

The evidence supporting most recommendations for antithrombotic therapy in neonates and children remains weak. Studies addressing appropriate drug target ranges and monitoring requirements are urgently required in addition to site- and clinical situation-specific thrombosis management strategies.

Vena cava interruption

Anticoagulation has been proven to be effective in preventing and treating deep vein thrombosis and pulmonary embolus. However, many critically ill patients are unable to receive anticoagulation or suffer recurrent venous thromboembolism despite adequate treatment. This article examines the use of vena cava filters in the critically ill. Indications for, techniques, and complications of vena cava filter insertion are reviewed. The importance of vena cava filters with the option to be retrieved and bedside insertion in the intensive care unit is emphasized.

Retrievable vena cava filters: a clinical review

Vena cava filters were developed as a method of preventing pulmonary embolism (PE) in patients with venous thromboembolism (VTE) at risk for bleeding from therapeutic anticoagulation. However, the long-term complications of filter placement, such as caval thrombosis, have mitigated some of the benefits, particularly in those patients with only a temporary contraindication to anticoagulation. Retrievable filters were designed to avoid the long-term risks of a permanent filter while still providing short-term protection against PE. As a result, their use has expanded from patients with known thrombosis to those without VTE who are at high risk for developing PE. In this review, we discuss the different types of retrievable filters, indications for their placement, complications that can occur during and after placement, and their use as prophylaxis in surgical patients. Although the use of retrievable filters in patients with known VTE is clear, further studies are needed to establish their prophylactic efficacy in the surgical patient. Until this evidence is available, we recommend that retrievable filters should be used only in patients with acute VTE who are at risk for recurrent thromboembolism and have a transient risk for bleeding.

Optional vena cava filters: indications, management, and results

BACKGROUND

When anticoagulation is contraindicated or ineffective, optional vena cava filters can be used to prevent pulmonary embolism. These devices can be removed within a defined period of time or can remain in the vena cava permanently.

METHODS

The status of optional vena cava filters was studied by a review of the relevant literature found in a selective Medline search from 2000 to 2008, including a Cochrane review and published guidelines.

RESULTS

Optional vena cava filter can be removed up to 20 weeks or even longer after insertion (depending on the filter model) in a small interventional radiological procedure if therapeutic anticoagulation has been achieved or the patient is no longer at risk for venous thromboembolism. Current studies show comparable results for optional filters and permanent filters, but there have not yet been any prospective studies comparing the two filter types.

CONCLUSIONS

Optional vena cava filters are an important addition to the management of venous thromboembolic disease. As only limited data are available to date, the use of optional filters should be considered on an individual case basis.

Optional vena cava filter with disengaging centering struts: retrieval in an animal model

An optional inferior vena cava (IVC) filter prototype was evaluated for safety and long-term retrievability as an initial feasibility study in an animal model. This filter has four centering struts that have the ability to disengage from the filtering cone portion, allowing the legs to slide out of endothelial growth. Retrieval of six filters in three animals was successful up to 27 weeks. There was no substantial filter tilt, migration, or IVC damage. In conclusion, this filter design may help overcome some of the shortcomings in currently approved optional IVC filters, including long-term retrieval difficulties, tilting, or migration.