Inferior Vena Cava Filters in the Management of Venous Thromboembolism

doi:10.1016/j.amjmed.2007.07.015

The American Journal of Medicine

Volume 120, Issue 10, Supplement 2, October 2007, Pages S13-S17

https://doi.org/10.1016/j.amjmed.2007.07.015 Get rights and content

Abstract

Inferior vena cava (IVC) filters, both retrievable and permanent, are indicated for the prevention of pulmonary embolism (PE) in patients contraindicated for anticoagulant therapy, in those with anticoagulant therapy complications, and perhaps for those with recurrent PE despite therapeutic anticoagulation. Because of the lack of randomized controlled trials (only 1 has been published), clinicians have little evidence-based information to assist them in determining proper use of IVC filters. The introduction of retrievable filters and the ease of insertion have stimulated increased use of these devices without strong evidence or follow-up to assess either efficacy or longer-term clinical outcomes. Current evidence-based guidelines recommend IVC filter insertion only in patients with proven venous thromboembolism and an absolute contraindication for anticoagulation.

Section snippets

Recommended Use

Evidence-based guidelines from the American College of Chest Physicians (ACCP) recommend IVC filter placement only in those patients with proven VTE with a contraindication for anticoagulation, a complication of anticoagulation treatment, or recurrent VTE despite adequate anticoagulation treatment (Table 1).² Although not specifically included in the ACCP guidelines, the insertion of IVC filters in patients with recurrent PE complicated by pulmonary hypertension is also a widely recognized

Inferior vena cava filter efficacy and safety

Clinically meaningful data on the safety and efficacy of IVC filters are lacking. Only 1 randomized controlled trial has been conducted on IVC filter insertion in patients with VTE4, 6; all other published data are primarily from consecutive case series or retrospective case reports.10, 12, 13, 14, 15, 16 Overall, the studies in the literature failed to collect data in a consistent form to allow comparative assessment of the relative safety and effectiveness of the IVC filters.10, 12, 17 Most

Summary

IVC filter placement, whether permanent or retrievable, is recommended only in those patients with proven acute VTE and a current contraindication for anticoagulation, a complication of anticoagulation (bleeding), or (perhaps) recurrent PE despite adequate anticoagulation. Use of IVC filters for prevention of PE in patients who do not have an acute DVT has not been compared with pharmacologic prophylaxis, is likely to result in clinicians not using proven prophylaxis in such patients, and is

Conflict of interest

Mark A. Crowther, MD, MSc, reports no conflict of interest with the sponsor of this supplement article or products discussed in this article.

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IVC filter – assessing the readability and quality of patient information on the Internet
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The internet is an increasingly favorable source of information regarding health-related issues. The aim of this study is to apply appropriate evaluation tools to assess the evidence available online about inferior vena cava (IVC) filters with a focus on quality and readability.
A search was performed during December 2022 using three popular search engines, namely Google, Yahoo, and Bing. Websites were categorized into academic, physician, commercial, and unspecified websites according to their content. Information quality was determined using Journal of the American Medical Association (JAMA) criteria, the DISCERN scoring tool, and whether a Health On the Net Foundation certification (HONcode) seal was present. Readability was established using the Flesch Reading Ease Score (FRES) and Flesch-Kincaid Grade Level (FKGL). Statistical significance was accepted as P < .05.
In total, 110 websites were included in our study. The majority of websites were categorized as commercial (25%), followed by hospital (24%), academic (21%), unspecified (16%), and physician (14%). Average scores for all websites using JAMA and DISCERN were 1.93 ± 1.19 (median, 1.5; range, 0-4) and 45.20 ± 12.58 (median, 45.5; range, 21-75), respectively. The highest JAMA mean score of 3.07 ± 1.16 was allocated to physician websites, and the highest DISCERN mean score of 52.85 ± 12.66 was allocated to hospital websites. The HONcode seal appeared on two of the selected websites. Physician, hospital, and unspecified websites had a significantly higher mean JAMA score than academic and commercial websites (all with P < .001). Hospital websites had a significantly higher mean DISCERN score than academic (P = .007), commercial (P < .001), and unspecified websites (P = .017). Readability evaluation generated a mean FRES score of 51.57 ±12.04, which represented a 10th to 12th grade reading level and a mean FKGL score of 8.20 ± 1.70, which represented an 8th to 10th grade reading level. Only 12 sources were found to meet the ≤6th grade target reading level. No significant correlation was found between overall DISCERN score and overall FRES score.
The study results demonstrate that the quality of online information about IVC filters is suboptimal, and academic and commercial websites, in particular, must enhance their content quality regarding the use of IVC filters. Considering the discontinuation of the HONcode as a standardized quality assessment marker, it is recommended that a similar certification tool be developed and implemented for the accreditation of patient information online.
The utility of routine head CT for hemorrhage surveillance in post-craniotomy patients undergoing anticoagulation for venous thromboembolism
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Anticoagulation for postoperative venous thromboembolism (VTE) may infer a higher risk of intracranial hemorrhage. We treat patients with VTE using slowly titrating intravenous heparin drip without bolus. When PTT is greater than 60 s, a head CT is obtained to monitor for the development of a intracranial hemorrhage before transition to oral anticoagulation. We evaluated the utility of routine surveillance head CT to monitor for intracranial hemorrhage during anticoagulation. This is a case series of neurosurgical patients in an academic quaternary hospital who developed a VTE after cranial procedures between 2007 and 2017. Over 11,000 patients were screened for the study. Patients’ demographics data, surgical indication, PTT at the time of surveillance CT head, surveillance CT head findings, and patient’s clinical course were reviewed. A total of 83 patients were included. Three patients (3.6%) developed a new subclinical hemorrhage on CT head imaging while on heparin drip. Interval CT head showed stable hemorrhage in all patients. Heparin drip was stopped in two patients and they both progressed from DVT to pulmonary embolism: one patient died due to cardiac arrest, the other patient was transitioned to oral anticoagulation. In the third patient heparin drip was continued uneventfully and transitioned to oral anticoagulation with no further clinical sequalae. Surveillance CT while on heparin drip for VTE management detected subclinical intracranial hemorrhage in a small subset of patients. Patients whose anticoagulation was stopped had progression of VTE. Undertreatment of VTE in the presence of subclinical hemorrhage may lead to significant morbidity and mortality.
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Agreement regarding indications for vena cava filter (VCF) utilization in trauma patients has been in flux since the filter's introduction. As VCF technology and practice guidelines have evolved, the use of VCF in trauma patients has changed. This study examines variation in VCF placement among trauma centers.
A retrospective study was performed using data from the National Trauma Data Bank (2005-2014). Trauma centers were grouped according to whether they placed VCFs during the study period (VCF+/VCF−). A multivariable probit regression model was fit to predict the number of VCFs used among the VCF+ centers (the expected [E] number of VCF per center). The ratio of observed VCF placement (O) to expected VCFs (O:E) was computed and rank ordered to compare interfacility practice variation.
In total, 65,482 VCFs were placed by 448 centers. Twenty centers (4.3%) placed no VCFs. The greatest predictors of VCF placement were deep vein thrombosis, spinal cord paralysis, and major procedure. The strongest negative predictor of VCF placement was admission during the year 2014. Among the VCF+ centers, O:E varied by nearly 500%. One hundred fifty centers had an O:E greater than one. One hundred sixty-nine centers had an O:E less than one.
Substantial variation in practice is present in VCF placement. This variation cannot be explained only by the characteristics of the patients treated at these centers but could be also due to conflicting guidelines, changing evidence, decreasing reimbursement rates, or the culture of trauma centers.
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Inferior Vena Cava Filters
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Venous thromboembolism (VTE) encompasses a range of clinical presentations, with pulmonary embolism (PE) being the most significant due to its potential to cause fatal cardiopulmonary compromise. An estimated 25,000 to 200,000 fatalities per year are attributable to PE with rates of nonfatal PE thought to reach 630,000 cases per year.1, 2, 3
Although systemic anticoagulation remains the gold-standard therapy for all forms of VTE, inferior vena cava (IVC) interruption with an implantable filter is advocated in a small subgroup of patients in whom anticoagulation is contraindicated or ineffective. This chapter provides an overview on the use of IVC filters in select patient groups (including those utilized in trauma patients), highlighting different filter types, indications, techniques, and potential associated complications.

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Inferior Vena Cava Filters in the Management of Venous Thromboembolism

Abstract

Section snippets

Recommended Use

Inferior vena cava filter efficacy and safety

Summary

Conflict of interest

Lancet

Chest

Prog Cardiovasc Dis

Chest

Chest

Blood

J Am Coll Surg

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol

J Vasc Interv Radiol