Indications, Complications, and Management of Inferior Vena Cava Filters: The Experience in 952 Patients at an Academic Hospital With a Level I Trauma Center.

JAMA Internal Medicine (Impact Factor: 13.12). 03/2013; 173(7):1-5. DOI: 10.1001/jamainternmed.2013.343
Source: PubMed


IMPORTANCE Retrievable inferior vena cava (IVC) filters were designed to provide temporary protection from pulmonary embolism, sparing patients from long-term complications of permanent filters. However, many retrievable IVC filters are left in place indefinitely. OBJECTIVES To review the medical records of patients with IVC filters to determine patient demographics and date of and indication for IVC filter placement, as well as complications, follow-up data, date of IVC filter retrieval, and use of anticoagulant therapy. DESIGN AND SETTING A retrospective review of IVC filter use between August 1, 2003, and February 28, 2011, was conducted at Boston Medical Center, a tertiary referral center with the largest trauma center in New England. PARTICIPANTS In total, 978 patients. Twenty six patients were excluded from the study because of incomplete medical records. INTERVENTION Placement of retrievable IVC filter. MAIN OUTCOME MEASURES In total, 952 medical records were included in the analysis. RESULTS Of 679 retrievable IVC filters that were placed, 58 (8.5%) were successfully removed. Unsuccessful retrieval attempts were made in 13 patients (18.3% of attempts). Seventy-four venous thrombotic events (7.8% of 952 patients included in the study) occurred after IVC filter placement, including 25 pulmonary emboli, all of which occurred with the IVC filter in place. Forty-eight percent of venous thrombotic events were in patients without venous thromboembolism at the time of IVC filter placement, and 89.4% occurred in patients not receiving anticoagulants. Many IVC filters placed after trauma were inserted when the highest bleeding risk had subsided, and anticoagulant therapy may have been appropriate. While many of these filters were placed because of a perceived contraindication to anticoagulants, 237 patients (24.9%) were discharged on a regimen of anticoagulant therapy. CONCLUSION AND RELEVANCE Our research suggests that the use of IVC filters for prophylaxis and treatment of venous thrombotic events, combined with a low retrieval rate and inconsistent use of anticoagulant therapy, results in suboptimal outcomes due to high rates of venous thromboembolism.

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    • "Despite recommendations against the use of inferior vena cava filters for venous thromboembolism events and prophylaxis [14,36,39] and clear evidence that they cause thrombosis, the filters continue to be widely used for prevention. Although we did not examine removal rates in this audit, it is also concerning in real-world practice that less than 20% of retrievable filters are actually removed [40]. "
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    ABSTRACT: Heparin is safe and prevents venous thromboembolism in critical illness. We aimed to determine the guideline concordance for thromboprophylaxis in critically ill patients and its predictors, and to analyze factors associated with the use of low molecular weight heparin (LMWH), as it may be associated with a lower risk of pulmonary embolism and heparin-induced thrombocytopenia without an increased bleeding risk. We performed a retrospective audit in 28 North American intensive care units (ICUs), including all consecutive medical-surgical patients admitted in November 2011. We documented ICU thromboprophylaxis and reasons for omission. Guideline concordance was determined by adding days in which patients without contraindications received thromboprophylaxis to days in which patients with contraindications did not receive it, divided by the total number of patient-days. We used multilevel logistic regression including time-varying, center and patient-level covariates to determine the predictors of guideline concordance and use of LMWH. We enrolled 1,935 patients (62.3 +/- 16.7 years, Acute Physiology and Chronic Health Evaluation [APACHE] II score 19.1 +/- 8.3). Patients received thromboprophylaxis with unfractionated heparin (UFH) (54.0%) or LMWH (27.6%). Guideline concordance occurred for 95.5% patient-days and was more likely in patients who were sicker (odds ratio (OR) 1.49, 95% confidence interval (CI) 1.17, 1.75 per 10-point increase in APACHE II), heavier (OR 1.32, 95%CI 1.05, 1.65 per 10-m/kg2 increase in body mass index), had cancer (OR 3.22, 95%CI 1.81, 5.72), previous venous thromboembolism (OR 3.94, 95%CI 1.46,10.66), and received mechanical ventilation (OR 1.83, 95%CI 1.32,2.52). Reasons for not receiving thromboprophylaxis were high risk of bleeding (44.5%), current bleeding (16.3%), no reason (12.9%), recent or upcoming invasive procedure (10.2%), nighttime admission or discharge (9.7%), and life-support limitation (6.9%). LMWH was less often administered to sicker patients (OR 0.65, 95%CI 0.48, 0.89 per 10-point increase in APACHE II), surgical patients (OR 0.41, 95%CI 0.24, 0.72), those receiving vasoactive drugs (OR 0.47, 95%CI 0.35, 0.64) or renal replacement therapy (OR 0.10, 95%CI 0.05, 0.23). Guideline concordance for thromboprophylaxis was high, but LMWH was less commonly used, especially in patients who were sicker, had surgery, or received vasopressors or renal replacement therapy, representing a potential quality improvement target.
    Critical care (London, England) 04/2014; 18(2):R82. DOI:10.1186/cc13844 · 4.48 Impact Factor
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    • "Suprarenal IVC filters may be suitable for patients with NS given a greater incidence of renal vein thrombosis in this group [67]. It is important to keep in mind that IVC filters are associated with some complications, though being found in a small number of patients [68–70]. The list of potential complications of IVC filter insertion includes thrombotic complications such as thrombosis at the site of insertion, local complications such as hematoma formation at the insertion site, and filter associated complications such as filter migration, filter embolization, and erosion of the IVC. "
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    ABSTRACT: Patients with nephrotic syndrome are at an increased risk for thrombotic events; deep venous thrombosis, renal vein thrombosis, and pulmonary embolism are quite common in patients with nephrotic syndrome. It is important to note that nephrotic syndrome secondary to membranous nephropathy may impose a greater thrombotic risk for unclear reasons. Increased platelet activation, enhanced red blood cell aggregation, and an imbalance between procoagulant and anticoagulant factors are thought to underlie the excessive thrombotic risk in patients with nephrotic syndrome. The current scientific literature suggests that patients with low serum albumin levels and membranous nephropathy may benefit from primary prophylactic anticoagulation. A thorough approach which includes accounting for all additional thrombotic risk factors is, therefore, essential. Patient counseling regarding the pros and cons of anticoagulation is of paramount importance. Future prospective randomized studies should address the question regarding the utility of primary thromboprophylaxis in patients with nephrotic syndrome.
    International Journal of Nephrology 04/2014; 2014:916760. DOI:10.1155/2014/916760
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    • "The IVCF use rate gradually increased each year from 2005, when the survey began, until 2008 and then began to decrease in 2009, an interesting trend. Non-permanent IVCFs rapidly achieved widespread use in Japan due to their simplicity, but their reported complications included migration, fracture, infection, and perforation of the venous wall [8] [9] [10] [11]. Warnings were issued in August 2010 by the US Federal Drug Administration and in December 2010 by the Japanese Ministry of Health, Labor and Welfare that indications for their insertion should be stringently evaluated and that they should be retrieved as often as possible, with long-term insertion to be avoided. "
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    ABSTRACT: To elucidate the current status of use of inferior vena cava filters (IVCFs) in cases of pulmonary embolism at institutions belonging to the Tokyo CCU Network. We conducted a retrospective investigation of 832 consecutive cases of pulmonary embolism reported on survey forms to the Tokyo CCU Network between 2005 and 2010. Of 832 cases of pulmonary embolism, IVCFs were used in 338 (40.6%) and not used in 415 (49.9%). Their use was unclear in 79 (9.5%) cases. The use rate gradually increased each year from 2005 until 2008 but decreased from 2009 onward. Moreover, 68.9% of the IVCFs used in cases were non-permanent types. In terms of pulmonary embolism severity, the rate of use was 37.2% in non-massive cases, 49.4% in sub-massive cases, 46.9% in massive cases, and 31.9% in collapse cases. Thirty-day mortality in cases of collapse in which IVCFs were not used was extremely high at 75.8%, suggesting that in many cases, rapid deterioration may occur with insufficient time for IVCF insertion. The differences in IVCF usage rate among institutions were large in the range of 12.5-90% from 2005 to 2008, which slightly declined to the range of 25.0-72.2% from 2009 to 2010. We elucidated the current IVCF use status in cases of pulmonary embolism at institutions belonging to the Tokyo CCU Network. Since the status of use differed among institutions, future studies of effective methods of use are required.
    Journal of Cardiology 11/2013; 63(5). DOI:10.1016/j.jjcc.2013.10.003 · 2.78 Impact Factor
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