The Use of Inferior Vena Caval Filters Prior to Major Surgery in Women With Gynaecological Cancer

Abstract

To evaluate the use of inferior vena caval filters (IVCF) prior to surgery in women with gynaecological cancer and venous thromboembolism (VTE).
Retrospective review of medical notes and electronic records.
Gynaecological oncology cancer centre.
Women with gynaecological cancer and VTE requiring major surgery.
A retrospective analysis was performed on women treated for gynaecological malignancies who had had VTE, and an IVCF placed before major abdominal surgery were reviewed during the period 1996-2006.
Safety of IVCF placement and retrieval, peri-operative morbidity and incidence of further VTE.
The median age was 66 years (range 30-84 years). Of the 39 women, 35 (90%) women had a primary cancer diagnosis and 4 (10%) had recurrent disease. Twenty-two women had ovarian cancer, 2 had borderline ovarian tumours, 9 had uterine cancer, 5 had cervical cancer and 1 woman had concurrent ovarian and endometrial cancers. The recurrent cancers were two cervical, one ovarian and one uterine. The IVCF used were either of the permanent or retrievable type, the latter being more commonly used in younger women. All filters were placed without morbidity, and none of these women who then underwent major abdominal surgery had VTE complications. In 43.6% of women (n = 17), surgery was performed within 6 weeks of the diagnosis of VTE. All women received perioperative anticoagulation in the form of subcutaneous low-molecular-weight heparin. Three retrievable filters were uneventfully removed postoperatively. No filter-related problems occurred.
Surgery in women with gynaecological cancer and life-threatening VTE is feasible with preoperative IVCF placement. The use of IVCF was safe with no worsening of the VTE, and without surgical or filter-related problems. A short interval between the diagnosis of VTE and surgery was not associated with increased perioperative morbidity.

Full text

The use of inferior vena caval filters prior to major
surgery in women with gynaecological cancer
T Adib,aA Belli,bJ McCall,cTEJ Ind,aJE Bridges,aJH Shepherd,aDPJ Bartona,d
aDepartment of Gynaecological Oncology, The Royal Marsden Hospital, London, UK bDepartment of Interventional Radiology,
St George’s Hospital, London, UK cDepartment of Interventional Radiology, Chelsea and Westminster Hospital and Royal Marsden Hospital,
London, UK dDepartment of Gynaecological Oncology, St George’s Hospital, London, UK
Correspondence: Mr DPJ Barton, Division of Gynaecological Oncology, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK.
Email dbarton@sgul.ac.uk
Accepted 4 March 2008.
Objective To evaluate the use of inferior vena caval filters (IVCF)
prior to surgery in women with gynaecological cancer and venous
thromboembolism (VTE).
Design Retrospective review of medical notes and electronic
records.
Setting Gynaecological oncology cancer centre.
Population Women with gynaecological cancer and VTE requiring
major surgery.
Methods A retrospective analysis was performed on women
treated for gynaecological malignancies who had had VTE, and an
IVCF placed before major abdominal surgery were reviewed during
the period 1996–2006.
Main outcome measures Safety of IVCF placement and retrieval,
peri-operative morbidity and incidence of further VTE.
Results The median age was 66 years (range 30–84 years). Of the
39 women, 35 (90%) women had a primary cancer diagnosis and 4
(10%) had recurrent disease. Twenty-two women had ovarian
cancer, 2 had borderline ovarian tumours, 9 had uterine cancer, 5
had cervical cancer and 1 woman had concurrent ovarian and
endometrial cancers. The recurrent cancers were two cervical, one
ovarian and one uterine. The IVCF used were either of the
permanent or retrievable type, the latter being more commonly
used in younger women. All filters were placed without morbidity,
and none of these women who then underwent major abdominal
surgery had VTE complications. In 43.6% of women (n= 17),
surgery was performed within 6 weeks of the diagnosis of VTE.
All women received perioperative anticoagulation in the form of
subcutaneous low-molecular-weight heparin. Three retrievable
filters were uneventfully removed postoperatively. No filter-related
problems occurred.
Conclusions Surgery in women with gynaecological cancer and
life-threatening VTE is feasible with preoperative IVCF placement.
The use of IVCF was safe with no worsening of the VTE, and
without surgical or filter-related problems. A short interval
between the diagnosis of VTE and surgery was not associated with
increased perioperative morbidity.
Keywords Gynaecological cancer, surgery, vena caval filters,
venous thromboembolism.
Please cite this paper as: Adib T, Belli A, McCall J, Ind T, Bridges J, Shepherd J, Barton D. The use of inferior vena caval filters prior to major surgery in women
with gynaecological cancer. BJOG 2008;115:902–907.
Introduction
Women with cancer have long been known to be at increased
risk of developing venous thromboembolism (VTE)1,2 and of
having recurrent thromboembolic events.3Benign gynaeco-
logical masses can also predispose to VTE, although this is
a much rarer event.4The standardised incidence ratio for ova-
rian cancer up to 2 years following a diagnosis of idiopathic
venous thrombosis is more than 5.0,5,6 with 40% of women
having distant metastases at the time of cancer diagnosis.7
VTE affects up to 15% of women with all cancer types8and
is the second leading cause of death in this group.9Survival is
reduced when VTE and malignant disease coexist,10 especially
in the presence of metastatic disease.11 The incidence of post-
operative VTE in women undergoing gynaecological oncolog-
ical surgery was 2.0% in the @RISTOS study12 and VTE
accounted for almost half of all postoperative deaths in these
women. This prospective observational trial identified five
risk factors for VTE: previous VTE, advanced stage cancer,
age above 60 years, anaesthesia (surgery) lasting longer than 2
hours and bed rest for more than 3 days.
Given the high incidence of perioperative VTE in women
with gynaecological cancer, surgical management of these
women presents a potentially challenging situation. Indeed,
902 ª2008 The Authors Journal compilation ªRCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
DOI: 10.1111/j.1471-0528.2008.01736.x
www.blackwellpublishing.com/bjog Gynaecological oncology

the accepted view is that surgery in women with known VTE
should be delayed for at least 4 weeks after the diagnosis of
VTE to minimise the risk of further VTE.13 However, in
women with a cancer diagnosis, such a delay may not be appro-
priate. Maintaining full preoperative anticoagulation of these
women increases the risk of perioperative haemorrhage,
whereas stopping anticoagulation will increase the risk of post-
operative pulmonary embolism and recurrent VTE. Providing
prophylaxis through pharmacological manipulation, use of
compression stocking(s) and sequential compression devices
perioperatively is the standard of care maintained in women
with VTE.14 The function of inferior vena caval filters (IVCF) is
to prevent pelvic and lower limb thrombi from passingthrough
the inferior vena cava (IVC) to the pulmonary arteries. Filters
are usually placed in the vena cava below the level of the renal
veins to prevent renal vein thrombosis as well as pulmonary
embolism. In cases where an existing clot in the IVC extends
above the level of the renal veins, the filter is placed in the
suprarenal vena cava. IVCF can be inserted through the femoral
vein if both pelvic veins and IVC are free of thrombus or
through the transjugular route. A significant number of women
with gynaecological cancer will require chemotherapy, and as
chemotherapeutic drugs have been found to have a separate
thrombogenic tendency,15,16 these women would benefit from
an IVCF during medical therapy. This retrospective observa-
tional study was designed to investigate whether the use of
IVCF was safe and effective in the management of women with
gynaecological cancers scheduled for majorsurgical procedures.
Methods
Between 1996 and 2006, an IVCF was placed in 39 women
with a primary presentation of VTE who were subsequently
found to have or were known to have a gynaecological malig-
nancy. Case records were reviewed and data retrieved relating
to presentation, cancer diagnosis, type of IVCF used and
morbidity associated with IVCF insertion and removal, and
surgical outcome.
Women scheduled for IVCF placement were appropriately
counselled, consented and had baseline blood investigations
performed including a coagulation profile. All filters were
placed by or supervised by a consultant interventional radi-
ologist (J.Mc.C. or A.B.) by the transjugular route. Generally,
permanent filters were placed in older women and retrievable
filters were placed in younger women or those who had a good
performance status. Retrievable filters are designed to be
retrieved but can also be left in situ. Before the filter was
inserted, women on oral anticoagulation were placed on
intravenous anticoagulation therapy. Anticoagulant therapy
was stopped 4 hours prior to the procedure and recom-
menced 1 hour after IVCF insertion at the therapeutic dose
followed by the prophylactic dose the evening before surgery.
During the procedure, an ultrasound scan was performed to
assess the extent of thrombosis and to exclude free-floating
thrombi in the pelvic veins or IVC.
Within 24–72 hours of filter placement, women underwent
open abdominal surgery under prophylactic anticoagulant
cover (low-molecular-weight heparin [LMWH] given the
night before surgery) with intermittent pneumatic compres-
sion of the contralateral leg during surgery. The affected lower
limb did not have any compressions device fitted. After sur-
gery, routine prophylactic measures were adopted to prevent
further VTE development; including sequential compression
devices, early ambulation and LWMH. At the time of place-
ment of these filters, the majority of retrievable IVCF were
removed within 10 days of placement to prevent difficult
retrieval secondary to endothelialisation of the filter causing
the hooks to become anchored. Therefore, insertion took
place 24–72 hours before surgery to maximise the postoper-
ative period when the filter was in situ. Postoperative anti-
coagulation was stopped 4 hours before planned filter
retrieval. A coagulation profile was checked in addition to
a full blood count. The position of the filter and of any adja-
cent thrombus was determined by radiological studies. A filter
with thrombus within it cannot be safely retrieved, but the
use of thrombolytic drugs delivered to the site of the filter
may be successful in lysing thrombus to allow safe retrieval17
(Figure 1). After filter retrieval, full anticoagulant therapy was
recommenced. Retrievable filters are now available that allow
an open-ended period between insertion and retrieval.
Results
Between 1996 and 2006, 39 women were identified in the
gynaecological oncology service with a diagnosis of gynaeco-
logical cancer, and VTE who required an IVCF before planned
major abdominal surgery. Thirty-five women (90%) had a
primary cancer diagnosis and 4 (10%) had recurrent disease.
Twenty-two women had ovarian cancer (56%), 2 had border-
line ovarian tumours (5%), 9 had uterine cancer (23%), 5 had
cervical cancer (13%) and 1 woman had concurrent ovarian
and endometrial cancers (Table 1). The recurrent cancers con-
sisted of two cervical, one ovarian and one uterine. Follow up
was between 1 month and 8 years. Patient deaths were due to
progression or metastatic disease; no deaths occurred due to
filter-related problems. Seventeen of the 39 women (43.6%)
underwent surgery within 6 weeks of the diagnosis of VTE, with
no increase in morbidity compared with those who underwent
surgery more than 6 weeks from the diagnosis of VTE (Table 2).
This latter group of women included those treated with neo-
adjuvant chemotherapy and those with recurrent cancer.
The indications for filter insertion were a history of either
pelvic/leg deep vein thrombosis (DVT) and/or pulmonary em-
bolism. Twenty-nine women had a femoral or iliac DVT, 2
had concurrent DVT and pulmonary embolism, 3 had DVT
and developed pulmonary embolisms despite anticoagulant
The use of IVC filters before surgery in women with gynaecological cancer
ª2008 The Authors Journal compilation ªRCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 903

Table 1. Clinical details of 39 women with gynaecological cancer and VTE who underwent IVCF placement before radical abdominal surgery
Case
number
Age
(years)
First
presentation
Thrombosis
type
Filter Histology Outcome Cause of death
1 53 Iliac DVT and
pulmonary
embolism
Retrievable Stage IC ovarian mucinous
cystadenocarcinoma and
stage IB endometrial cancer
a/w 46 months
2 67 Yes Iliac DVT Permanent Stage IIIC ovarian serous
cystadenocarcinoma
a/w 36 months
3 30 Iliac DVT and
pulmonary
embolism
Retrievable Stage IC ovarian clear cell
adenocarcinoma
a/w 62 months
4 50 Iliac DVT Permanent Stage IIIC endometrial cancer Died 9 months Disease progression
5 78 Yes Iliac DVT Permanent Stage IIIC ovarian serous
cystadenocarcinoma
Died 11 days
post-op
Multi-organ failure
6 55 Yes Iliac DVT and
pulmonary
embolism
Permanent Stage IIIC ovarian mucinous
cystadenocarcinoma
a/w 22 months
7 54 Iliac DVT Permanent Stage IIIC ovarian serous
cystadenocarcinoma
a/w 19 months
8 66 Pulmonary
embolism
Permanent Granulosa cell tumour a/w 47 months
9 78 Yes Iliac DVT Permanent Stage IIIC ovarian papillary
serous cystadenocarcinoma
Died 37 months Metastatic disease
10 70 Iliac DVT Permanent Borderline ovarian tumour a/w 62 months
11 51 Iliac DVT Permanent Stage IIIB endometrial cancer Died 10 months Disease progression
12 84 Iliac DVT Permanent Stage IV endometrial cancer Died 4 months Disease progression
13 65 Multiple
pulmonary
embolisms
Permanent Stage IIIB endometrial cancer Died 7 months Disease progression
14 67 Yes Iliac DVT Permanent Stage IIIC ovarian serous
cystadenocarcinoma
Died 46 months Metastatic disease
15 39 Iliac DVT and
pulmonary
embolism
Permanent Stage IIB cervical cancer a/w 15 months
16 54 Iliac DVT Permanent Stage IIIC ovarian papillary
serous cystadenocarcinoma
Died 50 months Metastatic disease
17 55 Multiple
pulmonary
embolisms
Permanent Stage IIIB endometrial cancer Died 5 months Disease progression
18 73 Yes Iliac DVT Permanent Stage IIIC ovarian papillary
serous cystadenocarcinoma
a/w 34 months
19 67 Iliac DVT Permanent Stage IIIC ovarian papillary
serous cystadenocarcinoma
a/w 21 months
20 47 Yes Iliac DVT Permanent Stage IIIC ovarian clear cell
cystadenocarcinoma
Died 14 months Disease progression
21 40 Iliac DVT Permanent Recurrent cervical cancer Died 3 months Disease progression
22 68 Multiple
pulmonary
embolisms
Permanent Immature teratoma Died 2 months Metastatic disease
23 81 Iliac DVT Permanent Borderline ovarian tumour a/w 23 months
24 59 Iliac DVT Permanent Stage IB endometrial cancer Died 8 years Metastatic disease
25 70 Iliac DVT Permanent Stage IIIB cervical cancer Died 6 months Disease progression
26 57 Femoral DVT Permanent Stage IV ovarian serous
cystadenocarcinoma
Died 1 month Disease progression
27 72 Iliac DVT Permanent Stage IV ovarian serous
cystadenocarcinoma
Died 1 month Neutropenic sepsis
28 70 Iliac DVT Permanent Stage IIIC ovarian papillary
serous cystadenocarcinoma
a/w 13 months
(continued)
Adib et al.
904 ª2008 The Authors Journal compilation ªRCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology

therapy prior to filter insertion, 2 had pulmonary embolisms
at presentation and 3 developed multiple pulmonary embo-
lisms on anticoagulant treatment. In nine women, the throm-
bosis was the presenting symptom. In total, six women
developed recurrent thrombotic events despite anticoagulant
therapy. No progression of thromboembolic disease occurred
postoperatively in women in whom the filter had been suc-
cessfully placed, based on repeat imaging. Although the num-
ber of cases in this series is small, our findings suggest that
major surgery within the first few weeks of the diagnosis of
VTE did not increase surgical morbidity in women with
gynaecological cancer.
Three women had the IVCF removed between days 8 and
10 postoperatively; two women on the first attempt and the
third woman on the second retrieval attempt; the difficulty
was due to migration of the filter inferiorly to the level of the
confluence of the iliac vein. The filter was removed on the
second attempt using an 11F sheath introduced through the
right common femoral vein.
Discussion
The risk of VTE is higher in women with cancer, although it
has also been reported in benign gynaecological conditions. A
DVT or pulmonary embolism may be the first manifestation
of a gynaecological cancer,7and it has been shown that for all
cancers, women who present with an idiopathic VTE have
a six-fold increase in risk of developing cancer, with the high-
est incidence being within the first 6 months18 and of these
40% have metastatic disease.10 Certain cancers are associated
with a worse outcome if there is a concurrent VTE,10 espe-
cially where there is metastatic disease.10,11 Ovarian cancer is
one of the most common cancers in women associated with
thrombotic complications,19 and in one observational study
looking at a number of solid tumours, 56% of women had
ovarian cancer. It has been estimated that more than 16% of
women with ovarian cancer will develop VTE, especially in
those with advanced disease.20 These women will have other
factors that contribute to thrombotic risk and progression of
VTE, including advanced age, immobility, obesity and other
medical co-morbidity. These women will require radical ovar-
ian debulking surgery that carries an independent risk for
thrombosis21 and chemotherapy, also linked to VTE.22 Recur-
rent VTE has been linked to development of metastases and
episodes of neutropenia,23 both of which are common in
women with advanced stage ovarian cancer who typically
relapse and receive further cycles of chemotherapy. Although
the accepted view is that surgery in women with known
VTE should be delayed for at least 4 weeks because of the in-
creased risk of VTE in the perioperative period,13 we found no
Table 1. (Continued)
Case
number
Age
(years)
First
presentation
Thrombosis
type
Filter Histology Outcome Cause of death
29 40 Iliac DVT and
pulmonary
embolism
Retrievable Stage IA endometrioid ovarian
cystadenocarcinoma
a/w 10 months
30 67 Popliteal DVT Permanent Uterine sarcoma Died 3 months Disease progression
31 70 Popliteal DVT Permanent Stage IIIC ovarian serous
cystadenocarcinoma
a/w 10 months
32 53 IVC DVT Permanent Uterine sarcoma a/w 8 months
33 61 Pulmonary
embolism
Permanent Stage IIIC ovarian papillary
serous cystadenocarcinoma
a/w 5 months
34 56 Iliac DVT Retrievable Cervical spindle cell sarcoma a/w 5 months
35 69 Iliac DVT Retrievable Stage IIIB cervical cancer a/w 5 months
36 72 Iliac DVT Permanent Stage IIIC ovarian papillary
serous cystadenocarcinoma
a/w 4 months
37 74 Yes Iliac DVT Permanent Stage IIIC ovarian clear
cell carcinoma
a/w 3 months
38 68 Iliac DVT Permanent Stage IC endometrial cancer a/w 3 months
39 52 Yes Femoral DVT Retrievable Stage IIIC ovarian papillary
serous cystadenocarcinoma
a/w 4 months
a/w, alive and well; post-op, post-operative.
Table 2. Interval between diagnosis of VTE and major surgery for
gynaecological cancer
Intervals (weeks) Number of women %
,2 4 10.3
2to,4 7 17.9
4to,6 6 15.4
6 22 56.4
The use of IVC filters before surgery in women with gynaecological cancer
ª2008 The Authors Journal compilation ªRCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 905

increased morbidity in women undergoing major surgery
within a few weeks of the diagnosis of VTE. Our experience
is that if major surgery is indicated, it should not be delayed.
The women in this study received either subcutaneous or
oral anticoagulation until the time of surgery. Full-dose anti-
coagulant therapy was stopped 4 hours prior to IVCF inser-
tion then recommenced 1 hour afterwards subcutaneously at
the usual therapeutic dose. A prophylactic subcutaneous dose
of LMWH was given the evening before surgery. During open
abdominal surgery, only the limb unaffected with thrombosis
received intermittent pneumatic compression. After surgery,
routine prophylactic measures in the form of sequential com-
pression devices, early ambulation and LWMH were insti-
tuted to prevent further VTE development.
Pulmonary embolism is a major cause of postoperative
death following gynaecological surgery.24 The rationale for
placing a vena caval filter is to prevent a potentially fatal
pulmonary embolism and is effective in trapping large
tumour thrombi within it and/or preventing migration of
the thrombus from the site of formation to the lungs.25 The
indications for IVCF placement in gynaecological oncology
include VTE in women requiring surgery either as initial
treatment or following chemotherapy (Table 3). The most
common situation is the woman with advanced stage ovar-
ian cancer and VTE requiring surgery and chemotherapy
(whether neoadjuvant or adjuvant). Although most filters
are placed prior to surgery, considering the known association
of VTE with chemotherapy and the increasing use of neo-
adjuvant chemotherapy in ovarian cancer, IVCF are increas-
ingly being placed at the time of diagnosis and not removed,
that is they are placed for the duration of treatment and
beyond, at our institution. This is appropriate for advanced
disease where the benefits of keeping the filter in situ outweigh
the risks. For early-stage cervical and ovarian cancers with
a good prognosis, especially in young women, we favour
removal of the filters postoperatively. This is because although
the documented fatality rate associated with IVC insertions is
extremely low (0.16%),26 the complications include insertion
site thrombosis, postphlebitic syndrome, filter migration or
IVC penetration by components of the filter. In addition, the
filters will not prevent contralateral DVTs postoperatively;
indeed, they have been reported to be an independent risk
factor for recurrent DVT, but not for pulmonary embolism.27
None of the women described in this study experienced these
potential filter-related complications, but this may be due to
the small sample size.
The pathogenesis of VTE in women with cancer is sum-
marised by the well-known Virchow triad of venous stasis,
endothelial injury and hypercoagulability. Venous stasis can
Table 3. Indications for IVCF placement in women with
gynaecological cancer and a diagnosis of VTE
Surgery necessary as primary treatment for cancer
Surgery as a delayed procedure as part of definitive
treatment (i.e. in those receiving [neoadjuvant]
chemotherapy)
When anticoagulation is contraindicated
Haemorrhage
Central nervous system vascular malformation/aneurysm
Thrombocytopenia (including heparin induced)
Intolerance of anticoagulation (injections or oral)
Failed anticoagulation
Figure 1. Venogram prior to planned removal of temporary filter
showing thrombus within the filter basket. Arrow points to thrombus.
Adib et al.
906 ª2008 The Authors Journal compilation ªRCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology

be caused by mechanical obstruction to the venous return by
a pelvic mass or abnormal blood flow through new but
aberrant vessels secondary to angiogenesis. Endothelial cells
may be damaged by tumour invasion or by chemotherapy.
Hypercoagulability is due to procoagulants secreted by tumour
cells, which react with platelets, clotting factors and fibrinolytic
products that contribute to thrombus formation. Clotting fac-
tor III (tissuefactor) has long been associated with cancer28 and
more recently has been shown to be upregulated in epithelial
ovarian cancers and are related to metastatic potential.29 Stud-
ies have shown a survival benefit from treatment with LMWH
in women with cancer, suggesting that inhibition of the clotting
pathway may have anti-tumour effects.30,31
In conclusion, we have shown that percutaneous IVCF
placement is an effective, safe and precise procedure that is
crucial to the surgical management of women with gynaeco-
logical cancer and VTE. Once a decision is made on treatment,
then the surgical care includes filter placement with cessation of
anticoagulation, continuation of prophylactic measures in the
perioperative period and resumption of anticoagulation after
surgery. Decisions regarding filter removal are made on an
individual basis. Major surgery in women with gynaecological
cancer within the first few weeks of the diagnosis of VTE does
not appear to increase surgical morbidity. j
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