Extreme obesity is associated with angulation during inferior vena cava filter placement

Relationship between vascular access and angulation of vena cava filter at placement and retrieval: a multicenter retrospective cohort study

Background

Inferior vena cava (IVC) filters are commonly used intravascular devices designed to prevent fatal pulmonary embolism (PE), maintaining the IVC filter as centered as possible is fundamental for achieving its filtration function.

Objective

This study aimed to characterize the tilt angles of IVC filter between the vascular access of internal jugular vein (IJV) and femoral vein (FV), as well as to identify factors associated with increased or decreased tilt angles between placement and retrieval.

Design

This is a multicenter retrospective study.

Methods

A multicenter retrospective study was conducted from October 2017 to March 2019. The primary outcome was the change in filter tilt between placement and retrieval. The secondary outcome was the identifications of factors associated with increased or decreased tilt angle. Relevant variables were analyzed using t-tests, Chi-square tests, Fisher's exact tests, while multivariate logistic regression analysis was used to determine risk factors.

Results

A total of 184 eligible patients were included in this study. The IJV group had a lower likelihood of tilt angle over 10° at the time of placement compared to the FVs group (0% versus 12.5%, p = 0.040). Among the 171 patients with a mean dwell time of 22.1 days, the IJV group had a higher likelihood of tilt angle over 10° than the FVs group (10.3% versus 2.3%, p = 0.080). The use of FVs access at placement was associated with a higher difference between placement and retrieval filter tilt angles (p < 0.01). Multivariate logistic regression analysis showed that hypertension [odds ratio (OR) 0.668; 95% confidence interval (CI) 0.328-1.358, p = 0.265], cardiologic artery disease (OR 0.537; 95% CI 0.136-2.130, p = 0.377), cerebral venous disease (OR 0.555; 95% CI 0.186-1.651, p = 0.290), filter types (OR 1.624; 95% CI 0.851-3.096, p = 0.141), and IVC filter thrombosis (OR 1.634; 95% CI 0.804-3.323, p = 0.175) were not associated with increased filter tilt angle. Right side (OR 0.434; 95% CI 0.202-0.930, p = 0.032) or bilateral lower extremity deep vein thrombosis (LEDVT) (OR 0.383; 95% CI 0.148-0.995, p = 0.049) were identified as protective factors.

Conclusion

IJV access was associated with a lower filter tilt angle at the time of placement, while FVs access was linked to a higher difference between placement and retrieval tilt angles. Right side or bilateral LEDVT were identified as protective factors against increased IVC filter tilt angle.

Inferior Vena Cava Filters and Complications: A Systematic Review

Inferior vena cava (IVC) filters have been used since the 1960s to treat patients with acute risk of pulmonary embolism (PE) to prevent migration of thrombus by trapping it within the filter. Traditional usage has been in patients with contraindication to anticoagulation that carry a significant mortality risk. In this systematic review, we sought to evaluate complications associated with placement of inferior vena cava filters based on published data from the past 20 years. A search was performed on October 6th, 2022, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews, using three databases (ProQuest, PubMed and ScienceDirect) for articles published between the dates of February 1, 2002 and October 1, 2022. Results were filtered to include full-text, clinical studies, and randomized trials written in English pertaining to keywords "IVC filter AND complications", "Inferior Vena Cava Filter AND complications", "IVC filter AND thrombosis" and "Inferior Vena Cava Filter AND thrombosis". Articles identified by the three databases were pooled and further screened for relevance based on inclusion and exclusion criteria. Initial search results yielded 33,265 hits from all three databases combined. Screening criteria were applied, with 7721 results remaining. After further manual screening, including removal of duplicate hits, a total of 117 articles were selected for review. While there are no consensus guidelines for best practice, there is compelling evidence that IVC filters can provide significant protection against PE with minimal complications if the treatment window is appropriate. Increase in the variety of filter models has led to broader availability, but skepticism remains about their efficacy and safety, with ongoing controversy surrounding appropriate indications. Further research is needed to establish clear guidelines on appropriate indications for IVC placement and to determine time course of complications versus benefits for indwelling filters.

Effect of access site choice on inferior vena cava filter angulation and outcomes

BACKGROUND

In the present study, we compared the outcomes of inferior vena cava (IVC) filter placement between the femoral vein (FV) and internal jugular (IJ) vein access sites.

METHODS

We performed a retrospective study using the Vascular Quality Initiative database to assess patients who had undergone IVC filter placement from 2013 to 2019. The patients were placed into two groups according to the access site location: FV and IJ vein. The FV group included patients with access via the right and left FVs and other leg veins, and the IJ group included patients with access via the right or left IJ vein. The primary outcome was the rate of filter angulation. The secondary outcomes included access site complications such as deep vein thrombosis, hematoma, and bleeding requiring transfusion.

RESULTS

Of 13,221 patients, 8214 (63%) had undergone IVC filter placement via FV access and 4789 (37%) via IJ access. The remaining 218 patients had had an unknown access site or were excluded. Within the IJ group, 4696 (98.0%) had undergone access via the right IJ and 93 (2%) via the left IJ. Within the FV (common femoral, femoral, or other infrainguinal veins) group, 7007 (85.3%) had undergone access via the right FV and 1207 (14.6%) via the left FV. The mean patient age was 63 ± 15.9 years, the mean body mass index was 30.9 ± 9.60 kg/m², and 6788 of the patients were men (52.0%). The most common indication for filter placement was a contraindication to anticoagulation because of a recent or active bleeding episode (30%), followed by planned surgery (22%), new deep vein thrombosis/pulmonary embolism (7%), fall risk (5%), and trauma (4%). Infrarenal filters had been placed in 97.9% of the patients. Univariate analysis identified body mass index and suprarenal placement as independent risk factors for angulation. The final multivariate analysis showed a significant increase in angulation (0.9% vs 0.34%; odds ratio, 1.46; 95% confidence interval, 1.02-2.11; P = .04) and increased access site complications (0.25% vs 0.07%; odds ratio, 2.068; 95% confidence interval, 1.01-4.23; P = .048) in the FV access group. No significant correlation between the access site and retrieval rate was found (P = .9270).

CONCLUSIONS

Placement of IVC filters via IJ access showed a lower rate of filter angulation in the IVC and fewer access site complications compared with FV access.