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

Developmental or Procedural Vena Cava Interruption and Venous Thromboembolism: A Review

The inferior vena cava (IVC) and superior vena cava are the main conduits of the systemic venous circulation into the right atrium. Developmental or procedural interruptions of vena cava might predispose to stasis and deep vein thrombosis (DVT) distal to the anomaly and may impact the subsequent rate of pulmonary embolism (PE). This study aimed to review the various etiologies of developmental or procedural vena cava interruption and their impact on venous thromboembolism. A systematic search was performed in PubMed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines per each clinical question. For management questions with no high-quality evidence and no mutual agreements between authors, Delphi methods were used. IVC agenesis is the most common form of congenital vena cava interruption, is associated with an increased risk of DVT, and should be suspected in young patients with unexpected extensive bilateral DVT. Surgical techniques for vena cava interruption (ligation, clipping, and plication) to prevent PE have been largely abandoned due to short-term procedural risks and long-term complications, although survivors of prior procedures are occasionally encountered. Vena cava filters are now the most commonly used method of procedural interruption, frequently placed in the infrarenal IVC. The most agreed-upon indication for vena cava filters is for patients with acute venous thromboembolism and coexisting contraindications to anticoagulation. Familiarity with different forms of vena cava interruption and their local and systemic adverse effects is important to minimize complications and thrombotic events.

INFERIOR VENA CAVA FILTER PLACEMENT FOR PREVENTION OF PULMONARY THROMBOEMBOLISM: CASE SERIES FROM NORTHWESTERN NIGERIA

Background

Inferior vena cava (IVC) filter placement is an image-guided procedure aimed at primarily preventing pulmonary thromboembolism in patients with lower limb venous thromboembolic (VTE) disease. In Northern Nigeria with a relatively high incidence of thromboembolic disease such as Deep vein thrombosis, reports on IVC filter placement are largely low. We report the feasibility of IVC filter placement on eight patients for the first time in a typical low-resource setting in Northern Nigeria.

Case Presentations

We had an equal number of males and females of the eight patients. Their ages ranged from 20 to 80 years. Five patients presented with bilateral lower limbs Deep vein thrombosis (DVT) of which one had a pulmonary embolism. Two other patients had extensive left femoral DVT and one had extensive IVC, iliac, femoral, and popliteal veins thrombosis. The medical records of seven patients, who had IVC filter placement in our department, were reviewed. The IVC filter was deployed with the aid of a C-arm fluoroscopic unit. In a single case, access was secured via an indwelling dialysis catheter.

Conclusions

All the patients had successful deployment with satisfactory postprocedure conditions. The intended benefit of pulmonary embolism prevention was achieved in the series of procedures that were performed. Indicating the value of IVC filter even in resource-poor settings and effort should be made towards exploring such intervention.

A Review of Healthcare Disparities Relevant to Interventional Radiology

Racial, ethnic, and gender disparities have received focused attention recently, as they became more visible in the COVID era. We continue to learn more about how healthcare disparities manifest for our patients and, more broadly, the structural underpinnings that result in predictable outcomes gaps. This review summarizes what we know about disparities relevant to interventional radiologists. The prevalence and magnitude of disparities are quantified and discussed where relevant. Specific examples are provided to demonstrate how factors like gender, ethnicity, social status, geography, etc. interact to create inequities in the delivery of interventional radiology (IR) care. Understanding and addressing health disparities in IR is crucial for improving real-world patient outcomes and reducing the economic burden associated with ineffective and low-value care. Finally, the importance of intentional mentorship, outreach, education, and equitable distribution of high-quality healthcare to mitigate these disparities and promote health equity in interventional radiology is discussed.

Retrievable Inferior Vena Cava Filters-Use, Removal, and Removal Techniques

The use of retrievable inferior vena cava filters is on the rise, but there is an inadequate number of these filters being removed even if their use as a prophylactic for venous thromboembolism is no longer indicated. Complications with retrievable filters that remain in the patient for an extended duration include examples such as filter tilt and embedding into the caval wall. This raises concerns for whether the filter is properly functioning and for consequent sequelae, including recurrent thrombosis, stenosis, or inferior vena cava perforation. With these complications, there are also challenges to retrieving these filters via the standard techniques and thus more advanced techniques are required. Both standard and advanced techniques, their uses, and possible risks of these methods are also discussed.

Single center experience of inferior vena cava filter retrieval in trauma patients: contrast-enhanced CT-based retrieval within hospital stay

PURPOSE

To assess the safety and retrieval rate of a predischarge inferior vena cava (IVC) filter retrieval strategy based on contrast computed tomography (CT).

METHODS

IVC filter insertion for trauma patients from 2010 to 2018 were reviewed. An active filter retrieval strategy was established in March 2017. The strategy sought early evaluation of venous thromboembolism (VTE) status and filter retrieval before a patient's discharge. The possibility of early IVC filter retrieval was evaluated by a multidisciplinary team based on pre-filter retrieval VTE-CT findings. Overall VTE-CT findings, retrieval rate, indwelling time, and recurrence of venous thromboembolic events were compared before and after the filter retrieval strategy setup.

RESULTS

177 IVC filters were inserted in trauma patients. All patients underwent pre-filter retrieval VTE-CT. VTE-CT findings were as follows: completely resolved VTE, n = 108 (61%); partially improved, n = 58 (33%); no change, n = 8 (5%); aggravated, n = 3 (2%). The overall retrieval rate was 84% with a mean indwelling time of 32 days. In subgroup analyses, 95 (53%) had filter retrieval with the before strategy (BS) setup and 82 (47%) with the after strategy (AS) setup. The retrieval rate was significantly higher in the AS group [81/82 (99%) vs. 68/95 (72%), (p < 0.001)]. No patients had recurrent VTE during the follow-up period.

CONCLUSIONS

The active strategy of VTE-CT-based filter retrieval during the hospital stay markedly improved the filter retrieval rate from 72% to 99% without evidence of recurrence of VTE. Hazards of low retrieval rate versus CT-related radiation exposure should be studied in the future.

Suprarenal Inferior Vena Cava Filter Placement and Retrieval: Safety Analysis

PURPOSE

To evaluate safety and retrieval success of retrievable suprarenal inferior vena cava (IVC) filters.

MATERIALS AND METHODS

A retrospective chart review of patients who received a retrievable suprarenal IVC filter between January 2008 and December 2017 was conducted. Suprarenal IVC filters were placed in 24 female and 27 male patients. The most common indications for filter placement were IVC thrombus (n = 20; 39.2%) and iliofemoral venous thrombosis with contraindication to anticoagulation (n = 16; 31.3%). The most common indications for suprarenal placement were IVC thrombus (n = 20; 39.2%), anatomic variants (n = 17; 33.3%), and external IVC compression (n = 8; 15.8%). Duplicated IVC was the most common anatomic variant requiring suprarenal placement (n = 7; 13.7%).

RESULTS

Günther Tulip (n = 40; 78.4%), Denali (n = 10; 19.6%), and Celect (n = 1; 2.0%) filters were used. Retrieval was attempted in 27 of the 51 filters placed (52.9%). Of the 27 attempted retrievals, the technical success rate was 100% (27/27). The median dwell time was 87.0 days (95% confidence interval, 28-137 d). One complication involving fractured struts during filter retrieval occurred. No significant change in craniocaudal filter position, lateral filter tilt, or renal function between placement and retrieval was observed (P < .05). There were no instances of indwelling filter fracture.

CONCLUSIONS

Suprarenal IVC filters, when indicated, can be placed and retrieved with a low complication rate.

Utility of Retrievable Inferior Vena Cava Filters: A Systematic Literature Review and Analysis of the Reasons for Nonretrieval of Filters with Temporary Indications

OBJECTIVE

To investigate the use of retrievable inferior vena cava (IVC) filters in the current practice and analyze the causes of filter left in situ despite initial plans for retrieval.

METHODS

A systematic search of all English-language studies of retrievable IVC filters was conducted, including clinical trials and observational studies published between January 1984 and March 2016.

RESULTS

A total of 103 studies were identified, including 10 filter models in 20,319 patients. Placement indications were reported for 11,128 (54.8%) patients, including therapeutic (n = 6270; 56.3%) and prophylactic (n = 4858; 43.7%) indications. A total of 13,224 (65.1%) filters were left as permanent devices; 7095 (34.9%) filters were removed. The reasons for filter nonretrieval among the 5308 (40.1%) reported cases were primary permanent indication (21.2%; 1127/5308), death (19.4%; 1031/5308), ongoing pulmonary embolism (PE) protection (19.0%; 1011/5308), failed retrieval (13.7%; 725/5308), loss to follow-up (13.0%; 689/5308), discontinued care (4.4%; 235/5308), physician oversight (4.0%; 213/5308), patient morbidity (2.8%; 149/5308), and patient refusal (2.4%; 128/5308). A total of 7820 patients presented for filter retrieval, and 7095 filters (90.7%) were successfully removed, with a mean indwelling time of 106.6 ± 47.3 days. Breakthrough PE was reported in 2.1% (191/9169) of patients. Filter tilt, recurrent deep vein thrombosis, penetration, IVC thrombosis, migration, and fracture occurred in 7.7% (798/10,348), 7.1% (362/5092), 5.4% (379/7001), 3.9% (345/8788), 1.4% (160/11,679), and 0.5% (50/9509) of patients, respectively.

CONCLUSIONS

Approximately two-thirds of retrievable filters were not retrieved even though more than 85% of the filters were initially intended for temporary use. The major reasons for filter left in situ despite initial plans for retrieval were death, need for ongoing PE protection, failed retrieval, loss to follow-up, discontinued care, and physician oversight.

Ten-year experience of retrievable inferior vena cava filters in a tertiary referral center

PURPOSE

A significant proportion of patients undergoing surgery have an increased incidence of acute pulmonary embolus (PE). We analyzed all patients who had a retrievable inferior vena cava (IVC) filter placed preoperatively for PE prophylaxis and investigated the long-term outcomes of the patients who did not have their filter removed.

METHODS

Patients who underwent retrievable IVC filter insertion and attempted removal were identified from the radiology information systems database in a large tertiary referral university teaching hospital. Results of all clinical investigations (including computed tomography, magnetic resonance imaging, ultrasonography, and plain radiography) while the IVC filters were in situ were reviewed.

RESULTS

In total, 393 retrievable IVC filters were inserted, 254 with the indication of preoperative thromboembolic prophylaxis. Recurrent PE was reported in five patients (1.9%) despite the IVC filter. Of the 254 retrievable filters inserted prior to surgery, an attempt at retrieval was made in 168 filters (66.1%). Successful retrieval at the first attempt occurred in 143 cases (85.1%), while 25 cases failed or were aborted (14.9%). No attempt at retrieval was made in 86 (33.9%) patients and a significant proportion of these patients had undergone cancer surgery (P < 0.0107). In those patients where there was no attempt at retrieval, there was an association between cancer surgery and a shorter absolute survival time (P < 0.0001).

CONCLUSION

The majority of attempted filter retrievals were successful, and a proportion of nonretrieved IVC filters are accounted for in patients who underwent cancer surgery and ultimately died with the filter in situ. A departmental protocol is recommended to ensure the filter is removed where appropriate and possible.

The Role of Inferior Vena Cava Filters in Pulmonary Embolism

Pulmonary embolism (PE) is a cause of significant morbidity and mortality, with an estimated 600,000 cases of clinically significant PE in the United States annually, and roughly 200,000 deaths per annum directly attributable to PE. By far the most frequent cause of PE is deep vein thrombosis originating in the lower extremities, which travels to the pulmonary vasculature. The mainstay of treatment is anticoagulation, but multiple additional treatments exist for patients in whom anticoagulation is inadequate or contraindicated. The absolute indications for inferior vena cava (IVC) filtration are narrow, but many filters are placed in patients with relative indications. There is growing concern for overuse of IVC filters, with a relatively low rate of retrieval. It is essential for interventional radiologists to understand the appropriate and correct use and retrieval of IVC filters. Familiarity with placement techniques, protocols and techniques for retrieval, current and emerging technologies, and the clinical model for management of venous thromboembolism, will ensure that interventional radiologists remain an integral member of the care team for these often complex patients.

A Dedicated Inferior Vena Cava Filter Service Line: How to Optimize Your Practice

Despite the increased placement of retrievable inferior vena cava filters (rIVCFs), efforts to remove these devices are not commensurate. The majority of rIVCFs are left in place beyond their indicated usage, and often are retained permanently. With a growing understanding of the clinical issues associated with these devices, the United States Food and Drug Administration (FDA) has prompted clinicians to remove rIVCF when they are no longer indicated. However, major obstacles exist to filter retrieval, chief among them being poor clinical follow-up. The establishment of a dedicated IVC filter service line, or clinic, has been shown to improve filter retrieval rates. Usage of particular devices, specifically permanent versus retrievable filters, is enhanced by prospective physician consultation. In this article, the rationale behind a dedicated IVC filter service line is presented as well as described the structure and activities of the authors' IVC filter clinic; supporting data will also be provided when appropriate.

Risk Factors Associated with Symptomatic Pulmonary Embolism of Catheter Directed Thrombolysis for Lower Extremity Deep Venous Thrombosis

OBJECTIVE

The aim was to study the risk factors associated with symptomatic pulmonary embolism (PE) in patients with deep venous thrombosis (DVT) in the lower limbs treated by catheter directed thrombolysis (CDT) without inferior vena cava filter (IVCF) placement.

METHODS

A total 266 patients with acute/subacute ilio-femoral, ilio-femoropopliteal, and femoropopliteal thrombosis confirmed by computed tomography venography or ultrasound Doppler were studied. All patients were treated with CDT. CTPA (computed tomography pulmonary angiography) examination was performed in all patients before thrombolysis. Patients with clinically suspected symptomatic PE were confirmed by repeated CTPA after treatment. The major outcome of this study was the occurrence of symptomatic PE events during CDT.

RESULTS

During CDT, the incidence of symptomatic PE events was 4.9% (13/266). Patients with silent PE had a higher risk of developing symptomatic PE (10/110, 9.1%) than those who had no prior PE (3/156, 1.9%); multivariate analysis confirmed this difference (OR 4.018, 95% CI 1.048-15.402). It was also found that patients with previous heart disease had a higher risk of developing symptomatic PE (11/90, 12.2%) than those with no prior heart disease (2/176, 1.1%). Multivariate analysis confirmed that previous heart disease increased the risk of developing symptomatic PE (OR 10.407, 95% CI 2.228-48.617). One patient who suffered from heart failure and silent PE before CDT died of symptomatic PE (1/13, 7.7%).

CONCLUSION

The risk of developing symptomatic PE is most markedly increased in patients with previous silent PE and heart disease. Selective rather than routine IVCF placement is an appropriate approach.

Iatrogenic percutaneous vascular injuries: clinical presentation, imaging, and management

Vascular interventional radiology procedures are relatively safe compared with analogous surgical procedures, with overall major complication rates of less than 1%. However, major vascular injuries resulting from these procedures may lead to significant morbidity and mortality. This review will discuss the etiology, clinical presentation, diagnosis, and management of vascular complications related to percutaneous vascular interventions. Early recognition of these complications and familiarity with treatment options are essential skills for the interventional radiologist.

Comparison of complication rates associated with permanent and retrievable inferior vena cava filters: a review of the MAUDE database

PURPOSE

To compare the safety of permanent and retrievable inferior vena cava (IVC) filters by reviewing the U.S. Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database.

MATERIALS AND METHODS

The MAUDE database was reviewed from January 1, 2009, to December 31, 2012. Product class search criteria were "filter, intravascular, cardiovascular." Type of device used and specific adverse events (AEs) were recorded.

RESULTS

For the period January 2009-December 2012, 1,606 reported AEs involving 1,057 IVC filters were identified in the MAUDE database . Of reported AEs, 1,394 (86.8%) involved retrievable inferior vena cava filters (rIVCFs), and 212 (13.2%) involved permanent inferior vena cava filters (pIVCFs) (P < .0001). Reported AEs included fracture, migration, limb embolization, tilt, IVC penetration, venous thromboembolism and pulmonary embolism, IVC thrombus, and malfunctions during placement. Each specific AE was reported with significantly higher frequency in rIVCFs compared with pIVCFs. The most common reported complication with rIVCFs was fracture, whereas the most commonly reported complications with pIVCFs were placement malfunctions. For rIVCFs, the most commonly reported AE varied depending on filter brand.

CONCLUSIONS

The MAUDE database reveals that complications occur with significantly higher frequency with rIVCFs compared with pIVCFs. This finding suggests that the self-reported complication rate with rIVCFs is significantly higher than the self-reported complication rate with pIVCFs.