Pregnancy in women with an inferior vena cava filter: a tertiary center experience and overview of the literature

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.

Venous Thromboembolism Management in Pregnant Patients

Pulmonary embolism (PE) in pregnancy accounts for 10% of maternal deaths in the United States. As maternal morbidity and mortality continue to increase, it is imperative for all specialties interfacing with pregnant patients to understand the current research and guidelines surrounding risk stratification, diagnosis, and treatments of PE in pregnancy. Given the complexity of high-risk pregnancy-associated PE (PA-PE), that is, which is associated with hemodynamic instability or collapse, and the rising popularity of new technologies to treat high-risk PA-PE in the nonpregnant population, this review aims to emphasize the differences in diagnosis, risk stratification, and management of the pregnant and nonpregnant PE patients. Furthermore, this review will cover treatment paradigms that include anticoagulation versus advanced therapies such as systemic thrombolysis, surgical embolectomy, extracorporeal membrane oxygenation, and inferior vena cava disruption as well as the more novel therapies which fall under the umbrella term of catheter-based treatments. Finally, this review will include a case-based review of 2 patients with PA-PE requiring catheter-based therapies and their ultimate clinical outcomes.

Peripartum management of deep venous thrombosis in the context of antithrombin deficiency and May-Thurner syndrome

Literature regarding the management of thrombus refractory to first-line treatment in the setting of pregnancy is limited, and management is made even more complicated in the context of thrombophilia. This case reviews the management of a patient with antithrombin deficiency who developed a massive thrombus during pregnancy, which was complicated by May-Thurner syndrome, lack of improvement with heparin, and preterm labor. The patient received multidisciplinary care throughout the pregnancy. At 35 weeks, anticoagulation was paused as she underwent induction of labor and delivery followed by postpartum placement of inferior vena cava filter and restarting heparin. Successful management of our pregnant patient with thrombus refractory to heparin hinged on individualized treatment for medical optimization with anticoagulation and antithrombin concentrate prior to labor followed by immediate postpartum placement of inferior vena cava filter.

Inferior vena cava filters in pregnancy: Safe or sorry?

Background

Potential hazards of vena cava filters include migration, tilt, perforation, fracture, and in-filter thrombosis. Due to physiological changes during pregnancy, the incidence of these complications might be different in pregnant women.

Aim

To evaluate the use and safety of inferior vena cava filters in both women who had an inferior vena cava filter inserted during pregnancy, and in women who became pregnant with an inferior vena cava filter in situ.

Methods

We performed two searches in the literature using the keywords “vena cava filter”, “pregnancy” and “obstetrics”.

Results

The literature search on women who had a filter inserted during pregnancy yielded 11 articles compiling data on 199 women. At least one filter complication was reported in 33/177 (19%) women and included in-filter thrombosis (n = 14), tilt (n = 6), migration (n = 5), perforation (n = 2), fracture (n = 3), misplacement (n = 1), air embolism (n = 1) and allergic reaction (n = 1). Two (1%) filter complications led to maternal deaths, of which at least one was directly associated with a filter insertion. Filter retrieval failed in 9/149 (6%) women. The search on women who became pregnant with a filter in situ resulted in data on 21 pregnancies in 14 women, of which one (6%) was complicated by uterine trauma, intraperitoneal hemorrhage and fetal death caused by perforation of the inferior vena cava filter.

Conclusion

The risks of filter complications in pregnancy are comparable to the nonpregnant population, but could lead to fetal or maternal death. Therefore, only in limited situations such as extensive thrombosis with a contraindication for anticoagulants, inferior vena filters should be considered in pregnant women.