Retrievable IVC filters – Friend or foe
Introduction
Venous thromboembolism (VTE) encompasses deep venous thrombosis (DVT) and pulmonary embolus (PE) and is a common condition with an estimated annual incidence 1–1.6 per 1000 population in the United States and Europe.1, 2, 3 Outcomes vary widely from complete recovery to chronic post-thrombotic syndrome, chronic thromboembolic pulmonary hypertension, and fatal pulmonary embolus. Reported all-cause mortality in PE cases varies from 5 to 17%, with specific case-fatality rates varying from 1 to 8%.4, 5, 6, 7, 8 Clinical predictors for fatal PE include the presence of PE compared with DVT alone, immobilisation of more than 4 days for neurological disease, cancer, and advanced age.5 Mortality is increased up to 18-fold in massive PE.
Treatment options for VTE are not without complication and appropriate therapy should be guided by risk stratification for fatal PE.9, 10 Management strategies include treatment of the acute VTE and prevention of recurrence. Pharmacological therapy with anticoagulant medication is first-line for both treatment and secondary prevention of VTE. In the acute setting, this may be supplemented with fibrinolytic therapy for selected high-risk cases. Pharmacomechanical or surgical embolectomy is reserved for acute massive or submassive PE where fibrinolytic therapy is contraindicated or has failed.11 In contrast, inferior vena cava filters do not treat an existing acute DVT or PE; their role is in prevention of recurrent PE in cases where anticoagulation treatment is not possible.11, 12, 13, 14, 15, 16
Considering the high prevalence of VTE and its potential mortality, there is an understandable demand for filter placement where pharmacological therapy is unsuitable. However, there is also a growing concern amongst the medical community regarding filter-related adverse events and the relative lack of high-level evidence supporting their use.17 In fact, a recent review of the filter literature concluded that no indication for filter placement is based on appropriate scientific evidence.18
Section snippets
Medical therapy
The mainstay of treatment for VTE is anticoagulant medical therapy, including low molecular weight heparin, vitamin K antagonists and novel anticoagulants. These prevent continued thrombogenesis, facilitating intrinsic thrombolysis and ultimately thrombus resorption.14, 15 Fibrinolytic treatment may be life-saving in massive PE but it is associated with adverse events and its use is controversial for sub-massive PE and contraindicated for haemodynamically stable patients without right
IVC filters
The purpose of IVCF is to prevent life-threatening pulmonary emboli originating from the pelvic or lower limb deep venous system where medical anticoagulant therapy is contra-indicated. It is a non-occlusive device which facilitates caval venous flow but captures and retains large mobile thrombi. Retrievable IVC filters are intended for temporary use and are indicated when the contraindication to anticoagulation is transient, for example in the peri-operative period or in the setting of
Evidence and guidelines (see table 1)
There has been no randomised study directly comparing anticoagulation and IVCF in prevention of VTE. Most of the available literature is retrospective and there is considerable heterogeneity related to the variety of filters available on the market. Much of the oft-quoted literature refers to filters no longer in general use, limiting the general applicability of their findings. The PREPIC (Prévention du Risque d'Embolie Pulmonaire par Interruption Cave) group carried out the only long-term
Retrieval and registries
This relaxed adherence to guidelines likely reflects an assumption that so-called “temporary” filters may be considered lower risk. However, ineffective tracking of patients results in lack of follow-up and poor retrieval rates, particularly in the USA.25, 38 Several studies have shown the benefits of dedicated filter monitoring databases, filter clinics, personnel responsible for follow-up of retrievable filters and automated booking and reminder systems for retrieval appointments.39, 40, 41
Complications
Procedural complications occurring at insertion or retrieval are uncommon and major complications rare. Reported complications include access site haematoma or thrombosis, pneumothorax, failure of proper deployment resulting in tilt, failure of mechanical retrieval device, jugular vein dissection and self-limiting caval tears.13, 42, 43 Later complications include strut penetration, filter migration, strut fracture and filter thrombosis and these are related to dwell-time.48 Penetration of
Conclusions
Retrievable IVC filters reduce the risk of fatal PE when anticoagulation treatment is contraindicated but they do not offer therapy or risk reduction for DVT, post-thrombotic syndrome or chronic thromboembolic pulmonary hypertension. Pharmacological therapy should be started or reinstated at the earliest opportunity. Guidelines are limited by a paucity of high-quality evidence specific to retrievable filters and are poorly adhered to. Retrieval rates are variable and can be improved by
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