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274 Chapter 27 Acute CVT in the setting of central lines, pacemaker wires, and dialysis catheters
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27.5 SITE SELECTION
A number of studies have addressed laterality, site selection, and previous thrombosis for CVC-related complications and thrombosis. In one of these studies, the internal
jugular vein route had a decreased incidence of malposition
as compared to the subclavian vein route: 5.3% and 9.3%
(RR=0.66, 95% CI 0.44–0.99), respectively.
also found no difference in thrombotic events. In another
study, Martin etal. addressed the risk of UEDVT in a prospective controlled trial with axillary vein cannulation and
found the incidence of CVT to be 11%.
27.5.1 Jugular or subclavian
A Cochrane review in 2012 by Ge etal. evaluated site location and analyzed three RCTs. In comparing the internal
jugular vein route versus subclavian route for long-term
access in cancer patients, the authors found no difference
in thrombotic complications (n=240, RR 1.97, 95% CI
0.87–4.48). Comparing femoral versus subclavian routes
for short-term CVC, the results showed that femoral access
thrombotic complications compared to subclavian access
(1.87%, n= 2/107) (n = 223, RR 11.53 95% CI 2.80–
47.52). Finally, comparing femoral to internal jugular
vein routes in hemodialysis patients for short-term needs,
there was no difference in thrombotic events between the
groups. This analysis concluded that subclavian and internal jugular vein routes have similar long-term catheter-related thrombotic complications.
13
The subclavian route
was preferred to the femoral route for short-term CVC
access. There were no RCTs addressing CVT and catheter
site location for either pacemaker or long-term hemodialysis catheter needs. However, in 2011 Saber etal. conducted
a meta-analysis evaluating a total of 5636 patients with
425 having CRT. They found that insertion of a CVC via
the subclavian route had a signicantly higher risk of CRT
(OR 2.16, 95% CI 1.07–4.34).
37
27.5.2 Laterality
Debourdeau et al. completed a review article and found
three studies that included CVC and thrombosis in cancer patients. One study was a prospective controlled trial
in solid cancers among patients with tunneled catheters.
It evaluated 5447 patients and found that left-sided subclavian and jugular veins versus right-sided access carry
an increased risk of DVT (RR=2.6; P ≤ 0.001). Another
study that examined 122 patients with solid tumors or
hematological malignancies found the risk of thrombosis
in left-sided versus right-sided access equals 19% versus
5%, respectively (RR=4.4; P = 0.04). Finally, the third
study sampled 334 patients with solid tumors or hematological malignancy also found left-sided versus right-sided
CVC thrombosis, which resulted in a rate of UEDVT of
25.6% versus 6.8%, respectively (P ≤ 0.001).
sided access may carry a higher risk of catheter-associated UEDVT in cancer patients.However, in Saber et al.’s
meta-analysis, they were unable to identify any signicant
difference based on laterality. They also found that catheter
tip positioned proximal to the junction between the SVC
35
The study
36
38
Thus, left-
and right atrium was signicantly associated with a higher
risk of CRT (OR 1.92; 95% CI 1.22–3.02).
37
27.5.3 Preexisting central lines
and catheters
There has been a traditional fear of inserting a hemodialysis catheter on the ipsilateral side as a pacemaker or other
CVC for risk of venous thrombosis or wire dislodgement.
Yet, Jung etal. presented interesting ndings during their
retrospective review of 600 dialysis catheters over 10years.
They found that in all 39 patients with preexisting CVC
(n= 19) or pacemaker wires (n =20), an insertion of a
tunneled dialysis catheter ipsilateral to the side of the other
CVC or pacemaker wires failed to reveal any patient exhibiting malfunction, infection, or dislodgement of the lines or
wires. Thus, they recommended that in patients with anticipation of need for arteriovenous stula placement on one
side, it is safe to place a hemodialysis catheter on the side
ipsilateral to the cardiac pacing wire or CVC.
39
27.6 DIAGNOSIS
Determination of thrombosis using duplex ultrasonography can demonstrate an acute UEDVT by the absence of
augmentation of ow with respiration and other augmentation maneuvers; inability to compress the vein, whenever
applicable; and hypoechoic signals.
a review article in 2009 and found that duplex ultrasonography exhibited a sensitivity of 78%–100% and a specicity
of 86%–100% for the diagnosis of symptomatic UEDVT in
an adult population.
15
In addition, the 2013 review article
by Murray etal. of cancer patients with thrombosis demonstrated that the sensitivity of duplex ultrasonography may
drop to 56% if proximal subclavian or brachiocephalic
veins need to be assessed. Patel etal. conducted a systematic
review and meta-analysis of nine studies. Pooled estimates
of sensitivity and specicity with moderate-quality evidence
for duplex US and D-dimer were conducted. D-dimer was
found to have high sensitivity 0.96 (95% CI 0.87–0.99),
with duplex US having a sensitivity of 0.87 (95% CI 0.73–
0.94). However, specicity of D-dimer testing was low at
0.47 (95% CI 0.43–0.52), and US had a specicity of 0.85
(95% CI 0.72–0.93).
40
Nevertheless, due to its noninvasive nature and cost advantage, duplex ultrasonography is
initially recommended. If the duplex exam fails to reveal
any thrombosis and clinical suspicion remains high, either
computed tomography venography (CTV) or magnetic resonance venography (MRV) may be needed to conrm diagnosis. Finally, venography remains the gold standard for the
diagnosis of central vein thrombosis.
For patients with pacemaker wires, MRV is often
contraindicated, and as such, another option to diagnose
thrombosis is transesophageal echocardiogram (TEE). In
their 2010 study, Korkeila etal. performed TEE at 6 months
post implantation of pacemakers and found approximately
9% of patients with either thrombus in the right atrium or
the central veins.
2
However, routine evaluation by TEE is
of limited value due to its invasive nature and cost. Therefore, duplex ultrasonography is suggested as the rst-line
tool for the investigation.
6
Baskin etal. completed
27.7 PREVENTION AND TREATMENT OF
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CENTRAL VENOUS THROMBOSIS
Most of the data for UEDVT treatment have been extrapolated using what we know from LEDVT. As such, anticoagulation has historically been the treatment of choice, and
a treatment algorithm can be found in Figure27.1. Multiple guidelines have been created regarding the treatment
of CVT associated with catheters. The National Comprehensive Cancer Network (NCCN), American Society of
Hematology (ASH), American College of Chest Physicians
(ACCP), and International Initiative on Thrombosis and
Cancer (IITC) have brought forth their own recommendations and guidelines regarding prevention and treatment
of CVC-associated thrombosis. The recommendations and
grade for prevention and treatment from each of these societies can be found in Table27.1.
The French National Federation of Cancer Centers
Workgroup on Standards, Options, and Recommendations reviewed 36 publications (studies between 1990 and
2007) to establish their guidelines on prevention of CRT.
Their analysis found that catheter position is the most
important factor and recommended that the distal tip of
all CVCs should be at the junction of the right atrium
27.8 Conclusion 275
38
and SVC.
The IITC guidelines do not recommend the
use of anticoagulation for routine prophylaxis of CRT,
while the NCCN, ACCP, and ASH do not have any recommendations regarding prevention.
41
The issue of catheter-associated thrombogenicity has also been discussed,
withMurray etal. demonstrating that polyethylene catheters are more thrombogenic than polyurethane catheters.
Furthermore, the authors found that rigid catheters may
damage venous walls, whereas softer ones may be more
compliant and remain in the optimal location, leading to
improved thrombotic outcomes.
14
Data on heparin-bonded
catheters are scarce, are largely inconclusive on thrombus
prophylaxis, and have not demonstrated prophylactic ben-
42,43
In the pediatric population, a Cochrane review
et.
examined two studies, one with 97 patients, the other with
209 patients. Both studies had participants randomized to
heparin-bonded catheters and non-heparin-bonded catheters. The review found no difference in catheter-related
thrombosis (RR=0.34, 95% CI 0.01–7.68).
44
Many of the published guidelines recommend that
anticoagulation be started when UEDVT is identied.
The recommendations for treatment of CVC-associated
UEDVT for the NCCN, ACCP, ASH, and IITC can be
found in Table27.1. The NCCN, ACCP, ASH, and IITC
recommend initial treatment should be at least 3 months’
duration, and if the catheter is no longer required, they
recommend removal.
45–48
Wires for pacing or debrillation
need not be removed, as their benet outweighs the risk
of UEDVT. However, if the catheter is functional and continues to be clinically indicated, then removal of the catheter is not mandated and anticoagulation is recommended
while the catheter remains in place.
45,46,48
The standard
for type of anticoagulation has been a topic of interest in
the treatment of CVT. The ASH, NCCN, ACCP, and IITC
guidelines recommend the use of DOACs or LMWHs over
vitamin K antagonists for treatment of VTE. Finally, in
those patients who are unable to complete anticoagulation, one may consider placement of an SVC lter to prevent PE.
16,49,50
The ACCP guidelines recommend against
the use of compression garments in symptomatic patients.
Further, the safety and efcacy of thrombolytics and
thrombectomy are not clearly established based on available data, but they may be benecial for phlegmasia. The
NCCN also suggests that catheter-directed thrombolysis
can be considered in select cases.
45
The treatment algorithm for CVC-associated thrombosis management can be
found in Figure27.1.
27
27.1 Treatment algorithm for central venous thrombosis associ-
ated with pacemaker wires, central venous catheters, or dialysis
catheters.
* If patient unable to undergo anticoagulation, consider SVC filter placement.
27.8 CONCLUSION
The Virchow triad is of signicant importance in the development of CVT. Indwelling catheters inherently contribute to
each of the components of the triad. They are foreign objects
to the venous system and may contribute to its local hypercoagulability. Furthermore, catheter or pacemaker wire presence
in the lumen may cause stasis due to low ow in the vessel
lumen. In addition, their initial insertion and presence carry
the potential to cause endothelial damage. The decision for
central venous access via the IJ or subclavian route compared
to PICC line placement typically hinges upon the duration of
which medication or nutrition support is anticipated. The risks
276 Chapter 27 Acute CVT in the setting of central lines, pacemaker wires, and dialysis catheters
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of UEDVT with PICC lines has been shown via meta-analysis
to be higher, and central venous access via the IJ or subclavian
approach should be the initial approach for decreased risk of
UEDVT if clinically appropriate.
Acute CVT is usually asymptomatic. Diagnosis starts
with a clinical exam, followed by duplex ultrasonography.
Once the diagnosis of UEDVT is conrmed, the mainstay
of treatment is anticoagulation. There is a limited role for
thrombectomy or thrombolysis. Furthermore, prevention
of thrombosis is best obtained by placing the CVC tip at
the junction of the right atrium and superior vena cava.
Finally, improving catheter and wire proles to be less
thrombogenic may have a role in decreasing the prevalence
of CVT.
TABLE 27.1 Guidelines for recommendations of prevention and treatment of CVC-associated UEDVT
Guideline Prevention recommendations Treatment recommendations
National Comprehensive Cancer
Network (2022)
American College of Chest
Physicians (2012,
46
2016)
American Society
of Hematology
47
(2020)
International Initiative on Thrombosis
and Cancer Guideline (2022)
48
No recommendations. • In cancer patients with CRT, anticoagulation is recommended for as long as
45
No recommendations. • In patients with UEDVT associated with CVC, they suggest that the catheter
No recommendations. • Suggests DOACs over VKAs in patients with DVT. Whether provoked by a
• Use of anticoagulation for
routine prophylaxis of CRT is
not recommended (Grade 1A).
• Catheters should be inserted
on the right side, in the jugular
vein, and the distal extremity
of the CVC should be located
at the junction of the SVC and
right atrium (Grade 1B).
the catheter remains in place.
• If the catheter is removed, at least 3 months of anticoagulation is recommended.
• Preferred anticoagulation for patients without gastric or gastroesophageal
lesions is DOACS (Category 1) and LMWH is preferred for patients with
gastric or GE lesions (Category 1).
• If symptoms persist, catheter is nonfunctional, or no longer necessary, then
removal of catheter should be considered.
• Catheter-directed thrombolysis can be considered in select cases (Grade
2A, Category 2a).
not be removed if functional and needed (Grade 2C).
• Recommend initial treatment of at least 3 months (Grade 2B) and recommend that anticoagulation is continued as long as the CVC is in place over
stopping after 3 months of treatment in patients with cancer (Grade 1C) and
suggest this in patients without cancer (Grade 2C).
• For patients with UEDVT that involves the axillary or more proximal veins,
they suggest LMWH or fondaparinux over IV UFH (Grade 2C) and over subcutaneous UFH (Grade 2B). They also suggest anticoagulant therapy alone
over thrombolysis (Grade 2C).
transient risk factor, chronic risk factor, or unprovoked, the ASH guideline
panel suggests a shorter course of anticoagulation treatment (3–6 months)
over a longer course (6–12 months) (conditional recommendation based
on moderate certainty in the evidence of effects).
• LMWHs are preferred over VKAs for the treatment of VTE in patients with
cancer when creatinine clearance is ≥30 mL/min (Grade 1A).
• For treatment of symptomatic CRT in patients with cancer, anticoagulation is
recommended for a minimum of 3 months or as long as the CVC is in place.
In this setting LMWHs are suggested.
• In patients with cancer and CRT, the CVC can be kept in place if functional
and well positioned, with resolution of symptoms under close surveillance
while anticoagulation therapy is administered. In children with cancer and
symptomatic CRT, anticoagulant treatment is recommended for a minimum
of 3 months and as long as the CVC is in place.
Guidelines 27.0 of the American Venous Forum on the management of acute central venous thrombosis in the setting
of central lines, pacemaker wires, and dialysis catheters
No. Guideline Grade
27.1 To decrease the risk of central venous thrombosis, we recommend placement of the tip of
the central venous catheter (CVC) at the junction of the right atrium and superior vena cava.1(strong)
27.2 If short-term central venous access is anticipated, we recommend placement of a CVC
via the internal jugular or subclavian vein in lieu of a PICC line placement to decrease
the risk of central venous thrombosis.
27.3 If catheter-related thrombosis is identied, we recommend initiation of anticoagulation.
Removal of the central line or catheter is recommended only if it is no longer needed.
Anticoagulation should be continued while the catheter is in place and continued for at
least 3–6 months after removal.
27.4 Low-molecular-weight heparin or direct oral anticoagulants are recommended as initial
anticoagulant for treatment of catheter-related thrombosis over vitamin K antagonists.1(strong)
of recommendation
1
(strong)
1
(strong)
Quality
of evidence
A
(high)
B
(moderate)
A
(high)
B
(moderate)
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CHAPTER
28
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Indications, techniques, and results
of inferior vena cava filters
Courtney E. Morgan and John E. Rectenwald
28.1 INTRODUCTION
Most pulmonary emboli (PE) arise from thrombosis in
the deep veins of the legs and pelvis. The rst-line therapy for venous thromboembolism (VTE) is pharmacologic
anticoagulation, but in instances where anticoagulation is
contraindicated or therapeutic anticoagulation cannot be
achieved, an alternative treatment strategy is required. This
subset of patients may benet from placement of venous
lter devices that provide partial interruption of the inferior vena cava (IVC) to prevent PE. The goal of IVC lter
placement is to trap clinically signicant thromboemboli
without causing complete occlusion of the IVC. The advent
of retrievable IVC lters has played a signicant role in
broadening the indications for the use of IVC lters to
include prophylactic placement. Although this practice
remains controversial, appropriately selected patients may
benet from IVC lter placement. In this chapter, we discuss the indications, clinical use, efcacy, insertion techniques, and complications of IVC lters.
28.2 INDICATIONS FOR IVC FILTER
PLACEMENT
It is well established that the rst-line therapy for the
treatment of VTE is anticoagulation.
most widely accepted indications for IVC lter placement
require the presence of a VTE and contraindications to systemic anticoagulation. Indications for IVC lter placement
are traditionally divided into absolute indications, relative
indications, and prophylactic indications. Absolute indications for IVC lter placement are well established and follow common sense. These indications include the presence
of VTE and one of the following: a baseline contraindication to anticoagulation, a complication from anticoagulation, or a recurrent deep venous thrombosis (DVT) or
PE despite adequate (therapeutic) anticoagulation. There
is considerable controversy surrounding numerous relative and prophylactic indications for IVC lter placement,
which is reected by variation in guidelines from the American College of Chest Physicians (ACCP), the American
Heart Association (AHA), and the Society of Interventional
1,2
Consequently, the
TABLE 28.1 Indications for inferior vena cava lter
placement
Absolute indications:
• Contraindication to anticoagulation in patients with pulmonary
embolism (PE)/deep venous thrombosis (DVT)
Relative indications:
• Complications of anticoagulation
• Failure of anticoagulation due to progression of DVT, recurrent
PE, or noncompliance
• Massive, life-threatening PE with residual DVT despite anticoagulation
• Free-oating thrombus in inferior vena cava (IVC), iliac, or
pelvic veins
• Chronic, recurrent PE with pulmonary hypertension and cor
pulmonale
• Patients undergoing advanced therapies for PE or DVT
Prophylactic indications:
• Patients with prior PE with signicantly increased risk for
second PE or those with poor cardiopulmonary reserve
• Patients with a signicant burden of proximal DVT or
free-oating thrombus
• Patients at high risk for complications of thromboembolism
like malignancies and major/multiple trauma
• Patients who cannot receive anticoagulants, such as those
with internal organ injury or active internal bleeding
• Multiple risk factors for DVT in a preoperative patient
Radiology (SIR). The indications for IVC lter placement
are summarized in Table28.1 and discussed in detail next.
28.2.1 Absolute indications (requires
presence of VTE)
Contraindication to anticoagulation is the most frequently
cited reason for selecting IVC lter placement over standard anticoagulation therapy. Major contraindications to
anticoagulation are serious active bleeding, recent spinal
cord or brain injury or neoplasm, recent stroke, surgery, or
trauma. Advanced age and pregnancy are also considered
relative contraindications to anticoagulation but remain
controversial. Many contraindications to anticoagulation
DOI: 10.1201/9781003328971-31
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therapy are self-limited or are reversed over time, allowing
a course of anticoagulation to be completed later. The latter advocates the increased use of retrievable IVC lters.
Complications secondary to anticoagulation include
bleeding or, in rare cases, an adverse reaction to the anticoagulant used. Up to 5%–10% of patients treated with
intravenous heparin will develop a bleeding complication
over the duration of therapy. The severity of bleeding is
variable, but appears to be dose dependent and varies with
the patient’s inherent risk (i.e., prior surgery or trauma,
predisposing clinical factors, or underlying hemostatic
conditions).
arin-induced thrombocytopenia develops in 1.1%–2.9%
of patients receiving unfractionated heparin.
3
In addition to bleeding complications, hep-
4
Should this
occur, all heparin must be discontinued, even that which
is used for ushing lines and catheters, as the condition
responds to cessation of therapy. Rarely, patients may
develop sensitivity to heparin with the development of
a cutaneous rash or anaphylaxis. The incidence of these
complications is much lower with the use of low-molecular-weight heparins, but they do occur. Alternatives to heparin such as argatroban or lepirudin should be considered
in these instances.
Bleeding with oral anticoagulation varies by treatment
type. While historically warfarin (Coumadin) was the only
oral anticoagulant for VTE with bleeding rates up to 10%,
direct oral anticoagulants (DOACs) that inhibit factors IIa
or Xa rather than acting on vitamin K–dependent factors
have been developed and demonstrated to have improved
safety proles. Bleeding rates for warfarin have been
demonstrated to be 7.4% vs 1.1% for DOACs over the
treatment course for VTA.
5
This has resulted in changes
in recommendations for VTE treatment to recommend
DOACs over warfarin in standard patients and DOACs
over low-molecular-weight heparin (LMWH) in patients
with cancer-associated VTE in the most updated version of
the CHEST guidelines.
1
Recurrent VTE while on therapeutic anticoagulation
is considered a failure of anticoagulation and is another
common indication for lter placement. Prior to determining that anticoagulation has failed, it should be established
that the patient was adequately anticoagulated to begin
with. Many times, failures of anticoagulation are failures
to reach therapeutic drug levels. The patient who develops
recurrence or extension of thromboembolism while anticoagulated may, in fact, not be adequately anticoagulated or
simply noncompliant. In large, randomized trials comparing DOACs to warfarin, rates of anticoagulation failures
were 2.4% for DOAC and 2.7% for warfarin.
6
One of the purported advantages of DOAC anticoagulants is that, unlike warfarin, regular monitoring of these
drugs is not required. However, the inability to assess for
therapeutic drug levels makes it extraordinarily challenging to establish whether a patient with a recurrent VTE
on DOAC therapy was adequately anticoagulated at the
time of the VTE event. At present, failure of a single agent
has been considered an indication for IVC lter placement;
however, as more oral therapies emerge for the treatment
of VTE, future guidelines may require failure of multiple
pharmacologic modalities prior to use of an IVC lter.
Despite over a decade and a half of experience with the
addition of DOACs to the treatment armamentarium for
VTE, there are still no recommendations regarding trialing
alternative drug classes prior to determining treatment failure of anticoagulation.
26.2.2 Relative indications (VTE required)
The group of relative indications for IVC lter placement
also require the conrmed presence of VTE in addition to
risk factors for future PE or cardiopulmonary compromise.
Such indications include individuals with a DVT and poor
cardiopulmonary reserve such as pulmonary hypertension
or cor pulmonale, who are unlikely to tolerate the hemodynamic and respiratory stress of a PE. Similarly, patients
with residual DVT who have experienced a massive PE
may not tolerate additional pulmonary insult and therefore may benet from IVC lter placement. Patients with
a large, free-oating iliocaval thrombus (typically greater
than 6cm in length) may also be considered for lter placement, as a large central thrombus with high embolic risk
could lead to a massive PE. Other relative indications for
IVC lter placement include patients with a VTE and relative contraindications to anticoagulation, as is demonstrated by poor adherence to medications or by those with
ataxia or a high fall risk. Additionally, patients with a high
periprocedural risk of PE, including those undergoing pulmonary thromboembolectomy, and patients with DVT and
a large clot burden undergoing thrombolysis could benet
from IVC lter placement.
There is ongoing debate with regard to the validity of
the relative indications for IVC lter placement. The ACCP
does not mention relative indications for IVC lter use in
its most recent update.
just one relative indication for IVC lter use: an acute PE
in a setting of poor pulmonary reserve.
1
Current AHA guidelines identify
9
Additionally, the
AHA guidelines state that IVC lters should not routinely
be used as an adjunct to anticoagulation or in a setting of
brinolysis.
7
The SIR offers the most inclusive set of recommendations for IVC lter use, with the multidisciplinary
clinical practice guidelines published in 2020, but cautions
several indications with caveats. In patients with recurrent
VTE despite anticoagulation, the reason for anticoagulation failure and potential remediation should be sought
prior to placing an IVC lter, and in patients undergoing
advanced therapies, consideration for IVC lter placement
should only be in select patients.
8
28.2.3 Prophylactic indications (no VTE
required)
Indications for prophylactic IVC lter placement remain
highly controversial, although more recent studies have
argued against their routine use. Only the SIR guidelines
recommend the use of IVC lters in a prophylactic setting,
and the ACCP guidelines explicitly recommend against the
use of prophylactic IVC lters. Nevertheless, certain populations may benet from the placement of an IVC lter,
even in the absence of DVT, to prevent possible PE. These
indications are discussed next.
Trauma patients with specic injuries may be at exces-
sively high risk of DVT, and thus have been considered
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candidates for prophylactic IVC lters. The cadre of traumatic injuries that constitutes high risk includes brain
injury, spinal cord injury, and pelvic and lower extremity
long bone fractures. These injuries carry a 50-fold increase
in thromboembolic complications compared to other
trauma patients. The use of IVC lters in these patients has
been criticized. By itself, the lter protects against large PE,
but does nothing to prevent additional episodes of thrombosis or to treat existing DVT. There are also concerns
about increased health care costs and procedural morbidity/mortality.
the indication for prophylactic IVC lters in the setting of
trauma is the SIR guidelines, which recommend against the
routine use of IVC lters for primary VTE prophylaxis, but
comments that there may be a subset of patients who do
benet who are not able to receive adequate and appropriate pharmacoprophylaxis.
may benet from prophylactic IVC lter placement include
patients undergoing bariatric surgery or spinal surgery. The
incidence of PE in bariatric surgery patients is reported to
be 1%–4% but may be even higher in super-obese patients.
This has remained unchanged despite the near-universal
institution of pharmacomechanical prophylaxis measures.
Several small retrospective studies have suggested IVC lter placement reduces the incidence of PE in bariatric surgery patients, but the practice remains controversial, and
a recent systematic review concluded IVC lter placement
offered no benet for protection from PE.
after spinal surgery is reportedly as high as 13%; therefore,
this patient population may benet from preoperative prophylactic IVC lter placement. Several small retrospective
studies support this contention
evidence at this time is low, and the ACCP, SIR, and ACR
guidelines recommend against the use of IVC lter placement as prophylaxis in patients without VTE undergoing
high-risk surgery.
Malignancy has long been known to carry a signicantly increased risk of VTE. The reported incidence of PE
in the literature is somewhere between 7% and 50% in
patients with malignancy.
risks of PE in cancer patients to be approximately 3.6-fold
higher than in patients without malignancy.
patients who are at increased risk of VTE also appear to
be at increased risk of bleeding while receiving anticoagulation therapy,
routine use of DOAC therapy.
of IVC lters in the setting of malignancy has persisted
since the 1990s. Despite frequent use for this indication
and continued attempts to clarify their role, the proper use
of IVC lters in the setting of malignancy remains a point
of contention.
Immobility is an established risk factor for VTE, with
prolonged immobility leading to a 4.9-fold increased risk
of PE.
pression devices may reduce the incidence of PE, certain
individuals who have a contraindication to anticoagulation may benet from IVC lter placement. For example,
patients with severe stroke can have prolonged immobility and, due to risk of intracerebral hemorrhage, cannot
receive anticoagulation. There are limited data demonstrating the efcacy of IVC lters in preventing PE in patients
9
The most current guidelines to comment on
8
Certain surgical patients who
10
The rate of PE
11
; however, the quality of
1,8,12
13
Two studies have estimated the
14,15
These same
15
which persists despite the transition to
17
While pharmacoprophylaxis and sequential com-
16
Debate regarding the use
with restricted mobility. Given the relatively low risk of
complications associated with IVC lters, these devices can
be considered in immobilized patients who cannot receive
anticoagulation
tal guidelines.
18
; however, this is not supported by socie-
28.3 CONTRAINDICATIONS TO IVC
FILTER PLACEMENT
The only absolute contraindications to IVC lter insertion
are complete thrombosis of the IVC and inability to gain
access to the IVC due to severe venous obstruction. Arelative contraindication is uncorrectable, severe coagulopathy
or thrombocytopenia, in which case surgical venotomy and
surgical placement may be safer, although IVC lters with
low-prole delivery devices and off-label use of percutaneous arterial closure devices may be useful in these cases.
Careful evaluation of the risks versus benets of lter placement should be done in such patients. Special situations
requiring caution prior to lter placement include patients
with untreated or uncontrolled bacteremia, who should be
treated with immediate and appropriate antibiotic treatment, and lter placement in pediatric patients and pregnant women, due to uncertain long-term effects and the
durability of the lters. Specically, women with an IVC
lter placed prior to pregnancy can experience additional
complications of the IVC lter during pregnancy.
retrievable lters may have a role in these patients depending on the specics of these cases. If an IVC lter must
be placed in a pregnant woman or woman of child-bearing age, placement of the lter in the suprarenal position
should be considered to avoid the potential complication
of compression of the lter by the enlarging uterus.
20
Again,
19
28.4 FILTER CHARACTERISTICS:
WHICH ONE IS AN IDEAL FILTER?
Several designs of lters in various size and shapes are available for clinical use. The availability of such a wide range
of lters suggests that not one type is by itself ideal. The
characteristics of an ideal lter are described in Table28.2.
The most important desirable factors are high ltering
efciency (large and small emboli) without impedance of
blood ow
rate of associated morbidity.
, stability of positioning and structure, and a low
28.5 TYPES OF IVC FILTERS
28.5.1 Permanent filters
Permanent lters are placed with the intention of providing lifelong protection from PE and are thus designed
with caval xation in mind. The rst widely used IVC
lter was the Greeneld lter, which was originally introduced in 1972 as a permanent lter. It is constructed of
stainless steel and was originally intended for open surgical placement via a 28-Fr sheath. It has been discontinued
28
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TABLE 28.2 Characteristics of an ideal lter
1. High ltering efciency for both large and small emboli without impedance of blood ow
2. Stability of position/xation and structural integrity
3. Low procedural morbidity, no mortality, and low cost
4. Ideal biomechanical property: biocompatible, nonthrombogenic, and magnetic resonance imaging compatible
5. Ideal delivery system: small caliber and easy deployment with ability to reposition
6. Safe retrievability when no longer needed
TABLE 28.3 Permanent inferior vena cava lters
Name Manufacturer Year introduced FDA approval
Titanium Greeneld Boston Scientic/Medi-tech, Natick, MA 1988 1989
Over-the-wire stainless steel Greeneld Boston Scientic/Medi-tech, Natick, MA 1994 1995
VenaTech/LGM B. Braun Medical, Evanston, IL 1986 1989
Low-prole VenaTech B. Braun, Boulogne, France 2000 2001
Simon Nitinol Bard, Covington, GA 1988 1990
TrapEase Cordis, Miami, FL 1998 2000
Bird’s nest Cook, Bloomington, IN 1982 1989
Name Delivery
system size
Titanium Greeneld 14.3 Fr 38mm 47mm Titanium Compatible
Over-the-wire stainless steel Greeneld 15 Fr 32mm 49mm Stainless
VenaTech/LGM 14.6 Fr 30mm 38mm Phynox Compatible
Low-prole VenaTech 9 Fr 40mm 43mm Phynox Compatible
Simon Nitinol 9 Fr 28mm 45mm Nitinol Compatible
TrapEase 8 Fr 35mm 50–65mm Nitinol Compatible
Bird’s nest 14 Fr 40mm 70–
Maximum diameter Length Material MRI compatibility
Not compatible
steel
Stainless Not compatible;
110mm
creates large
artifacts
from clinical use and replaced with a lower-prole system.
In addition to the Greeneld lter, several other permanent
IVC lters are available for clinical use (Table28.3). Brief
descriptions of available permanent IVC lters are included
next and in Figure28.1.
28.5.2 Titanium Greenfield filter
The titanium version of the Greeneld lter has a conical
conguration consisting of six struts that is compressed
into a 12-Fr carrier (14.3-Fr outer diameter) sheath. The
sheath is inserted with a guidewire, but actual lter deployment occurs without the use of a guidewire, unlike the
original and stainless steel over-the-wire design. The lter
is designed for IVC diameters smaller than 28 mm. The
lter comes in femoral and jugular versions.
28.5.3 Stainless steel over-the-wire
Greenfield filter
The lter has six stainless steel struts that are press-tted
into a cylindrical cap with a hole that the guidewire can
pass through. This lter is placed over a centering guidewire to address frequently encountered instances of lter
tilting and asymmetry with the titanium version. The hooks
of four of the legs point superiorly, and two opposite hooks
point inferiorly to prevent migration. The hooks are also
“recurved,” forming a complete circle before protruding to
decrease the degree of hook penetration. There are separate
femoral and jugular versions of this lter. The lter is safe
for magnetic resonance imaging but causes a signicant
amount of artifact.
28.5.4 VenaTech LGM and low-profile filter
This original LGM lter has a six-strut conical conguration with side rails containing hooklets that provide caval
centering and xation, respectively. The lter is designed
for IVC diameters of 28mm or less. The lter is loaded in
an injection syringe, with the orientation of the lter injection into the sheath determined by the access route (femoral or jugular). The low-prole lter replaces the LGM, and
instead of six side struts as with the original VenaTech lter, this design uses eight Phynox (cobalt-chromium-nickel
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(a) (b) (c) (d) (e)
(f) (g) (h) (i)
(j)
(k)
28
28.1 Various available lters. (a) Stainless steel Greeneld (Boston Scientic/Medi-Tech); (b) Günther Tulip MREye (Cook); (c) Simon
Nitinol (Bard); (d) VenaTech LGM (B. Braun); (e) low-prole VenaTech (B. Braun); (f) OptEase (Cordis); (g) TrapEase (Cordis); (h) G2
Filter (Bard); (i) bird’s nest (Cook); (j) ALN (ALN); (k) Denali (Bard); (l) Crux (Volcano).
Source: (Reprinted with permission from GetzenTM, Rectenwald JE. J Natl Compr Canc Netw 2006;4:881–8.)
(l)
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