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Figure 43. 4 Vena cava lters:(a)Stainless steel Green eld lter, (b)percutaneous stainless steel Green eld lter, (c)titanium Green eld lter,
(d)Bird’s Nest lter, (e)Simon Nitinol lter, (f )Vena Tech lter, (g )Nitinol TrapEase lter, (h)Gunther Tulip lter.
MB. e role of vena caval lters in the management of venous thromboembolism. Blood Reviews . 2005. 19:179–202, published by Elsevier).
Experience with this lter has accumulated since the
device was approved by the FDA in 1991. e initial prospective multicenter trial showed that lter insertion was
successful in 181 out of 186 patients (97%):placement of
the remainder was precluded only because of unfavorable
61
anatomy.
Initial follow-up data, obtained from all participating centers at 30 d, showed minimal lter movement in
11%; with no signi cant proximal migration. ere was evidence of penetration of the wall of the IVC in only one case
(0.8%), with no clinical sequelae. In another clinical study
of the titanium Green eld lter, the follow-up period was
extended to at least 12months. e late patency rate was
99%, with recurrent PE in 3.7% of 176 patients who were
62
enrolled in this study.
358 • VENOUS THROMBOEMBOLISM
STAINLESS STEEL OVERTHEWIRE
GREENFIELDFILTER
is is a 12-Fr stainless steel lter (Boston Scienti c, MA)
that is used as an alternative device for percutaneous placement (Figure 43.4). is device allows for over-the-wire
delivery and a exible carrier system to facilitate safe delivery. It is the tallest of the Green eld lters, at 4.9cm, with
a resting base diameter of 3.2cm, between those of the titanium Green eld lter (3.8cm) and the original Green eld
lter (3.0cm). Two of the six hooks of this lter are angled
distally (Figure 43.4), which facilitates secure xation
within the vena cava. e device is manufactured from the
same material as the original stainless steel Green eld lter,
but the wires exit from the apex at a di erent angle, which
(With permission from Hann CL, Strei
facilitates delivery via a 12-Fr system. e results of clinical
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trials of this lter have demonstrated comparable results to
the 24-Fr and titanium lters with respect to e cacy (95%)
63
and patency (95%).
B I R D ’ S N E S T F I L T E R
e use of the Bird’s Nest lter (Cook, Bloomington,
64
IN) was rst reported in 1984,
patients was reported in 1988.
and a large series of 568
65
e device consists of
four stainless steel wires 25cm long and 0.18 in diameter.
e wires are preshaped into a criss-crossing, nonmatching array of bends intended to provide multiple barriers
to thromboemboli (Figure43.4). e end of each wire is
attached to a strut that ends in a hook for xation to the
64,65
wall of the vena cava.
One strut is z-shaped so that a
pusher wire can be attached for insertion. e lter was
redesigned in 1986 using a sti er 0.46mm wire to improve
xation. Modi cation of the lter resulted in as increase in
the preload system from 8-Fr to a 12-Fr size. During insertion of the lter, the pusher is used to set the rst group of
hooks into the caval wall. e wires are then extruded with
the goal of closely packing the formed loops into a 7-cm
segment of the infrarenal vena cava. e second group of
hooks are then pushed into the wall of the cava, and the
pusher is removed by unscrewing it from the lter. e
theoretical advantages of this lter include:(1)the ability to trap small emboli; (2)the ability to accommodate
cavae as large as 40mm in diameter; (3)the possibility that
wires may be able to occlude nearby collaterals; (4)avoidance of the need for intraluminal centering because of the
con guration of the device; and (5)the lack of radically
oriented struts, thereby limiting the tendency toward
caval wall penetration. Only 37 of 481 patients with the
lter in place for more than six months were available for
follow-up. Seven patients (19%) had occlusion of the vena
cava; three symptomatic patients had pulmonary angiography for recurrent thromboembolism that was con rmed in
one (3%), and proximal migration was seen in ve patients
resulting in one death secondary to the lter being embedded in a massive PE. ese results occurred before strut
modi cation. In a study of the new modi ed strut, there
were three cases of lter migration in thirty-two place-
66
ments;
two were identi ed within 24 h of placement and
were corrected by angiographic manipulation, and one was
not detected until six months a er placement, and it was
embedded in the right atrium and ventricle and could not
be repositioned.
67
More recently, Nicholson et al.
reported on the
long-term clinical follow-up of the Bird’s Nest lters in a
small group of patients. Seventy-eight consecutive patients
with lters placed between 1989 and 1994 were recalled
for clinical assessment and imaging studies. Recurrent PE
occurred in 1.3% of patients, and IVC occlusion in 4.7%.
ere was no lter migration. Wire prolapse was visualized
in 70% by abdominal plain lm. CT also showed asymptomatic penetration of the IVC wall in 85.3% of the patients
studied. Aortic penetration was also reported, resulting in a
clinically signi cant aortic pseudoaneurysm from penetra-
68
tion of one of the lter struts, which required repair.
e
rate of IVC occlusion associated with the Bird’s Nest device
appears to be similar to other caval devices, although esti-
64,69
mates range from 0% to 19%.
SIMON NITINOLFILTER
e Nitinol lter (Bard, Covington, GA), rst described
in 1977, is made of a nickel-titanium alloy and is a pliable
straight wire when cool, but transforms rapidly into a previously imprinted, rigid shape when warmed. e lter is
a 28-mm dome shape with eight overlapping loops, below
which the wires are shaped into a cone with six diverging
legs with terminal hooks, used to a x it to the vena cava
70
wall (Figure43.4).
e lter wire is advanced rapidly with
a feeder pump using iced, normal saline infused through
a 9-Fr delivery catheter. When it is discharged from the
storage tube, it expands instantly, assumes the appropriate
shape, and is locked into place (Figure43.4).
Of 103 patients undergoing placement at seventeen
centers, only forty-four were available for follow-up.
70
ere were three cases of recurrent PE, seven cases of
con rmed vena cava occlusion, and two suspected cases
based on clinical examination. In a more recent study of
224 patients, 65 patients (29%) completed a 6-month
71
follow-up.
Four percent of patients developed recurrent
PE, one of which was fatal; 19.6% had caval occlusion; and
three deaths were associated with massive caval thrombosis. It is currently believed that the Nitinol lter may be
71
thrombogenic.
In 1998, Poletti etal.
72
reported on the long-term performance of Simon Nitinol lters in 114 consecutive patients
with an average follow-up of 27months. ey prospectively
evaluated thirty-eight of these patients, and the remaining patients were retrospectively evaluated from follow-up
clinical data. Five patients (4.4.%) had recurrent PE and
5.3% had documented DVT, with thrombosis at the exit
site noted in 3.5%. Filter migration was not found in this
series, but IVC thrombosis was noted in 3.5%. e Nitinol
lter was found to have penetrated the IVC wall in 95%
of patients, and was found to be in contact with adjacent
organs in 76%; however all of these were asymptomatic.
Sixty-three percent of the lters were eccentrically positioned within the vena cava, and 16% were found to have
partial disruption that did not appear to a ect lter func-
73
tion. In 2001, Wolfe etal.
reported a recurrent PE rate of
7.7% with evidence of IVC penetration in all 117 patients
they analyzed. Strut fracture was noted in 2.9% of patients,
and 19% had eccentrically oriented lters. ere were no
cases of IVC thrombosis in theirstudy.
PERMANENT VENA CAVA FILTERS • 359
V E N A T E C H F I L T E R
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e Vena Tech lter (B. Braun, Boulogne, France) was
rst introduced in France in 1986. It is a cone-shaped lter with stabilizing struts added to each limb that are
designed for percutaneous use. e lter is made of phynox
and is a stamped, six-prong device with hooked stabilizers with sharp ends intended to center and a x the device
74,75
(Figure 43.4).
e lter uses a 12-Fr catheter system,
usually inserted through the right internal jugular vein over
a guidewire.
e early experience from France shows 100 attempts
at insertion, resulting in 98 lter discharges. Eighty-two lters were in the correct position, eight showed a tilt of 15
degrees or greater, and eight had opened incompletely, with
74
three of these associated with a tilt.
Amore recent report
showed a 2% recurrent embolism rate, a 23% rate of insertion site venous thrombosis, a 92% IVC patency rate at six
months, a 14% migration rate, and a 6% rate of incomplete
75
opening of the lter.
Breakage of the stabilizer struts has
also been reported. is lter was designed to prevent tilt,
but continues to show a high incidence of tilting.
Long-term studies of this device by Crochet etal.
76,77
have demonstrated that there has been a 73% incidence of
lter occlusion overtime.
VENA TECH LOW PROFILEFILTER
e Vena Tech low pro le lter (Vena Tech LP) has a
release wire design contained within a 6-Fr introducer
sheath, which allows placement of the lter through alternative venous access sites. is lter is 43mm in height and
40mm in diameter in its unconstrained state. is lter was
approved in 2001 by the FDA for placement in IVCs that
were 28mm or less in diameter, but can be used for a cava as
78
large as 35mm.
retrievable lter in Europe, it has not received FDA approval
for this application. Several Canadian medical centers have
reported successful retrieval of this lter using an endovascular approach within 12 to 14 d a er insertion. Recent
reports state that the lter can actually be repositioned
every seven days; which potentially increases the likelihood
79
that it can be removed.
Millward et al.
80
reported the results of placement of
Gunther Tulip lters in ninety patients from eight hospitals. Filter retrieval was attempted in y-two patients with
y-three lters, and was successful in y-two lters. e
duration of lter implantation was 2 to 25 d, with a mean
implantation time of 9 d.In thirty-nine patients in whom
the lter was not retrieved (a mean follow-up of 85days),
two lter occlusions (5%) were noted. No other complication of lter placement werenoted.
G 2 F I L T E R
e G2 lter jugular/subclavian system (Bard, Figure43.5)
consists of a lter and delivery system. It can be delivered via
the femoral and jugular/subclavian approaches, and a separate delivery system is available for each approach. It consists of twelve shape-memory nitinol wires emanating from
a central nitinol sleeve. ese twelve wires form two levels
of ltration of emboli: the legs provide the lower level of
ltration, and the arms provide the upper level of ltration.
e delivery system consists of a 10-Fr introducer sheath
and dilator, the G2 lter, and a delivery device. e lter
is packaged preloaded within the delivery device, and it is
designed to act as a permanent l t e r.
When clinically indicated, the G2 lter may be percutaneously removed a er implantation using the recovery cone
removal system. It is intended to be used in an IVC with a
diameter of ≤28mm. e system consists of a dilator and
introducer set and a delivery device. e dilator accepts a
GUNTHER TULIPFILTER
e Gunther Tulip lter (Cook, Inc.) is a low-pro le lter
that uses the same funnel-shaped design as the Green eld
lter (Figure43.4). is lter was introduced in 1992 for
use in Europe and has been available in the United States
since 2001. e lter is constructed from elgiloy, and an
MRI-compatible material. It consists of four main struts,
each 0.45 mm in diameter, con gured as a cross. Each
strut has an elongated wire loop that extends inferiorly
three-fourths of the length from the apex to the hooked
end of the four main cross struts. e four main struts contain 1-mm-long hooks at the inferior end for caval xation.
e lter is 30mm in diameter and 45mm long in its fully
expanded state. e lter can be placed using 8.5-Fr introducer sheaths via the femoral or jugularvein.
is lter is FDA-approved for permanent implan-
tation. Although the Gunther Tulip lter is used as a
Figure 43. 5 G2 lter.
360 • VENOUS THROMBOEMBOLISM
0.038-inch guide wire and allows for an 800-psi maximum
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pressure contrast power injection. e 10-Fr introducer
sheath contains a radiopaque tip and hemostasis valve with
a side port for saline infusion and a delivery mechanism to
deploy the G2 lter. e delivery device contains a spline
cap that mechanically separates the lter hooks from one
another in a unique pattern to prevent leg entanglement.
Once the introducer sheath is in position, the delivery
device is advanced through the introducer sheath until the
introducer and delivery hubs snap together. e safety clip
is then removed. e introducer hub is pulled back over the
pusher wire handle to unsheath and release the lter, allowing it to recover to its predetermined shape. Nonclinical
testing has demonstrated that the G2 lter is MRI conditional. It can be scanned safely under speci c conditions.
e jugular or subclavian delivery system should not be
used for the femoral approach, as this will result in improper
lter orientation within theIVC.
A clinical study involving 100 patients was conducted to
assess the safety of removal of the G2 lter. Sixty-one patients
underwent a lter retrieval procedure, and y-eight were
successful. Of the forty-two patients who did not have their
lter retrieved, six died of unrelated causes, three withdrew,
two were lost to follow-up, and thirty-one failed to meet
retrieval eligibility criteria (within 6 months a er lter
placement). e time to retrieval in the y-eight patients
with successful lter retrievals ranged from ve to 300 d,
81,82
with a mean of 140 d.
T R A P E A S E F I L T E R
e TrapEase caval lter (Cordis, Figure43.4), approved by
the FDA in 2002, is a symmetric double-basket caval lter
constructed from nickel-titanium (nitinol) material. It is a
small pro le lter that is inserted through a 6-Fr introducer.
It has a unique biconvex symmetric lter that allows a single lter to be placed from either direction. is lter has
six struts that frame the lter in a diamond or trapezoidal
con guration and ends in two superior and inferior baskets created by six struts converging at the apex of the lter.
Proximal and distal hooks are xed at the straight struts that
parallel the wall of the cava. e superior basket is conical
and oriented in the conventional concave position. e
inferior basket is oriented in a mirror position with the apex
pointing inferiorly (Figure43.4). e hook is placed at one
apex of the lter for manipulation and possible retrieval of
the lter. e lter can be inserted through the femoral,
42,44
jugular, subclavian, or antecubital vein.
e deployed lter measures 50–62mm in length and is approved for vena
cavas <30mm in diameter and it is MRI compatible.
83
Rousseau etal.
reported the results of a small French
multicenter prospective trial to evaluate the TrapEase IVC
lter. Atotal of sixty- ve patients were enrolled in twelve
centers throughout Europe and Canada. ey reported
a 95.4% technical success rate in lter placement, with a
clinical success rate of 100% at 6months (with no symptomatic PE). ere was no lter migration, lter fracture,
vessel wall penetration, or insertion site thrombosis during
this short follow-up period, however two patients had early
IVC thrombosis within30d.
84
Schutzer etal.
reported the results of a retrospective
study of 189 consecutively inserted infrarenal TrapEase
lters at a single institution over a 22-month period. e
technical success rate was 100%, with a symptomatic caval
thrombosis rate of 1.5%, one case of symptomatic PE, and
85
one case of intracardiac migration.
86
Kalva etal.
reviewed the clinical and imaging data of
751 patients who had TrapEase IVC lters placed during
a 4-year period. Indications for lter placement were:contraindications to anticoagulation (61%), complications of
anticoagulation (6%), failure of anticoagulation (5%), and
prophylaxis (28%). Filters were placed in the infrarenal
(n=738) or suprarenal (n=13) position through a femoral
(n=729) or jugular vein (n=22) approach. Follow-up CT
scans of the chest and abdomen were evaluated for recurrent
PE and lter-related complications, respectively.
During a mean 295-day clinical follow-up, 7.5% of
patients developed symptoms of PE, and one (0.1%) death
was attributed to PE. Chest CT performed for various clinical indications in 219 patients at a mean of 192days showed
PE in 15 patients (6.8%; 2/3 were symptomatic, but none
were fatal). Follow-up abdominal CTs at a mean of 189days
showed fracture of lter components in 3.0%, thrombus
within the lter in 25%, thrombus extending beyond the
lter in 1.5%, near total caval occlusion in 0.7%, and no
cases of migration. ey concluded that the TrapEase vena
cava lter is e ective in the prevention of PE, with minimal
complications.
COMPARISON OF VARIOUS
PERMANENT IVC FILTER DEVICES
Table43.2 summarizes various commonly used caval lters.
As noted in this table, the majority of lters are comparable in regard to their e ectiveness in preventing recurrent
PE, with some variations in regard to the incidence of IVC
thrombosis and DVT. ey also vary somewhat on the rates
o f m i g r a t i o n .
87
Usoh et al.,
in a prospective randomized study,
compared the outcome of the Green eld lter with the
TrapEase lter. One hundred and y-six patients were
enrolled over a 2-year period, prior to the study’s premature
termination. During the mean 12- month follow-up (range,
0–39 months), symptomatic IVC iliac vein thrombosis
developed in ve patients (6.9%) in the TrapEase group,
compared to none in the Green eld group (p=0.019). No
access-site thrombosis, lter migration, misplacement, or
IVC perforation occurred. Recurrent PE was suspected in
one of the ve patients with IVC iliac vein thrombosis. e
PERMANENT VENA CAVA FILTERS • 361
Table43.2 COMPARISON OF VARIOUS IVC FILTERS
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FILTER REF CARRIER TYPE OF
Stainless steel
24 F Meta-analysis 3184 18 (1–60) 2.6% (0–9%) 3.6% (0–18%) 5.9% (0–18%) 35%; >3mm 4%
EVALUATION
NO. F.U. MOS. RECURRENT PE IVC THROMBOSIS DVT MIGRATION
RATE %
MISPLACEMENT
RATE %
Green eld (61)
Titanium
12 F Meta-analysis 511 5.8 (0–81) 3.1% (0–3.8%) 6.5% (1–31%) 22.7% (0–36%) 11%; >9mm 0.5%
Green eld (61)
Stainless steel over-the-wire
12 F Case series 599 26 2.6% 1.7% 7.3% — —
Green eld (94)
Bird’s nest (61) 12 F Meta-analysis 1426 14.2 (0–60) 2.9% (0–4.2%) 3.9% (0–15%) 6% (0–20%) 9% —
Simon nitinol (61) 7 F Meta-analysis 319 16.9 (0–62) 3.8% (0–5.3%) 7.7% (4–18%) 8.9% (8–11%) 1.2% —
Vena Tech (61) 12 F Meta- analysis 1050 12 (0–81) 3.4% (0–8%) 11.2% (0–28%) 32% (0–32%) 14%:>10mm —
Vena Tech Low Pro le 6 F — 30 2.3 0% 0% 10.3% — —
Gunther tulip (95) 8.5 F 83 4.5 (0–36) 3.6% 9.6% — — —
TrapEase (96) 6 F Clinical trial 189 (0-24) 0% 1.5% — — —
—, none or not reported
overall mortality rate was 42.3% (sixty-six patients), and the
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30-d mortality rate was 13.5% (twenty-one patients: ten
TrapEase and eleven Green eld). ey concluded that a
higher rate of symptomatic IVC iliac vein thrombosis was
associated with TrapEase lter placement.
88
Corriere et al.
conducted a comparative analysis of
consecutive patients undergoing placement of retrievable
versus permanent IVC lters to analyze the incidence of
IVC thrombosis during a 4-year period at one institution.
A total of 189 IVC lter cases (165 permanent and 24
retrievable) were examined. Over a median follow-up of
8.5months, no signi cant hemorrhage, no IVC lter migration, and four cases of vena cava thrombosis were observed.
Vena cava thrombosis was observed more frequently with
retrievable IVC lters, compared to permanent IVC lters
(12.5% versus 0.6%; p = 0.007). All observed vena cava
thromboses were associated with severe clinical symptoms
and occurred in patients who received opposed biconical IVC lter designs (TrapEase and OptEase). Although
causative factors remain unclear, lter design and resultant
ow dynamics may play an important role, because all episodes of vena cava thrombosis occurred in patients with a
single- lter design.
89
Fox and Kahn
conducted a systematic review to
assess the frequency of symptoms and signs of postthrombotic syndrome in relation to IVC lter placement. ey
also assessed whether the initial indication for IVC lter
placement—prevention of PE in a patient without known
venous thrombosis (i.e., primary prevention) versus prevention of PE in patients with known venous thrombosis
(i.e., secondary prevention)—or concurrent use of anticoagulation or compression stockings in uenced this rate.
Eleven articles describing 1,552 patients met the criteria
for review. At a mean follow-up of 4.5years, the weighted
pooled incidence of edema was 43%, and that of chronic
skin changes (including venous ulcers) was 12%. Among
patients who had IVC lter insertion for secondary prevention, 52% had edema and 14% had skin changes at
follow-up, compared with 20% and 8%, respectively, in
patients who received an IVC lter for primary prevention. One study reported no di erence in the frequency of
symptoms and signs of postthrombotic syndrome according to whether anticoagulation was initiated in addition to
lter placement.
90
Nazzal etal.,
in a retrospective review of 400 IVC lter
implants, predominately permanent lters (80% TrapEase
and Green eld); demonstrated a signi cant di erence in
lter complications based on lter type. Migration and or
tilt were seen more frequently with Bard lters, compared
to other lters individually (p < 0.004, 11.8% versus 0.55%
as a group), and IVC thrombosis was signi cantly more
common with the TrapEase lter. Speci cally, in patients
with either hypercoagulable or malignant conditions, 25%
of patients developed IVC thrombosis with the TrapEase
lter, compared to none in its absence.
Additional complications related to permanent IVC lters include penetration and perforation of the IVC into the
gastrointestinal tract. Asystematic review of the literature
reported symptomatic duodenal perforations in twenty-one
patients. e most common presentation was abdominal
pain, with most presenting over 2years a er implant. e
most common IVC lter was the Green eld lter in 7/19
of known lter type. Management varied from the trimming of the legs of the lter with intestinal repair to com-
91
plete extraction of lter and caval repair.
FOLLOWUP AFTER IVC FILTERS
ere is no speci c protocol for late follow-up of patients
receiving IVC lters, especially when the patient is asymptomatic. It is generally believed that a simple physical
examination in conjunction with a plain abdominal X-ray
can detect the majority of complications of IVC lters. CT
scanning and duplex ultrasonography are helpful in assessing any abnormalities. Venography should be reserved for
patients in whom these modalities are not helpful.
In a prospective observational study of patients with
92
permanent IVC lters,
patients without a contraindication for anticoagulation were evaluated with duplex examination of the IVC lower extremity veins at least once per
year. Patients with IVC thrombus were managed with a
more intensive anticoagulation regimen by speci ed protocol. Despite anticoagulation, new PEs were diagnosed in
5% of patients, new DVTs in 20%, IVC thrombus in 30%,
and a major bleeding episode occurred in 7%. With these
prospective ultrasound-based ndings despite anticoagulation, it raises concerns for long-term implantation, even in
patients who can receive anticoagulation.
COMMENTS/CONCLUSIONS
Many di erent and ingenious caval lters are currently
available on the market for clinical use; however, the perfect lter has not been developed. It appears likely that
caval lters do reduce the incidence of PE, but may result in
IVC thrombosis and a higher incidence of recurrent lower
extremity DVT than is seen with anticoagulation alone.
Prospective randomized trials comparing the e cacy of lters and various lter devices are presently lacking. Each of
these lters has its own advantages and disadvantages, therefore the physician must select a lter that is suitable to his
patient and the one with which he or she is familiar. Because
of concerns over the long-term performance characteristics
of caval lters, it is best to adhere to strict indications for
lter insertion.
93
Recently, Berczi et al.
investigated the long-term
retrievability of IVC lters and whether we should abandon permanent devices, and they concluded that there is
PERMANENT VENA CAVA FILTERS • 363
still a de nite role for permanent lters, which have a far
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longer clinical practice history—and this is the Achilles heel
of the retrievable lters. Follow-up (preferably prospective)
is necessary for all retrievable lters, regardless of whether
or not they are retrieved. Until these data become available,
we should restrict ourselves to the present indications for
permanent lters. If long-term follow-up data on a larger
number of cases con rm that retrievable lters are as safe
and e ective as permanent lters, use of retrievable lters is
likely to expand.
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PERMANENT VENA CAVA FILTERS • 365
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366 • VENOUS THROMBOEMBOLISM
44.
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COMPLICATIONS OF VENA CAVA FILTERS
Teresa L. Carman and Linda M. Graham
BACKGROUND
Venous thromboembolism (VTE) is optimally treated by
anticoagulation. When anticoagulation must be withheld,
inferior vena cava (IVC) interruption a ords protection
against major embolic events. IVC interruption has progressed from cava ligation, plication, or caval clips to percutaneously placed devices. Complications associated with
surgical caval interruption and rst-generation IVC lters
have driven the modi cation and design of devices to minimize endothelial cell interaction, use smaller deployment
hardware, use alloys compatible with magnetic resonance
imaging (MRI) and computed tomography (CT) imaging,
and have decreased thrombogenicity. Currently available
devices include permanent lters that once deployed remain
in place inde nitely and optionally retrievable lters that
may be le in place permanently or may be removed within
weeks to months depending on the device. Optionally
retrievable lters have modi cations to the caval attachment
sites and/or hooks at one end to facilitate removal. is is
appealing because absolute contraindications to systemic
anticoagulation may be short-lived, and the long-term outcomes of IVC lters may not be as benign as once thought.
So optionally retrievable lters are designed to provide the
e cacy of a permanent lter and yet minimize the complications of a long-term indwelling vascular device. ere are
no unique indications or recommendations that have been
1
made regarding optionally retrievable IVC lters.
e decision regarding the use of a permanent or optionally retrievable lter must be made individually for each patient.
Table 44.1 outlines the current absolute and relative
indications for IVC lter placement. Contraindications
to anticoagulation, complications of anticoagulation, or
thromboembolism (pulmonary embolism [PE] or recurrent/propagation of deep venous thrombosis [DVT])
despite adequate anticoagulation are considered indica-
2
tions for lter placement.
ese accepted indications are
frequently expanded to include a number of relative indications. In addition, in some centers IVC lters are used for
3,4
primary prophylaxis against pulmonary embolism.
With
these indications in mind it is important to recognize that
an IVC lter does not treat VTE but protects that patient
from the most serious adverse event, massive, fatal pulmonary embolism. Anticoagulation should be initiated despite
2
the presence of a lter when deemed safe.
However, there
are no recommendations regarding the duration of anticoagulation in this setting.
ere has been a trend toward increasing IVC lter use
for both VTE management and for primary prophylaxis.
In a recent population based study of 9,665 IVC lters
the authors demonstrated a 40% increase in lter placement; 1,446 lters were placed in 1991 with an increased
to 2,447 lters in 1995. Sixty percent (5,621/9,665) of the
lters were deployed in patients without a primary diagnosis of VTE (i.e., used for primary or secondary VTE pro-
5
phylaxis).
During a 21-year period data from the National
Hospital Discharge Survey (NHDS) database demonstrated an increase in lter placement from 2,000 in 1979
to 49,000 in 1999. In 1999, 45% of lters were placed in
patients with DVT, 36% in patients with PE, and 19% of
IVC lters were placed in patients without a coded diag-
6
nosis for VTE.
Registries of patients treated for VTE have
demonstrated IVC lter insertion rates of 2% in Spain
7,8
compared with 14% in a US study.
In the US study, 33%
of IVC lters were inserted for primary prophylaxis in
patients with DVT, and 17% were placed for indications
other than the three absolute indications for IVC lter
8
placement.
e robust use of IVC lters for prophylaxis and for relative indications is concerning, given the lack of comparative
data or prospective, randomized trials regarding IVC lter
use. Most of the literature regarding the use and complications of IVC lters is derived from case series, retrospective
studies, or prospective trials enrolling patients with a single
9
lter type.
In addition, as more lters are approved there is
little long-term data for most devices.
Several comprehensive reviews of IVC lters and lter
complications have been published detailing the design,
deployment, and complications of both the permanent and
10–13
optionally retrievable lters.
e use and complications
367
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