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Table44.1 INDICATIONS FOR INFERIOR VENA CAVA
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IVC FILTER PLACEMENT
Table44.2 COMPLICATIONS RELATED TO INFERIOR
VENA CAVA FILTERS
Absolute indications
• Contraindication to anticoagulation either permanent or
temporary
• Complications of anticoagulation that prevent further therapy
• Recurrent pulmonary embolism or iliofemoral deep vein
thrombosis despite adequate anticoagulation
Relative indications
• Di culty managing anticoagulation or poor compliance
• Inability to manage anticoagulation despite patient compliance
• Massive pulmonary embolism
• Poor cardiopulmonary reserve
• Increased risk for complications of anticoagulation
• Recurrent pulmonary embolism despite an IVC lter
• Prior to pulmonary thromboendarterectomy for chronic
thromboembolic disease
• Prior to thrombolysis
• Free oating proximal deep venous thrombosis
• Iliocaval thrombus
Prophylactic indications (when mechanical or pharmacologic
prophylaxis is suboptimal)
• Trauma patients with multiple fractures, pelvic injury, spinal cord
or head trauma
• Surgical patient with high risk for VTE including neurosurgery,
orthopedic, or bariatric
• Medical patient with a high risk for VTE
Venous thromboembolism
Recurrent deep venous thrombosis
rombus propagation
Recurrent pulmonary embolism
Inferior vena cava thrombosis
Insertion site complications
Insertion site thrombosis
Hematoma/hemorrhage
Arteriovenous stula
Infection
Deployment complications
Tilting
Malposition in the incorrect vein/vessel
Failure to fully deploy
Device complications
Strut fracture
Strut embolism
IVC perforation or strut extrusion
Guide wire entrapment
Migration (proximally or distally)
Filter embolism
complications are uncommon. Four (0.16%) lter-related
14
deaths were noted in one review.
of the stainless steel Green eld lter and its modi ed designs
have been best studied and characterized. Considerably less
literature is published regarding the most recently approved
lters. One can only assume that these lters will have the
same success and complication rates as the devices that have
a longer history of use. Certainly IVC lters appear to prevent major pulmonary embolism in patients with DVT,
however, complications related to IVC lter use are not negligible. Complications may include VTE, deployment and
positioning issues, insertion site complications, and migration a er placement. Table44.2 lists complications related
to permanent or optionally retrievable IVC lters. ere
are no large case series or comparable studies examining the
true rates of complications by lter-type. It is also important
to note that radiographic follow-up a er lter placement is
not standardized and there are no guidelines for identifying patients who should undergo additional radiographic
imaging a er lter placement. Many complications, such
as minor degrees of lter migration, limited penetration
through the caval wall or even compromise of the structural
integrity of the lter, may be clinically silent. Major complications related to IVC lters, such as migration or signi cant caval perforation, are relatively rare. Life-threatening
THROMBOTIC COMPLICATIONS
rombotic complications related to IVC lters including
recurrent DVT (propagation of an existing thrombus into
additional venous segments or involvement of new venous
segments including the contralateral limb), PE, IVC or lter thrombosis, and insertion site thrombosis are well documented, however, they have not been thoroughly studied.
ere are no prospective comparative studies of IVC lters
so it is di cult to determine whether the risk of recurrent
venous thrombosis relates to the presence of a lter or if
speci c design issues are related to thrombogenesis. Since
it is unlikely that comparative studies of speci c devices will
be performed, however, further study of lter design and
thrombogenicity may help clarify factors contributing to
these events.
D V T
A comprehensive review of IVC lters by Strei in 2000
reported on complications from the then available lters
including the stainless steel Green eld (SSG), titanium
Green eld (TG), Bird’s Nest (BN), Simon nitinol (SN),
368 • VENOUS THROMBOEMBOLISM
and Vena Tech (VT). 11 Most studies involved relatively few
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patients and were either retrospective reviews or prospective follow-up performed by chart review, questionnaires, or
clinic visits as opposed to serial radiographic surveillance. In
this review the SSG and the BN lters had the lowest rates
of recurrent deep venous thrombosis, 5.9% and 6%, respec-
11
e highest rates of DVT have been seen with the TG
tively.
(22.7%), the VT (32%), and the TrapEase lters (45.7%).
11,12
Both retrospective and prospective studies have demon-
strated an increased incidence of recurrent DVT a er IVC
15–17
lter placement despite the use of anticoagulation.
e
only prospective, randomized trial of IVC lter outcomes
was performed by the PREPIC study group. Four hundred
patients with proximal DVT at risk for PE were randomized to receive treatment with either anticoagulation alone
or an IVC lter followed by anticoagulation. is trial used
the Vena Tech and the Titanium Green eld lters in 56%
and 26.5% of patients, respectively, and there was no signi cant di erence in the duration of anticoagulation between
16
the two groups.
At both 2 and 8years of follow-up, there
was a signi cantly increased risk of recurrent DVT in
patients with an IVC lter compared to patients without
15,16
lters (Table44.3).
If recurrent deep venous thrombosis is suspected,
patients should undergo further evaluation. Imaging with
venous duplex ultrasound or venogram may help determine
whether the patient has had proximal or distal propagation
of existing thrombus or recurrent DVT in a new venous segment. In some cases determining the age or chronicity of the
thrombus is di cult. In this setting further investigation
with D-dimer or alternative imaging modalities may assist
in making the determination.
Given the risk for recurrent VTE, anticoagulation
should be initiated when possible even a er an IVC lter
has been placed. Guidelines have been published regarding current anticoagulation recommendations. It is unclear
at this time whether the presence of an IVC lter should
extend the duration of anticoagulation for a particular
2,18
clinical situation.
Some practitioners advocate long-term
anticoagulation in patients with vena caval lters, but this
has not been well studied. For now, the duration of antico-
2
agulation must be individualized for each patient.
P E
IVC lter placement is one method of managing DVT
and preventing PE in patients unable to be anticoagulated.
However, despite IVC interruption, PE may occur. e origin of pulmonary emboli in this setting includes propagation of thrombus proximal to the IVC lter (Figure44.1),
small emboli that pass through the lter, emboli from
unprotected venous beds including the upper extremity, or
embolism through developed pelvic or abdominal veins or
collaterals such as the azygous or ovarian vein. Cumulative
rates of recurrent symptomatic PE in the PREPIC trial were
1.1%, 3.4%, and 6.2% at 12 d, 2-year, and 8-year follow-up,
respectively. At 2years there was no di erence in the rate
of symptomatic PE between the groups, however, by 8years
of follow-up there was a 63% decrease in the risk of recurrent PE in patients with an IVC lter compared to patients
without (Table44.3).
15,16
Two patients (1%) su ered fatal PE.
From the
reviews by Strei and Kinney, forty studies of the SSG lter
demonstrated a composite rate of pulmonary embolism of
11,12
2.6%, with a range of 0–9%.
e composite rates for the
other available lters were:TG 3.1% (range 0–3.8%), BN
2.9% (range 0–4.2%), SN 3.8% (range 0–5.3%), and VT
3.4% (range 0–8%). e rates of fatal pulmonary embolism
were between 0.3% in the VT series up to 1.9% for the SN
11,12
lter.
Athanasoulis etal. documented a fatal PE rate of
3.7% following lter insertion in a 26-year review of their
Suprarenal
Günther-Tulip
lter
rombus
Recovery
lter
Table44.3 2YEAR AND 8YEAR RESULTS OF THE
PREPIC TRIAL OF ANTICOAGULATION WITH OR
WITHOUT AN INFERIOR VENA CAVA FILTER TO
PREVENT PULMONARY EMBOLISM
RECURRENT DVT SYMPTOMATIC PE
2 Years 8 Years 2 Years 8 Years
Filter 20.8% 35.7% 3.4% 6.2%
No Filter 11.6% 27.5% 6.3% 15.1%
P 0.02 0.16 0.042 0.008
From References 15 and 16.
Figure44.1 rombus both within and above a lter (inset) demonstrated
by venogram in a patient who developed massive pulmonary embolism
despite the presence of an infrarenal Recovery lter. Asuprarenal
Günther-Tulip lter was placed to protect against further embolism
until anticoagulation could be initiated.
COMPLICATIONS OF VENA CAVA FILTERS • 369
IVC lter experience. 19 So, the rates reported for recurrent
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symptomatic pulmonary embolism and fatal pulmonary
embolism are not negligible. Studies have not addressed
clinical conditions likely to predispose to this complication.
In a patient with suspected PE, PE protocol chest CT,
pulmonary angiography, or ventilation/perfusion nuclear
medicine lung scanning should be performed. If the diagnosis is con rmed, the source of the event should also be
identi ed. IVC lter thrombosis can be investigated using
contrast enhanced abdominal CT with venous phase imaging or contrast vena cavography. Duplex ultrasound of
unprotected venous beds should also be performed to evaluate other potential sources of embolism.
IVC THROMBOSIS OR OCCLUSION
IVC thrombosis may result from innate thrombogenicity
of the lter, trapped emboli within the lter, or propagation of thrombus through the venous system up to and
including the lter (Figure44.2). e PREPIC trial documented symptomatic IVC thrombosis in 13% of patients
16
a er 8-years of follow-up.
Other reports have documented
IVC lter thrombosis rates of 0–31%. Once again the SSG
and BN lters have documented the lowest rates of IVC
thrombosis, 3.6% and 3.9% respectively. e highest rates
10
of IVC thrombosis occurred with the VT lter, 11.2%.
In
initial studies, the TrapEase lter had a documented IVC
20
lter thrombosis rate at 6months of 3.1%.
Early studies of optionally retrievable lters docu-
mented IVC thrombosis in up to 10% of patients with the
21,22
Günther-Tulip lters.
In addition, thrombus trapped
within the lter at attempted retrieval has been documented
in 10% of Günther-Tulip and 22% of Recovery lters suggesting the lters may have performed well in preventing
21
whether this could lead to eventual caval thrombosis
PE;
if the lter is not removed is unknown. Longer follow-up is
required to determine whether the rates of IVC thrombosis in optionally retrievable lters will remain constant or
increase overtime.
When IVC thrombosis is identi ed, or if the source of
the pulmonary embolism is suspected or documented to
be due to thrombosis proximal to the lter, management
must be individualized. One option is placement of a more
proximal vena caval lter, typically suprarenal placement
(Figures44.1 and 44.2). e major concern in this setting
is the continued propagation of the thrombus with the
potential for involvement of the renal veins. In the hands of
a skilled interventionist, lter thrombosis can be managed
by endovascular techniques (Figure44.3). Mechanical and
TrapEase
lter
Figure44.2 Chronic IVC and lter thrombosis demonstrated below a
TrapEase lter with collateral drainage.
Greeneld
lter
Bird’s nest
lter
Figure44.3 Bilateral iliac vein stents in a patient with chronic venous
occlusion following Bird’s Nest and Green eld lter placement.
370 • VENOUS THROMBOEMBOLISM
pharmacologic thrombolysis may be used to restore patency
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23–25
of the IVC lter.
Other endovascular techniques including balloon maceration of the thrombus or stent placement
to collapse the lter and exclude it from the IVC have been
23,26
reported.
POSTTHROMBOTIC SYNDROME
A er a DVT, clinical symptoms of the postthrombotic
syndrome increase over time. At 8-year follow-up, postthrombotic symptoms are observed in approximate 70% of
patients with DVT with or without IVC lter placement.
16
Fox and Kahn recently published a review of postthrombotic syndrome (PTS) related to IVC lter placement for
either primary or secondary prophylaxis. ey included
1,552 patients in 11 studies in their pooled analysis. Overall,
43% (647/1,507), 12% (176/1,470) and 3.4% (501/1,470)
of patients su ered edema, trophic skin changes of PTS,
or venous stasis ulcers following IVC lter placement.
27
Given the high rate of postthrombotic complications in
patients with VTE, recurrent symptoms of discomfort, erythema, edema, and increased warmth are not uncommon
and may lead to repeated investigation for recurrent DVT.
Compression stockings are recommended following a DVT
with or without IVC lter placement to decrease the development of PTS symptoms.
INSERTION SITE COMPLICATIONS
Insertion site DVT is likely the most common access site
complication following IVC lter placement. With routine
surveillance, insertion site thrombosis has been identi ed in
14–64% of patients. Since IVC lters may be inserted by
femoral, jugular, or brachial routes, insertion site thrombo-
12
sis may occur in an unprotected venous bed.
e newer
low-pro le delivery systems may decrease the risk for insertion site thrombosis, but to document the actual frequency
of this complication, studies will need to incorporate routine surveillance of the insertion site into protocols.
DEPLOYMENT COMPLICATIONS
Deployment complications are largely dependent on the
technical skill and the equipment used to place the lter
as well as the lter type. ese complications may be generalized into tilting or malposition, incorrect anatomical placement, or failure of the device to fully deploy at
its intended site. An incorrectly deployed lter may not
achieve the desired protection from pulmonary embolism
and yet exposes the patient to all the complications of the
procedure, the potential for migration, and possible thrombosis as previously discussed. In addition, the patient and
the physician may derive a false sense of security from the
lter placement, despite the suboptimal deployment. us,
incorrect deployment of a lter has clinical implications as
well as possible secondary complications.
Insertion site complications a er lter placement have
perhaps the most varied manifestations. ese complica-
12
tions occur in 4–11% of all lter insertions.
Some are
site-dependent while others may be directly related to the
device delivery system. Insertion site complications range
from minor bleeding to major complications that may be
the source of signi cant morbidity and even mortality.
Death related to IVC lter insertion has been reported to
12
occur in 0.12% of patients.
Most of the complications are similar to other procedures in which central venous access is obtained; bleeding
(major or minor), arteriovenous stula, infections, vessel
damage/rupture, and access site thrombosis. Some of the
vascular complications at the access site are considered to be
directly related to the pro le of the delivery system. is has
been a major reason for the development of new lters with
a lower pro le delivery system, which limits the size of the
venipuncture and potentially decreases these complications.
e internal jugular vein is o en a preferred site of access,
but due to its anatomic proximity to vital structures, complications related to access at this site may have devastating
consequences. Stroke caused by inadvertent carotid puncture, pneumothorax, vocal cord paralysis caused by damage
to the recurrent laryngeal nerve, arrhythmia, and air embolism have all been documented.
MALPOSITIONING
Filter malposition or tilting theoretically may result in
inadequate protection from pulmonary embolism. For
permanent lters, this is traditionally managed with either
observation or additional lter placement, typically in the
suprarenal position. In a single-center study of 486 patients
undergoing duplex ultrasound-guided (n=435) or intravascular ultrasound (IVUS)-guided (n = 51) IVC lter
insertion, by Corriere et al., twelve patients (2.4%) had
inadequate positioning as determined by postoperative
28
radiography.
Two of these patients had no further lter
manipulation, three had a second lter placed under uoroscopic guidance, and ve patients had lters retrieved and
repositioned under uoroscopic guidance. All ve patients
undergoing retrieval and repositioning in this series had
Green eld lters, which are not traditionally regarded as
retrievable. is manipulation was possible using endovas-
28
cular techniques.
In another long-term study of Green eld
lters followed by abdominal radiography, Messmer etal.
reported ve patients (7%) in whom the lter was at an
29
angle of more than 16 degrees from the vertical.
Achange
in lter angle may result from displacement of a strut into
the right renal vein as well as from physiologic changes.
29
Retrievable lters are typically manipulated at the time of
insertion to achieve minimal tilting. In the review by Stein
COMPLICATIONS OF VENA CAVA FILTERS • 371
etal., 12% (20/169) of Günther-Tulip lters and 6% (2/32)
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21
Recovery lters were tilted.
e e ect of IVC lter tilt and asymmetry on lter
function is considered controversial. Clinical concerns
include reduced protection from emboli due to a larger
space between the struts allowing transit of thrombi as well
as a potential for increased thrombogenicity due to ow disturbances from the asymmetric lter struts along the vessel
wall. Astudy conducted by Katsamouris etal. demonstrated
when centered, the original Green eld IVC lter allowed
passage of small clots, and eccentric positioning (de ned
as >14°) allowed small and large clots to pass through the
30
Another study by Green eld and Proctor showed
lter.
that alignment only assumed importance when the IVC
31
is larger than 22mm.
One clinical study evaluated recurrent PE and caval thrombosis in patients with titanium
Green eld IVC lters and included a subgroup analysis of
patients with lter asymmetry, de ned by strut pattern in
the cava. Out of a total of 738 lters, asymmetry was found
in 42 cases (5%). Recurrent PE was diagnosed in a total of
3 of 35 patients (8.6%) with asymmetric lters compared
with 11 of 338 patients (3.3%) with symmetric IVC lters
32
( P =NS).
While it is di cult to know exactly how tilting or malpositioning a ects the functioning of a given device in
view of the lack of routine clinical follow-up, device modi cations have been used to reduce this complication. e
currently available Green eld lters use a guide wire deployment system designed to promote midline deployment.
Other devices have adopted a symmetrical lter design to
optimize vertical deployment. Modi cations such as a dual
level lter design have also been used optimize centering
and to provide more e cient thrombus trapping.
vena cava, double cava, le -sided vena cava, caval thrombus, circumaortic renal veins, retroaortic veins, multiple
renal veins, or congenital absence of the kidneys may a ect
deployment. In one study, anatomical variation or IVC
thrombosis was documented in 9.6% of patients prior to
deployment and warranted an adjustment in the deploy-
19
ment strategy in 4% of patients.
Imaging by venography/
cavography using iodinated contrast, gadolinium, or occasionally carbon dioxide has traditionally been used prior
to IVC lter placement. More recent reports have focused
on using duplex ultrasound or IVUS, which may allow for
bedside insertion in patients who are critically ill or if transportation is di cult due to extensive spine or orthopedic
injuries.
FAILURE TODEPLOY
e failure of vena caval lters to fully deploy is frequently discussed but rarely documented in the literature
(Figure 44.4). While this complication may manifest as
lter migration or even embolization, most cases are not
clinically apparent. Partial deployment has usually been
attributed to a malfunction of the lter itself that occurs
on a case-by-case basis and is not necessarily design speci c. In one study of Vena Tech lters, major complications
of placement occurred in three patients, all when the right
internal jugular vein was used for introduction. One lter
was inadvertently placed in the right renal vein and two
INADVERTENT DEPLOYMENT IN AN
INCORRECTVESSEL
Filter deployment in the incorrect vessel or at an unplanned
location in the appropriate vessel can occur. Misplaced lter
18
deployment has been documented in the right atrium.
33
innominate vein,
renal veins or partially within a renal vein,
34
Forty-six IVC lters that were inadvertently placed
vein.
above the renal veins, juxtaposed to the
19
and in the iliac
the
in the suprarenal IVC, juxtarenal IVC, or renal vein were
19
compared with infrarenal IVC lters.
No di erences in
lter e cacy were identi ed. PE a er lter placement was
identi ed in 7% of patients, but renal complications were
19
not discussed.
Although a misplaced lter is an unusual
complication and in most cases is tolerated without clinical e ect, serious consequences may occur in some settings
and the utmost care should be used to avoid inadvertent
deployments.
Venous anomalies may lead to problems in lter deployment. Anomalous IVC or renal vein anatomy, megacava
(>30 mm), small caliber cava, congenital absence of the
372 • VENOUS THROMBOEMBOLISM
Greeneld
lter
Figure44.4 Partial deployment of this Green eld lter was documented
by abdominal radiograph.
lters failed to open fully. 35 Deployment complications
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with the Green eld lter and modi ed designs have been
19
documented in another series.
e TrapEase lter has not
demonstrated failure to deploy, however, lter shortening
20
and maldeployment have been documented.
In many cases
the failure to fully open can be addressed at the time of lter placement with endovascular manipulation of underdeployed or partially deployed l t e r s .
DEVICE COMPLICATIONS
Vena Tech
lter
L
Complications that are device and equipment speci c provide an impetus for the development of new lter designs
and delivery systems. Strut fracture due to compromise of
the structural integrity of the lter has been documented
19
for most lter designs.
To date there are no large series
comparing strut fractures among di erent lter types.
Because of the lack of routine imaging follow-up, the identi cation of a strut fracture is typically a serendipitous discovery during radiological imaging performed for other
clinical indications. Clinical issues may arise when a fractured strut embolizes to the cardiopulmonary circulation or
is extruded thru the IVC into adjacent structures. In some
cases the fractured leg may be retrieved and in other cases
36
this may be impractical.
e most vulnerable points for
fracture are welded seams. To this extent lters such as the
TrapEase or OptEase, which are laser cut in a unibody style,
are less likely to have fracture complications.
Guide wire entrapment is another device-related complication that may occur at the time of lter placement or
when a wire is passed thru the lter for central access. In
one in vitro study, the TrapEase lter entrapped 3.0-mm
and 1.5-mm J-tipped guide wires, whereas the Vena Tech LP
37
(low pro le) and Günther Tulip lters did not.
Another
study described entrapment of both the 1.5-J and 3-J guide
wires by the stainless steel Green eld and Vena Tech LGM
38
devices.
e 1.5-J guide wire became entrapped regardless of engagement pattern; while the 3-J became entrapped
only when engaged in the hole in the apex of the SSG and
VT lters. In a series of superior vena cava lters, 56% of
patients had subsequent central access without complica-
39
In another series, one lter was dislodged during
tions.
central line placement and repositioned into the innomi-
33
nate vein.
is complication may be avoidable if uoroscopy is used during central access in patients with residing
lters. Retrieval of an entrapped guide wire can be a technically challenging proposition, snares and other endovascular devices may be used for percutaneous retrieval.
Figure44.5 Vena Tech lter with migration to the level of the intrahepatic
inferior vena cava demonstrated on CTscan.
position as well as dimensions over time.
40
ese changes
can result clinically in lter migration or penetration/extrusion through the vessel wall. Case series have documented
10
migration in all lter types.
e Vena Tech lter appears to
be most a ected by this complication; up to 18% migrated
10
in one study.
Migration may be cephalad or caudal; typically movement >20mm is considered clinically signi cant.
In one study of sixty-nine patients with a Green eld IVC
lter in place for 1–9years evaluated with supine abdominal radiographs, the lter span diameter had increased by
3–11mm in twenty-two (32%) patients, and had decreased
by 3–18mm in six patients (9%). Twenty patients (29%)
had caudal migration of 3-18mm, and four (6%) had ceph-
29
alad migration.
Proximal migration to clinically signi cant structures
such as the intrahepatic IVC (Figure 44.5) or the right
19
atrium may occur.
Anumber of case reports describe serious complications of embolization to the heart, including
pericardial tamponade and intracardiac migration with
40,41,42
life-threatening arrhythmias.
Retrieval of these lters has been attempted using endovascular techniques.
However, because of the unusual location, retrieval may
require extraordinary measures including surgical procedures with cardiopulmonary bypass or circulatory arrest.
It is unclear what places a patient at risk for lter embolism. Occasionally, embolization is considered to have
occurred because of a large thrombus burden entrapped
22,40
within the lter.
Routine clinical follow-up and serial
radiographic surveillance has not been advocated following IVC lter placement, so migration is usually identi ed serendipitously unless a serious clinical consequence
o c c u r s .
Filters are long-term intravascular devices that are subject to a number of external forces that may change their
M I G R A T I O N
COMPLICATIONS OF VENA CAVA FILTERS • 373
E X T R U S I O N
Most lters will have some change in dimension following
30
placement.
wall is a near universal phenomenon (Figure44.6).
Extrusion of the lter struts through the caval
10,40,43
Filter
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legs
Figure44.6 Bard G2 lter with strut foot penetration through the IVC
wall (arrows).
In a study to determine the long-term clinical and radiographic outcome of patients who undergo insertion of a Bird’s
Nest lter, perforation of the caval wall was universal but
44
not clinically symptomatic.
Strut extrusion typically does
not assume clinical importance until there is involvement of
adjacent structures and associated clinical complications.
ere are a number of case reports in the literature detailing individual clinical experiences and unusual complications
resulting from strut or even lter extrusion from the IVC.
Reports of small bowel obstruction occurring as a result of
45
volvulus occurring around an extruded lter strut,
a frag-
mented IVC lter penetrating the aorta and causing a small
46
infrarenal aortic pseudoaneurysm,
by transcaval penetration of a Bird’s Nest lter,
hydronephrosis caused
47
laceration of
a lumbar artery by a stainless steel Green eld lter strut that
48
resulted in a near fatal hemorrhage,
and upper gastrointes-
tinal bleeding secondary to Bird’s Nest inferior vena caval
49
lter migration into the duodenum
to name a few. ese
are rare, usually reportable, complications of lter placement.
RETRIEVAL COMPLICATIONS
e optionally retrievable lters typically have FDA approval
for both permanent and retrievable options. However, most
of the optionally retrievable lters have little to no data
available on their long-term performance when used as
permanent lters. ere are no unique indications for the
use of optionally retrievable lters compared to permanent
devices. In addition, there are no absolute indications for
retrieval or removal of an IVC lter unless it is a source of
1
morbidity.
When used as an optionally retrievable lter,
two visits to the interventional suite are required; initially
for placement and when indicated for removal. is creates a potential for increased numbers of complications not
only related to the device or to venous access (Table44.2)
but also an entirely new category of complications related
to the explantation of devices. Retrieval complications may
include injury to the IVC during retrieval, failure to retrieve,
device fracture, and retained legs/hooks. Furthermore,
explantation complications can be of a serious nature (e.g.,
caval perforation).
e FDA has recommended maximum dwell times
before which the devices should be retrieved. However,
studies have demonstrated safe retrieval with longer indwell-
50
ing durations. Binkert et al.
have reported the retrieval
of such type of lter at 317 days without complications
on follow-up venogram. Repeated repositioning has been
51
used to prolong the deployment of these devices.
While
most retrievable IVC lters are placed in patients with a
well-de ned, short-term risk for VTE and contraindications to anticoagulation, the percentage of retrievable lters
52
actually removed is less than 50%.
e most common reason stated for not retrieving a lter is due to caval or lter
thrombus or continued contraindication to anticoagulation. All retrieved lters have strands of organized thrombus
on the lter struts. e presence of small thrombi does not
dictate the need to abort the retrieval, but larger thrombi
preclude lter removal. Given the large numbers of these
lters remaining in situ, data on the potential longer-term
complications of these lters should be emerging.
Data on failed retrievals based on technical di culties
is sparse. Most limited case series of the various lter types
report successful snaring and device retrieval with no caval
53,54
injuries.
angulation within the vena cava that precluded safe capture.
In one series, retrieval failure was related to device
53
Di culties with retrieval may be encountered more frequently with longer dwell times, but data is lacking at present.
SPECIAL CONSIDERATIONS
ere are identi ed patient populations in whom IVC lter
use generates special consideration. ese include trauma
patients, children, pregnant women, and patients with septicemia. In the trauma population IVC lter placement has
gained popularity as a mechanism of both primary and secondary prophylaxis. e body of literature regarding lter
use in this setting is growing. On the other hand, very few
studies focus on lter placement in children, during pregnancy, or in patients with septicemia.
In most clinical settings lters are deployed into the infrarenal IVC. However, placement in the suprarenal IVC or
superior vena cava has also been used for speci c clinical indications. Superior vena cava positioning has been employed to
protect against embolism from upper extremity DVT.
T R A U M A
e use of IVC lters for primary prophylaxis in trauma
patients has increased, especially when sequential compression or pharmacologic therapy is contraindicated, for
374 • VENOUS THROMBOEMBOLISM
example, in vertebral fracture or spinal cord injury, multiple
https://t.me/med1917
lower extremity fractures, and closed head injury. e use
of IVC lters for primary prophylaxis in this setting is open
to controversy. Analysis of 450,375 patients registered in
the American College of Surgeons National Trauma Data
Bank identi ed a VTE (DVT, PE, or both) rate of 0.36%.
e mortality rate in patients with PE was 18.7%. Atotal of
3,883 patients had IVC lters placed; 83% were prophylactic. is analysis also identi ed risk factors for VTE including:age ≥40(OR 2.29); pelvic or lower extremity fracture
(OR 2.93 and 3.16 respectively); spinal cord injury with
paralysis (OR 3.39); head injury (OR 2.59); more than 3d
of ventilator dependency (OR 10.62); venous injury (OR
55
7.93); shock (OR 1.95); and major surgery (OR 4.32).
Yet
data regarding IVC lter use in the trauma setting is based
solely on case series reports and retrospective registry studies. Girard etal. reviewed sixteen series published before
56
1999 with a total of 1,112 trauma patients.
PE occurred
following IVC lter placement in 0-3.9% of cases. Fatal PE
was documented in a single patient in each of two studies.
DVT was identi ed in 0–20.6% of patients. IVC thrombosis or occlusion occurred in 0–6.7% of cases. Insertion site
thrombosis and procedural complications were identi ed in
56
0–5.7% and 0–4.6% of cases respectively.
e results do
not support the general use of lters in all trauma patients,
but since this review encompassed reports prior to 1999,
the use of newer, low pro le devices may demonstrate more
favorable results. Furthermore, selected use of lters in
high-risk subgroups of trauma patients may be appropriate.
Optionally retrievable lters have also been used in the
trauma population. In recently published series, recurrent
DVT was documented in 2.9% and 8.6%; and in one study,
34,57
insertion site DVT was documented in 1.9%.
Filter
retrieval was successful in 51% and 66% of patients. If the
practice of permanent or optionally retrievable lter placement for primary prophylaxis in the trauma population is to be
supported, further systematic study is should be encouraged.
CHILDREN
romboembolic events are less frequent in children than
adults. When present, the options for therapy remain the
same. e potential for growth and increased life-expectancy
for children raises concerns regarding the use of IVC lters.
One study has published results of IVC lter placement in
een children with clinical follow-up. No insertion complications, migration, or lter related mortality occurred.
During follow-up, one patient demonstrated PTS symptoms
and three patients had common femoral vein re ux, but no
58
recurrent PE occurred.
In another study of eight patients;
three patients died. e remaining ve patients, followed
up to 13 months, demonstrated no lter migration, IVC
59
occlusion or thrombosis, or symptomatic PE.
Chaudry
etal. published their experience with deployment in three
60
children with successful retrieval in two.
From the limited
data available, IVC lter placement in children may serve as
a useful management tool in patients with a contraindication to anticoagulation. Children do not appear to have an
increased risk of complications compared with other study
groups. However, if successful retrieval can be accomplished
this may also decrease concerns for long-term complications.
S E P T I C E M I A
Infectious complications of IVC lters appear as case
61
reports,
but there is a paucity of data regarding this complication or the use of lters in septic patients. e single retrospective publication of IVC lter placement is patients with
septicemia demonstrated no need for lter retrieval due to
62
infectious complications.
Documented 30-d survival was
67%. Filter complications included caval occlusion (1%),
recurrent nonfatal PE (1%), recurrent DVT (2.9%), and
procedure/deployment complications in 8.6% of patients.
62
Rare case reports of IVC lter infection should not sway the
decision to place an IVC lter when clinically indicated in
patients with septicemia.
A T Y P I C A L F I L T E R L O C A T I O N
Nontraditional locations for lter placement are used in
various clinical circumstances. Filters may be place in iliac
veins in patients with a mega cava (>40mm). Suprarenal
IVC lter placement may be indicated in patients with an
anomalous IVC, thrombus or mass in the IVC that precludes infrarenal placement, or lter occlusion or thrombosis. Suprarenal placement has also been advocated in women
who are pregnant or of child-bearing age, although there is
63
very little literature to support this practice.
Concern surrounds suprarenal IVC lter placement due to the risk for
IVC thrombosis or thrombus propagation and the potential
for fatal renal vein thrombosis. is complication has been
59,63,64
seen, however, it appears to be relatively rare.
From one
survey of cancer patients with suprarenal IVC lter placement two of thirteen patients developed renal vein throm-
64
Green eld etal. reviewed data on 148 suprarenal
bosis.
IVC lters and compared outcomes to 1,932 infrarenal
65
IVC lters placed during the same period.
Overall there
was no statistically signi cant di erence in the complication rates between the two lter groups. Recurrent PE was
documented in 8% and 4% of suprarenal IVC and infrarenal IVC lters, respectively. Caval occlusion was found in
65
5% of patients. ere were no renal complications.
While
suprarenal IVC lter placement does not appear to be
complicated by a preponderance of renal vein thrombosis,
in patients with advanced malignancy, a single functioning kidney, chronic kidney disease, or previous renal vein
thrombosis, suprarenal IVC lter placement should be
avoided if possible.
In view of the very limited treatment options available,
superior vena cava lters are sometimes used in patients
COMPLICATIONS OF VENA CAVA FILTERS • 375
with upper extremity DVT who have a contraindica-
https://t.me/med1917
tion to anticoagulation or experience PE despite adequate
33,39
anticoagulation.
In one series, no lter migration, dislodgement, or fracture was identi ed in forty-one patients
(median follow-up 12 weeks). No clinical symptoms of
SVC syndrome were identi ed. Central venous catheters
or Swan-Ganz catheters were subsequently placed in 56%
of patients without complication. One patient had sub-
39
sequent PE related to le lower extremity DVT.
Usoh
etal. reviewed their experience in 154 patients with SVC
33
lter placement.
Only y-eight patients survived longer than 60 d.In-hospital death was documented in 49%
of patients unrelated to the SVC lter or VTE. In forty of
the y-eight patients surviving more than 60 d, no migration was identi ed by follow-up radiographs. One lter was
misplaced in the innominate vein and remained patent at
2months of follow-up. No patients had clinical symptoms
of PE or SVC thrombosis following lter placement. ree
patients su ered SVC perforation and cardiac tamponade.
One patient was noted to have an aortic perforation at the
33
time of autopsy.
Upper extremity DVT is not free of typical thromboembolic complications. SVC lter placement
may be an alternative form of management in this clinical
setting. However, the relative increase in the use of indwelling catheters and transvenous devices such as pacemakers
and de brillators may make permanent deployment of a
lter in this position less favorable. Optionally retrievable
lters may have a role in this setting, but data is lacking at
present.
C O N C L U S I O N
IVC lter use is increasing. In many cases the deployment is
for indications other than a contraindication or complication
of anticoagulation. Device development and design has been
directed toward decreasing the complications associated with
IVC lters. Despite device improvements, complications
related to IVC lters remain a signi cant clinical concern.
Deployment should be used when clinically indicated; however, a focus on retrieval when possible may also be warranted.
Further study of all of these considerations is warranted.
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lter repositioning to prolong
COMPLICATIONS OF VENA CAVA FILTERS • 377
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