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19.3 Conclusions forClinical Practice
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reintervention, including for in-stent restenosis in 44 limbs, stent compression in 2
limbs, in-stent restenosis and stent compression in 48 limbs, and stent occlusion in
17 limbs. Use of a composite stent conguration of Wallstent and Z stent in patients
requiring iliac vein stenting resulted in improved outcomes compared to published
data from use of Wallstents alone. A composite stent conguration resulted in less
need for contralateral iliac vein stenting and less contralateral deep vein thrombosis
than the use of Wallstents alone.
Robertson etal. [25] evaluated the association between stent length and patency
in patients treated for iliofemoral venous outow obstruction. A total of 108 patients
(58.3% female) had had 6-month duplex ultrasound scans available for review.
Their mean age was 55.6 +/− 17.2years. Overall, the 6-month patency was 89.9%.
Of the 108 patients, 56 (51.9%) had had a total stented length of ≤100mm with a
6-month patency of 92.9%. The remaining 52 patients (48.1%) had had a total
stented length>100mm with a 6-month patency of 86.5%. The rate of patency did
not differ signicantly between the two groups (P=.222). Stent patency at 6months
for patients with nonthrombotic iliac vein lesions (NIVLs) was 98% (40 of 41).
Stent patency for patients with post-thrombotic venous stenoses (PTs) was 84% (32
of 38). Patency for patients with acute DVT who had undergone stenting after
thrombectomy was 86% (25 of 29). Overall, 10 patients with thrombotic disease,
including PT and acute DVT, had developed stent thrombosis. The total stented
length was not predictive of the loss of patency. The ndings from the present study
suggest that the length of stent coverage does not differ in the likelihood of stent
thrombosis for patients with NIVLs and PTs. Interventionalists should treat affected
venous segments identied on IVUS and effectively stent from normal to normal
venous areas.
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19.3 Conclusions forClinical Practice
1. Patients with proximal DVT should be anticoagulated for at least 3-months.
2. In the absence of contraindications, DOACs should be preferred as rst-line
anticoagulant therapy in non-cancer patients with proximal DVT.
3. Catheter-directed thrombolysis (CDT) and pharmacomechanical catheter-
directed thrombolysis (PCDT), in experienced centers, may be considered in
select patients with acute (≤14 days) symptomatic, extensive proximal DVT
who have good functional capacity, ≥1-year life expectancy, and low expected
bleeding risk.
4. Balloon angioplasty with or without stenting of underlying anatomic venous
lesions may be considered after CDT and PCDT as a means to prevent rethrombosis and subsequent PTS.
5. In patients with PTS, a composite stent conguration resulted in less need for
contralateral iliac vein stenting and less contralateral deep vein thrombosis than
the use of Wallstents alone.
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19 Deep Vein Thrombosis oftheLower Limb andPost-Thrombotic Syndrome
6. A staged approach to iliofemoral stenting in patients with PTS and bilateral
symptoms focusing initially on the more symptomatic limb is suggested.
7. For patients with deep vein thrombosis treated by early thrombus removal, with
or without stenting, it is recommended that the duration of anticoagulation
should be at least as long as if the patients were treated by anticoagulation alone
and at the discretion of the treating physician.
References
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of aorta and peripheral vascular diseases and pulmonary circulation and right ventricular function. Eur Heart J. 2018;39:4208–18.
2. Kahn SR, Comerota AJ, Cushman M, etal. American Heart Association Council on Peripheral
Vascular Disease, Council on Clinical Cardiology, and Council on Cardiovascular and Stroke
Nursing. The postthrombotic syndrome: evidence-based prevention, diagnosis, and treatment strategies: a scientic statement from the American Heart Association. Circulation.
2014;130:1636–61.
3. Stevens SM, Woller SC, Baumann Kreuziger L.Executive summary: antithrombotic therapy
for VTE disease: second update of the CHEST guideline and expert panel report. Chest.
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4. De Maeseneer MG, Kakkos SK, Aherne T, et al. Editor's choice—European Society for
Vascular Surgery (ESVS) 2022 clinical practice guidelines on the management of chronic
venous disease of the lower limbs. Eur J Vasc Endovasc Surg. 2022;63:184–267.
5. Kakkos SK, Gohel M, Baekgaard N, etal. Editor's choice—European Society for Vascular
Surgery (ESVS) 2021 clinical practice guidelines on the management of venous thrombosis.
Eur J Vasc Endovasc Surg. 2021;61:9–82.
6. Broderick C, Watson L, Armon MP. Thrombolytic strategies versus standard anticoagulation for acute deep vein thrombosis of the lower limb. Cochrane Database Syst Rev.
2021;1:CD002783.
7. Javed A, Machin M, Gwozdz AM, Turner B, Onida S, Shalhoub J, Davies AH.Meta-analysis
of lytic catheter-based intervention for acute proximal deep vein thrombosis in the reduction of
post-thrombotic syndrome. J Vasc Surg Venous Lymphat Disord. 2023;11:866–75.
8. Li W, Zaid Al-Kaylani A, Zeebregts CJ, El Moumni M, de Vries JPM, van der Doef HPJ,
Bokkers RPH.Effectiveness and safety of catheter-directed thrombolysis in conjunction with
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9. Vedantham S, Goldhaber SZ, Julian JA, et al. ATTRACT Trial Investigators.
Pharmacomechanical catheter-directed thrombolysis for deep-vein thrombosis. N Engl J Med.
2017;377:2240–52.
10. Yang X, Zhang X, Yin M, Wang R, Lu X, Ye K.Elastic compression stockings to prevent postthrombotic syndrome in proximal deep venous thrombosis patients without thrombus removal.
J Vasc Surg Venous Lymphat Disord. 2022;10:293–9.
11. Tang A, Lakhter V, Zack CJ, Comerota AJ, Shah N, Zhao H, Bashir R.Contemporary nationwide trends and in-hospital outcomes of adjunctive stenting in patients undergoing catheterdirected thrombolysis for proximal deep venous thrombosis. J Vasc Surg Venous Lymphat
Disord. 2021;9:62–72.
References
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12. Brailovsky Y, Yeung HM, Lakhter V, Zack CJ, Zhao H, Bashir R. In-hospital outcomes of
catheter-directed thrombolysis versus anticoagulation in cancer patients with proximal deep
venous thrombosis. J Vasc Surg Venous Lymphat Disord. 2020;8:538–44.
13. Pouncey AL, Gwozdz AM, Johnson OW, Silickas J, Saha P, Thulasidasan N, Karunanithy
N, Cohen AT, Black SA.AngioJet pharmacomechanical thrombectomy and catheter directed
thrombolysis vs. catheter directed thrombolysis alone for the treatment of iliofemoral deep
vein thrombosis: a single centre retrospective cohort study. Eur J Vasc Endovasc Surg.
2020;60:578–85.
14. Jiang C, Zhao Y, Wang X, Liu H, Tan TW, Li F.Midterm outcome of pharmacomechanical
catheter-directed thrombolysis combined with stenting for treatment of iliac vein compression syndrome with acute iliofemoral deep venous thrombosis. J Vasc Surg Venous Lymphat
Disord. 2020;8:24–30.
15. Avgerinos ED, Saadeddin Z, Abou Ali AN, Pandya Y, Hager E, Singh M, Al-Khoury G,
Makaroun MS, Chaer RA. Outcomes and predictors of failure of iliac vein stenting after
catheter-directed thrombolysis for acute iliofemoral thrombosis. J Vasc Surg Venous Lymphat
Disord. 2019;7:153–61.
16. Turner BRH, Thapar A, Jasionowska S, Javed A, Machin M, Lawton R, Gwozdz AM, Davies
AH.Systematic review and meta-analysis of the pooled rate of post-thrombotic syndrome after
isolated distal deep venous thrombosis. Eur J Vasc Endovasc Surg. 2023;65:291–7.
17. Williams ZF, Dillavou ED.A systematic review of venous stents for iliac and venacaval occlusive disease. J Vasc Surg Venous Lymphat Disord. 2020;8:145–53.
18. Notten P, Ten Cate H, Ten Cate-Hoek AJ.Postinterventional antithrombotic management after
venous stenting of the iliofemoral tract in acute and chronic thrombosis: a systematic review.
J Thromb Haemost. 2021;19:753–96.
19. Garcia MJ, Sterling KM, Kahn SR, Comerota AJ, Jaff MR, Ouriel K, Weinberg I, ACCESS
PTS Investigators. Ultrasound-accelerated thrombolysis and Venoplasty for the treatment
of the postthrombotic syndrome: results of the ACCESS PTS Study. J Am Heart Assoc.
2020;9:e013398.
20. Espitia O, Douane F, Hersant J, Abbadie F, Sobocinski J, Heautot JF, Miossec A, Lapébie FX,
Hartung O, Venous Stent Network Investigators. Predictive factors of stent patency in iliofemoral venous diseases in a multicentre cohort study. Eur J Vasc Endovasc Surg. 2023;65:564–72.
21. David A, Thony F, Del Giudice C, Société Française d’Imagerie Cardiovasculaire Diagnostique
et Interventionnelle. Short- and mid-term outcomes of endovascular stenting for the treatment
of post-thrombotic syndrome due to iliofemoral and caval occlusive disease: a multi-centric
study from the French Society of Diagnostic and Interventional Cardiovascular Imaging
(SFICV). Cardiovasc Intervent Radiol. 2022;45:162–71.
22. Jayaraj A, Noel C, Raju S.Contralateral limb improvement after unilateral iliac vein stenting argues against simultaneous bilateral stenting. J Vasc Surg Venous Lymphat Disord.
2020;8:565–71.
23. Moeri L, Lichtenberg M, Gnanapiragasam S, Barco S, Sebastian T.Braided or laser-cut selfexpanding nitinol stents for the common femoral vein in patients with post-thrombotic syndrome. J Vasc Surg Venous Lymphat Disord. 2021;9:760–9.
24. Jayaraj A, Noel C, Kuykendall R, Raju S.Long-term outcomes following use of a composite Wallstent-Z stent approach to iliofemoral venous stenting. J Vasc Surg Venous Lymphat
Disord. 2021;9:393–400.
25. Robertson B, Shapiro J, Muck A, Fellner AN, Recht M, Kulwicki A, Broering M, Kuhn B,
Muck P.Venous stent patency is independent of total stented length in nonthrombotic iliac vein
and post-thrombotic venous stenoses. J Vasc Surg Venous Lymphat Disord. 2023;11:339–45.
26. Wells PS, Hirsh J, Anderson DR, Lensing AW, Foster G, Kearon C, Weitz J, D'Ovidio R,
Cogo A, Prandoni P. Accuracy of clinical assessment of deep-vein thrombosis. Lancet.
1995;345(8961):1326–30.
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Chapter 20
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Vena Cava Filter
20.1 Guidelines
20.1.1 Society ofInterventional Radiology Clinical
Practice Guideline
The Society of Interventional Radiology developed in collaboration with other societies clinical practice guidelines for the use of inferior vena cava (IVC) lters in the
treatment of patients with or at substantial risk of venous thromboembolic disease
[1]. They recommend:
20.1.1.1 Acute Pulmonary Embolism
• In patients with acute pulmonary embolism (PE) with a contraindication to anti-
coagulation therapy, we suggest an IVC lter be considered based on various
clinical risk factors, as outlined in the rationale. (Strength of recommendation:
limited)
Benets and Harms
The panel judged that the benets associated with IVC lter placement (reduction
in short-term PE recurrence and possibly a reduction in mortality from acute PE)
outweigh the potential harms (bleeding, vascular injury, device migration, and
increased risk of recurrent DVT) in most patients.
Switzerland AG 2023
E. S. Debus, R. T. Grundmann, Evidence-based Therapy in Vascular Surgery,
https://doi.org/10.1007/978-3-031-47397-5_20
427© The Author(s), under exclusive license to Springer Nature
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20 Vena Cava Filter
20.1.1.2 Acute Deep Vein Thrombosis (DVT)
• In patients with acute DVT without PE and with a contraindication to anticoagu-
lation therapy, we suggest that an IVC lter be considered based on various clinical risk factors, as outlined in the rationale. (Strength of recommendation:
consensus)
20.1.1.3 Anticoagulation forVenous Thromboembolism (VTE)
• In patients undergoing anticoagulation for acute VTE (DVT, PE) in whom a con-
traindication to anticoagulation develops, we suggest that an IVC lter be considered in the setting of ongoing signicant clinical risk for PE. (Strength of
recommendation: consensus statement)
• In patients receiving extended anticoagulation after acute treatment for VTE in
whom a contraindication to anticoagulation develops, we suggest that an IVC
lter not be placed, with rare exceptions. (Strength of recommendation: consensus statement)
20.1.1.4 Recurrent Venous Thromboembolism
• In patients who are receiving therapeutic anticoagulation for VTE (DVT, PE)
who experience a recurrent VTE, we suggest that a lter not be placed, with few
exceptions. Reasons for anticoagulation failure should always be addressed.
(Strength of recommendation: consensus statement)
20.1.1.5 Routine IVC Filter Placement
• In patients with acute VTE (DVT, PE) who are being treated with therapeutic
anticoagulation, we recommend against routine placement of an IVC lter.
(Strength of recommendation: moderate)
20.1.1.6 Trauma Patients without Known Venous Thromboembolism
• In trauma patients without known acute VTE, we recommend against the routine
placement of IVC lters for primary VTE prophylaxis. (Strength of recommendation: moderate)
20.1 Guidelines
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20.1.1.7 Major Surgery inPatients without Known VTE
• In patients without known acute VTE who are undergoing major surgery, we
suggest against routine placement of IVC lters. (Strength of recommendation:
consensus statement)
20.1.1.8 Indwelling IVC Filters withno Anticoagulation Indication
• In patients who have indwelling IVC lters with no other indication for antico-
agulation, we cannot recommend for or against anticoagulation. (Strength of recommendation: consensus statement)
20.1.1.9 Indwelling IVC Filters withMitigated PE Risk
• In patients with indwelling retrievable/convertible IVC lters whose risk of PE
has been mitigated or who are no longer at risk for PE, we suggest lters be routinely removed/converted unless risk outweighs benet. (Strength of recommendation: consensus statement)
• In patients with indwelling permanent IVC lters whose risk of PE has been
mitigated or who are no longer at risk for PE, we suggest against routine removal
of lters. (Strength of recommendation: consensus statement)
20.1.1.10 Complications andIndwelling IVC Filters
• In patients with complications attributed to indwelling IVC lters, we suggest
lter removal be considered after weighing lter- versus procedure-related risks
and the likelihood that lter removal will alleviate the complications. (Strength
of recommendation: consensus statement)
20.1.1.11 Structured Follow-Up
• In patients who have an IVC lter, we suggest the use of a structured follow-up
program to increase retrieval rates and detect complications. (Strength of recommendation: limited)
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20.1.1.12 Planned Filter Removal
• In patients who are having an IVC lter removed or converted, we suggest
against routine preprocedural imaging of the lter and the use of laboratory studies except in select situations. (Strength of recommendation: consensus
statement)
20.1.1.13 Filter Removal without Standard Snare Techniques
• In patients undergoing lter retrieval/conversion whose lter could not be
removed/converted by using standard techniques, we suggest attempted removal
with advanced techniques, if appropriate and if the expertise is available, after
reevaluation of risks and benets. (Strength of recommendation: consensus)
20.1.1.14 Filter Placement Technique
• In patients undergoing IVC lter placement, we cannot recommend for or against
any specic placement technique. (Strength of recommendation: consensus
statement)
20 Vena Cava Filter
20.1.2 International Clinical Practice Guidelines
fortheTreatment andProphylaxis ofVenous
Thromboembolism inPatients withCancer
These guidelines [2] comment on IVC lters:
• In the initial treatment of VTE, inferior vena cava lters may be considered when
anticoagulant treatment is contraindicated or, in the case of pulmonary embolism, when recurrence occurs under optimal anticoagulation. Periodic reassessment of contraindications for anticoagulation is recommended, and
anticoagulation should be resumed when safe (guidance, based on evidence of
very low quality and an unknown balance between desirable and undesirable
effects).
• Prophylaxis of VTE in patients with cancer who have undergone surgery: infe-
rior vena cava lters are not recommended for routine prophylaxis. (Grade 1 A
recommendation).
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20.1.3 NICE (National Institute forHealth
andCare Excellence)
The NICE guidelines for venous thromboembolic disease recommend [3]:
• Do not offer an inferior vena caval (IVC) lter to people with proximal DVT or
PE unless:
– It is part of a prospective clinical trial or
– anticoagulation is contraindicated or a PE has occurred during anticoagula-
tion treatment.
• Consider an IVC lter for people with proximal DVT or PE when anticoagula-
tion treatment is contraindicated. Remove the IVC lter when anticoagulation
treatment is no longer contraindicated and has been established.
• Consider an IVC lter for people with proximal DVT or PE who have a PE while
taking anticoagulation treatment only after taking the steps outlined in the recommendation on treatment failure.
• Before tting an IVC lter, ensure that there is a strategy in place for it to be
removed at the earliest possible opportunity. Document the strategy and review
it if the clinical situation changes.
20.1.4 European Society ofCardiology (ESC) Guidelines
fortheDiagnosis andManagement ofAcute
Pulmonary Embolism [4]
20.1.4.1 Recommendations forVena Cava Filter
• IVC lters should be considered in patients with acute pulmonary embolism and
absolute contraindications to anticoagulation. (Recommendation class IIa / Level
of evidence C)
• IVC lters should be considered in cases of pulmonary embolism recurrence
despite therapeutic anticoagulation. (Recommendation class IIa/Level of
evidence C)
• Routine use of IVC lters is not recommended. (Recommendation class III/
Level of evidence A)
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20 Vena Cava Filter
20.2 Results
20.2.1 Meta-Analyses andSystematic Reviews
A Cochrane review assessed the evidence for the effectiveness and safety of vena
caval lters (VCFs) in preventing pulmonary embolism (PE) [5]. Six studies involving 1388 participants were included. The six studies were clinically heterogeneous
and the authors were unable to carry out meta-analysis. Two of the six identied
studies were relevant for current clinical settings. One showed no evidence of a
benet of retrievable lters in acute PE for the outcomes of PE, death, DVT and
bleeding during the initial 3 months in people who can receive anticoagulation
(moderate-certainty evidence). The other study did not show any benet for prophylactic lter insertion in people who sustained multiple traumatic injuries, with
respect to symptomatic PE, mortality, or lower extremity venous thrombosis
(moderate- certainty evidence). No rm conclusions regarding lter efcacy in the
prevention of PE could be drawn from the remaining four RCTs identied in this
review. With the paucity of evidence for groups of people for whom lters are
potentially benecial and for the use of retrievable lters data suggest the current
accepted indication for lters is a contraindication to anticoagulation.
Liu etal. [6] performed a meta-analysis of randomized trials to investigate the
effect of IVC lters on PE-related mortality and complications. Seven articles with
1274 patients were included. They found no signicant difference in mortality
related to PE between the IVC lter and control groups within 3months (P=.11)
nor during the entire follow-up period with low heterogeneity. However, the use of
IVC lters decreased the new occurrence of PE without increasing deep vein thrombosis or major bleeding.
In a meta-analysis of 10 studies (two of which were randomized controlled trials), Shariff et al. [7] investigated the prophylactic IVC lter placement among
patients with major trauma. The use of prophylactic IVC lters was associated with
a reduced risk of symptomatic PE among subjects with major trauma (RR: 0.27, CI
0.12–0.58, P value <0.05), the evidence was further reinforced by a trial sequential
analysis. However, the use of IVC lters was not associated with a decreased risk of
fatal PE among subjects with major trauma.
20.2.2 Randomized Trials
Data from the French multicentre randomised PREPIC (Prévention du Risque
d’Embolie Pulmonaire par Interruption Cave) trial were rst published by Decousus
etal. [8]. In this trial, 400 patients with proximal deep-vein thrombosis who were at
risk for pulmonary embolism were assigned to receive a vena caval lter (200
patients) or no lter (200 patients), and to receive low-molecular-weight heparin
(enoxaparin, 195 patients) or unfractionated heparin (205 patients). At day 12, two
20.2 Results
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patients assigned to receive lters (1.1%), as compared with nine patients assigned
to receive no lters (4.8%), had had symptomatic or asymptomatic pulmonary
embolism (odds ratio, 0.22; 95% condence interval, 0.05–0.90). At 2 years, 37
patients assigned to the lter group (20.8%), as compared with 21 patients assigned
to the no-lter group (11.6%), had had recurrent deep-vein thrombosis. The initial
benecial effect of vena caval lters for the prevention of pulmonary embolism was
counterbalanced by an excess of recurrent deep-vein thrombosis, without any difference in mortality. An 8-year follow-up was performed to assess the very longterm effect [9]. At 8years, vena cava lters reduced the risk of pulmonary embolism
but increased that of deep-vein thrombosis and had no effect on survival. Although
their use may be benecial in patients at high risk of pulmonary embolism, systematic use in the general population with venous thromboembolism was not
recommended.
In the PREPIC2-study [10], the efcacy and safety of retrievable vena cava lters
plus anticoagulation vs anticoagulation alone for preventing pulmonary embolism
recurrence in patients presenting with acute pulmonary embolism and a high risk of
recurrence was evaluated. In the lter group, the lter was successfully inserted in
193 patients and was retrieved as planned in 153 of the 164 patients in whom
retrieval was attempted. By 3months, recurrent pulmonary embolism had occurred
in 6 patients (3.0%; all fatal) in the lter group and in 3 patients (1.5%; 2 fatal) in
the control group (relative risk with lter, 2.00 [95% CI, 0.51–7.89]; P = .50).
Results were similar at 6months. No difference was observed between the 2 groups
regarding the other outcomes. Filter thrombosis occurred in 3 patients. These ndings do not support the use of this type of lter in patients who can be treated with
anticoagulation.
In a multicenter, randomized, controlled trial, Ho etal. [11] assessed whether
insertion of a retrievable vena cava lter within 72hours after admission for trauma
would result in a lower incidence of pulmonary embolism than no lter in patients,
who had a contraindication to anticoagulant agents. 240 patients were enrolled and
underwent randomization. Of the 122 patients assigned to the vena cava lter group,
89% had the lter inserted within 24h after enrollment. Early placement of a vena
cava lter did not result in a signicantly lower incidence of symptomatic pulmonary embolism or death than no placement of a lter (13.9% in the vena cava lter
group and 14.4% in the control group; P=0.98). Among the 46 patients in the vena
cava lter group and the 34 patients in the control group who did not receive prophylactic anticoagulation within 7days after injury, pulmonary embolism developed in none of those in the vena cava lter group and in 5 (14.7%) in the control
group, including 1 patient who died (relative risk of pulmonary embolism, 0; 95%
CI, 0.00 to 0.55). Except in the case of one patient, all lters were removed before
day 232. An entrapped thrombus was found in the lter in 6 patients. In conclusion,
early placement of a vena cava lter after major trauma did not result in a lower
incidence of symptomatic pulmonary embolism or death at 90days (the primary
composite end point) than no placement of a lter.
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