Outcomes with Retrievable Inferior Vena Cava Filters

ABSTRACT: This was a retrospective study of 144 patients with retrievable inferior vena cava (IVC) filters inserted 2004–2008 at a community/teaching hospital. The purpose was to evaluate the incidence of complications and the rate and success of retrieval. Retrieval of IVC filters was attempted in 14 of 144 (10%) patients at an average of 4.6 months. Retrieval was successful in 10 of 14 (71%). Within 6 months of insertion, retrieval was successful in 10 of 12 (83%). Unsuccessful attempts were at 3, 6, 8 and 9 months. Non-bleeding complications of IVC filters occurred in 12 of 144 (8.3%). Half (6 of 12) of the complications occurred after 3 months of insertion. Complications included IVC thrombosis in 3 (2.1%) (1 also had a new deep venous thrombosis [DVT]), a new DVT alone in 6 patients (4.2%), a new DVT with new pulmonary embolism (PE) in 1 patient (0.7%) and filter migration in 2 patients (1.3%). In conclusion, retrieval was attempted in only a small proportion of patients at a community/teaching hospital. Formalized guidelines for follow up may increase the proportion of patients in whom retrieval is attempted. Half of the complications of IVC filters could have been avoided with retrieval within 3 months. J INVASIVE CARDIOL 2010;22:235–239 Key words: pulmonary embolism, deep venous thrombosis, venous thromboembolism, inferior vena cave filter, anticoagulants The use of inferior vena cava (IVC) filters has increased markedly during the last two decades in patients with pulmonary embolism (PE), patients with deep venous thrombosis (DVT) alone and patients at risk who had neither PE nor DVT. ¹ Although there was a reduced risk of PE in patients with proximal DVT who had permanent IVC filters compared to patients who had not received IVC filters, there was an increased risk of DVT with no survival benefit. ² Retrievable IVC filters may reduce the incidence of PE without the long-term complications associated with permanent IVC filters provided that the filters are removed after the risk of further PE or DVT resolves. ³ Inferior vena cava filters are recommended for patients with DVT or PE in whom anticoagulants are contraindicated. ⁴ If retrievable IVC filters were used, a suggestion was made to retrieve the filters once the contraindication to anticoagulants resolved. ⁴ However, the risks and benefits of using a retrievable filter compared with a permanent filter are uncertain. ⁴ The purpose of this study was to evaluate retrievable IVC filters in terms of outcome, complications according to whether anticoagulants were used, rate of retrieval and success of retrieval in relation to duration of insertion. We evaluated data from our own hospital and complemented this with an analysis of the published literature.

Methods

Records of patients with retrievable IVC filters were assessed to determine efficacy, complications, duration of insertion and number of attempts at retrieval. Data on outcomes were obtained retrospectively from hospital records, office charts and radiological reports. Approval from the institutional review board was obtained. At St. Joseph Mercy Oakland Hospital, Pontiac, Michigan, 144 patients underwent insertion of a retrievable IVC filter from January 2004 to September 2008. In patients in whom there was a clinical suspicion of recurrent PE or DVT, lower extremity venous ultrasound, computed tomographic (CT) pulmonary angiography and/or ventilation-perfusion lung scans were obtained. Follow-up duplex scans were considered positive when there was a development of new DVT (defined as DVT not previously shown by compression ultrasound or CT venography). New PE was defined as a new pulmonary artery filling defect on CT angiography. Major bleeding was defined as overt bleeding with a fall in hemoglobin ≥ 2 g/dl or a need for a transfusion of ≥ 2 units, retroperitoneal or intracranial bleed, or if it warranted permanent discontinuation of anticoagulants. ⁵ Post-thrombotic syndrome was defined as any of the following: persistent edema, purpura, increased skin pigmentation, pruritis, ulceration or cellulitis. PubMed searches of inferior vena cava filters and inferior vena cava filter complication were conducted for all years and all languages. Review articles, guidelines, and prior meta-analyses were also searched for additional references. Statistical methods. Chi-square was used to assess differences of proportions (InStat version 3.0 GraphPad Software, San Diego, California)

Results

Mean follow up was 11 ± 10 months (range 1–42 months). Total experience was 112 patient-years. Eighty-five percent of these patients had subsequent hospitalizations and/or outpatient visits, 5% died in the hospital and 10% were lost to follow up. The age of patients with successfully inserted filters was 69 ± 2 years (mean ± standard deviation; range of 19–100 years). Sixty percent were women. The types of retrievable IVC filters inserted are shown in Table 1. In two additional patients (1 Bard Recovery, Bard Peripheral Vascular, Inc., Tempe, Arizona; 1 OptEase, Cordis Corp., Miami Lakes, Florida), filter insertion was unsuccessful. All retrievable IVC filters were inserted in patients who either had DVT, PE or both; none were inserted prophylactically. Post-deployment venograms were performed and spot fluoroscopic images were taken in all patients to confirm filter alignment and deployment. Among the 144 patients with retrievable IVC filters, 77 had venous thrombo-embolism (VTE) and a contraindication to anticoagulants, 9 had VTE with cancer or thrombophilia, 21 had VTE recurrent PE or DVT while on anticoagulants, and 37 needed greater protection because of a large PE, extensive DVT, compromised pulmonary function or concurrent embolectomy and endarterectomy. Retrieval of IVC filters was attempted in 14 of 144 (10%) patients at 4.6 ± 2.1 months (mean ± standard deviation) after insertion (Figure 1). Retrieval was successful in 10 of 14 (71%) (Figure 1). Within 6 months of insertion, retrieval was successful in 10 of 12 (83%). Unsuccessful attempts at retrieval were at 3, 6, 8 and 9 months after insertion (Figure 2). One of the failed attempts caused a cephalic displacement of the IVC filter. No further attempts were made to retrieve the filter because of a high risk of perforation of the IVC. In the remaining 3 patients, the reason for failed retrieval was not stated. Non-bleeding complications of IVC filters occurred in 12 of 144 (8.3%) (Figure 3). Complications included IVC thrombosis in 3 (2.1%)(1 also had new DVT), new DVT alone in 6 patients (4.2%), new DVT with new PE in 1 patient (0.7%) and filter migration in 2 patients (1.3%). In addition, 9 of 144 (6.3%) had post-thrombotic syndrome, but it is uncertain whether this represented a complication of the IVC filters, or whether the post-thrombotic syndrome resulted from DVT irrespective of the IVC filters. Half of the complications (6 of 12) occurred after 3 months of insertion. Among the 77 patients with retrievable IVC filters inserted because of a contraindication to anticoagulants, 63 (82%) did not receive anticoagulants during the entire period of follow up and 14 (18%) eventually received anticoagulants after resolution of the contraindication (Figure 3). All of the 67 patients with a high thromboembolic risk, prior anticoagulant failure, or need for greater protection received full-dose anticoagulant therapy. The incidence of thrombotic complications (new DVT, PE, IVC thrombosis) was similar in those who received anticoagulants for the entire duration of IVC filter insertion, 5 of 62 (8%)(8.3/100 patient-years) and those who did not receive anticoagulants 4 of 47 (9%) (7.7/100 patient-years) (Figure 3). Among those who received anticoagulants for the full duration of insertion, major bleeding occurred in 4 of 62 (6%)(6.7/100 patient-years), one of which was fatal. Discussion Retrieval of IVC filters was attempted in only 10% of patients. Reported studies showed a wide range of the proportion of attempted IVC filter retrievals, ranging from 2–100% (Table 2).6–45 On average, however, the proportion of patients in whom filter retrieval was attempted was higher than we report, 44% (Table 2). The low rate of attempted IVC filter retrieval that we report in a community/teaching hospital emphasizes the need for protocols or guidelines for retrieval. We showed an overall incidence of non-bleeding complications with retrievable IVC filters of 14% and an additional 4 of 62 (6%) on anticoagulants suffered major bleeding (Figure 3). Complications of retrievable filters have also been reviewed.46 Pooled data among 284 patients showed PE in 1%, IVC thrombosis in 3%, post-thrombotic syndrome in 1%, and filter migration (usually asymptomatic) in 4%.46 Retrieval of IVC filters has been shown to be successful in 274 of 289 (95%) cases within 2 weeks after insertion. ^{15,16,18,28,30-32,34,41–44} Combining our data with published results, when the attempted retrieval was performed ≤ 1 month after insertion, the retrieval was successful in 50 of 52 (96%);^{7,14,19,25,27,28,30,36,38,43} between 31–90 days, retrieval was successful in 27 of 30 (90%);^{14,19,23,25,27} between 91–180 days, retrieval was successful in 12 of 15 (80%);7,14,27 and after 180 days, including our patients, retrieval was successful in only 3 of 8 (38%).¹⁴ The maximum length of time a filter can remain in place and still be retrieved has yet to be established. ⁴⁷ Successful retrieval of IVC filters has been described in 441 days, ²⁶ 419 days, ^8,9 345 days, ¹⁴ 268 days, ¹⁰ 165 days, ⁶ 149 days²³ and 139 days. ²¹ In our experience, only 1 of 4 attempts at retrieval was successful at 6 months or longer after insertion. In a review of patients with permanent IVC filters, meta-analysis showed a trend toward decreased rates of venous thromboembolism in patients with post-filter anticoagulation, 12.3% versus 15.8%, but the results failed to reach statistical significance. ⁴⁸ In the small number of patients with retrievable filters reported here, the incidence of thrombotic complications was similar in those who received anticoagulants for the entire duration of filter insertion (8%) and those who did not receive anticoagulants (9%).

Conclusion

In conclusion, retrieval was attempted in only a small proportion of patients at a community/teaching hospital. Formalized guidelines for follow up may increase the proportion of patients in whom retrieval is attempted. Half of the complications of IVC filters could have been avoided with retrieval within 3 months.

References

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_________________________________________________________________________ From the *Department of Internal Medicine, St. Joseph Mercy Oakland, Pontiac, Michigan, the §Departments of Internal Medicine and Research and Advanced Studies Program, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, and the £Department of Medicine, University of Calgary, Calgary, Alberta, Canada. The authors report no conflicts of interest related to the content herein. Manuscript submitted December 1, 2009, provisional acceptance given January 15, 2010, final version accepted February 1, 2010. Address for correspondence: Paul D. Stein, MD, Michigan State University, College of Osteopathic Medicine, Department of Internal MedicineVenous Thromboembolism Research Unit, St. Joseph Mercy Oakland Hospital, 44405 Woodward Avenue, Pontiac, MI 48341-5023. E-mail: steinp@trinity-health.org