|Year : 2015 | Volume
| Issue : 2 | Page : 44-48
Adverse Events Following Placement of Retrievable Inferior Vena Cava Filters and How to Avoid Them - A Single Centre Experience
Aasim Khan1, James May2, Chris Rogan3
1 Department of Vascular and Endovascular Surgery, Royal Prince Alfred Hospital, Sydney, Australia
2 Department of Vascular and Endovascular Surgery; Department of Surgery, University of Sydney, Sydney, Australia
3 Department of Radiology and Medical Imaging, Royal Prince Alfred Hospital, Sydney, Australia
|Date of Web Publication||31-Jul-2015|
Dr. Aasim Khan
Department of Vascular and Endovascular Surgery, Royal Prince Alfred Hospital, Sydney
Source of Support: None, Conflict of Interest: None
Context: Use of inferior vena cava filters (IVCFs) is associated with complications which can be minimized by early follow-up and retrieval.
Aim: The aim of this study was to document types of retrievable IVCFs, complications after placement, and how to prevent them.
Settings and Design: Institutional ethics committee approval was obtained to perform a retrospective review of hospital medical records for all patients who had an IVCF placed between Jan 2003 and Oct 2013.
Patients and Methods: Retrospective data were collected from the picture communicating and archiving system radiology database. Patients' records and radiological imaging were reviewed. Data extracted included patient demographics, indications for inferior vena cava (IVC) placement, filter retrieval, follow-up, and complications namely IVC perforation, filter fracture, filter migration, and filter embolization.
Statistical Analysis Used: The data collected were analyzed using SPSS version 21. The output data were summarized using tables and graphs as shown below.
Results: A total of 182 patients (93 males) and (89 females) had retrievable IVCFs inserted. The most common indication for filter insertion (56.59%) was venous thromboembolism and contraindication to anticoagulation. Retrieval rate was 42.85%. Procedural success was achieved in 78 of 85 attempted filter retrievals (91.76%). Fourteen patients (7.69%) had IVCF related complications.
Conclusion: Timely follow-up increases the likelihood of successful retrieval of optional IVCFs and reduces potential complications.
Keywords: Complications, inferior vena cava filter, retrieval
|How to cite this article:|
Khan A, May J, Rogan C. Adverse Events Following Placement of Retrievable Inferior Vena Cava Filters and How to Avoid Them - A Single Centre Experience. Indian J Vasc Endovasc Surg 2015;2:44-8
|How to cite this URL:|
Khan A, May J, Rogan C. Adverse Events Following Placement of Retrievable Inferior Vena Cava Filters and How to Avoid Them - A Single Centre Experience. Indian J Vasc Endovasc Surg [serial online] 2015 [cited 2021 May 7];2:44-8. Available from: https://www.indjvascsurg.org/text.asp?2015/2/2/44/161940
| Introduction|| |
The use of endovascular inferior vena cava filters (IVCFs) historically dates back to 1967 when the Mobin-Uddin filter, an endoluminal device was successfully placed. The initially used metal alloy device underwent considerable metamorphosis both in design and concept until temporary or optional filters gained popularity, yet associated with complications.
To date, three types of filters have been used worldwide. Permanent, temporary, and optional or retrievable filters. ,,,,,, Permanent filters cannot be removed once inserted percutaneously and meant to stay in situ for the rest of the patient's life. These include Greenfield (Boston Scientific, Natick, MA, USA) and Bird's Nest (Cook, Brisbane, Australia) and TRAPEASE (Cordis) filters. 
Temporary filters have a short lifespan and fixed externally to the skin or placed in a subcutaneous pouch with a catheter or guide wire to aid easy removal. These include Tempofilters (B.Braun), (Neuhaus, Tokyo, Japan) and Antheor (Boston Scientific). 
Optional or retrievable filters offer flexibility to be removed after a certain period or to be left in situ to become permanent filters. These include Cordis-OptEase, Gunther-Tulip, Recovery G2/G2X Bard ® , and Cook Celect™ filters. 
In literature, six types of filter-related complications have been described namely recurrent deep vein thrombosis (DVT), vena cava thrombosis, inferior vena cava (IVC) perforation, filter migration, filter fracture, and filter embolization, most commonly when filters are left in situ for more than 30 days.
The purpose of this study was to review the indications, type of filters, follow-up, retrieval rates complications, and methods to prevent them.
| Patients and Methods|| |
A total of 182 patients had retrievable filters inserted. Most commonly used filters were Cook Celect™ (99) followed by Bard ® G2X (53) [Graph 1 [Additional file 1] ].
The most common indication for filter insertion (56.59%) was venous thromboembolism (VTE) and contraindication to anticoagulation [Graph 2 [Additional file 2] ]. IVCFs were placed mostly by interventional radiologists (95.55%) and surgeons (4.45%). All IVCFs were placed at the level of L2−L4 vertebral bodies under imaging guidance. The routine approach was to image the IVC with a calibrated pigtail, followed by identification of renal veins and any prominent lumbar veins with venography as required.
Complications were noted at time of retrieval or if investigations were performed for clinical symptoms or suspicion. Fourteen patients who suffered complications were discussed in a radiology multidisciplinary meeting to decide the approach for retrieval of the filter.
Seven of 14 patients with filter complications had successful filter retrieval either by open or endovascular technique. A jugular vein approach and an endovascular snare device were used in all retrieval attempts. The retrieval procedure was abandoned in seven patients, and the indwelling filters were left permanently in situ.
Filter migration (n = 2)
Among the filters that migrated from the original IVC location (level of vertebral bodies L3/L4), one Bard ® G2X filter migrated to the left iliac vein with legs protruding outside the vein after a dwell time of 2 months and was unable to be retrieved. One Cook Celect™ filter migrated into the left renal vein 3 months post-insertion and was successfully retrieved using an endovascular approach.
Filter embolization (n = 1)
A 47-year-old male underwent IVCF (Cordis OptEase ® ) insertion for VTE during preoperative planning for removal of brain tumor. Six months later, he presented to our emergency department with sudden onset chest pain and shortness of breath. After initial resuscitation, further investigations were performed. Computerized tomography scan confirmed migration of the OptEase ® filter from its original location in the IVC to the bifurcation of the pulmonary trunk [Figure 1]. The device was successfully retrieved in its entirety by open pulmonary endarterectomy.
Filter fracture (n = 4)
All four cases of suspected filter fracture showed IVC in severely tilted position. A One Cook Celect™ filter was successfully retrieved using an endovascular approach. One Bard ® G2X filter was left in situ due to significant thrombus adherent to the filter 2 months post-insertion. One Cook Celect™ filter was left in situ due to suspected filter fracture and two failed retrieval attempts at 9 months. The patient declined further intervention.
A 29-year-old female admitted to Intensive Care Unit postliver transplantation surgery developed myopathy and VTE. A Bard ® G2X IVCF was inserted. Two months later and still in hospital, she was found to be hypotensive on the surgical ward and medical emergency team call was made. CT scan of abdomen and pelvis showed a large retroperitoneal bleed secondary to a fracture of the Bard ® G2X filter and perforation of IVC [Figure 2]. Multiple endovascular retrieval attempts (2 days apart) after resuscitating the patient were unsuccessful and the procedure was abandoned. The patient underwent a planned laparotomy for removal of filter. However, the device could not be retrieved in entirety due to its incorporation into IVC wall tissue. The fractured elements were left in situ.
|Figure 2: Filter fracture - failed endovascular retrieval of a Bard® G2X filter|
Click here to view
Inferior vena cava perforation (n = 7)
All seven cases of IVC perforation had two to four legs of the IVCF protruding through the wall of IVC. Two Cook Celect™ and one Bard ® G2X filters were retrieved successfully using an endovascular technique. Three Bard ® G2X filters were deeply embedded into the wall of the IVC at 2 and 3 months post-insertion. After two failed retrieval attempts, they were left in situ.
A 74-year-old male underwent an IVCF placement (Cook Celect™) preoperatively for removal of an adenocarcinoma of the caecum. He had a past history of multiple admissions for DVT and considered high-risk for this surgery. A retrieval procedure 6 months later was abandoned after repeated failed attempts to remove this device embedded into the wall of IVC. The cone of the filter perforated the anterior wall of IVC with several legs lying outside of it. The device was left in situ [Figure 3].
| Results|| |
A total of 182 patients (93 males) and (89 females) had retrievable IVCF filters inserted. Eighty-five patients (46.70%) were followed up for retrieval of the filter. Seventy-eight of 85 filters (91.76%) were retrieved successfully using either endovascular technique or open surgery [Table 1]. The mean retrieval time after filter placement was 115 days (range 30-480 days). Ninety-seven patients (53.29%) were lost to follow-up.
Fourteen serious filter-related complications occurred in our patients. There were two cases of IVCF migration (1.09%), one case of filter embolization (0.55%), seven cases of confirmed IVC perforation (3.84%), and four cases of suspected filter fracture (2.19%). Four out of seven unsuccessful retrievals were associated with Bard ® G2X filter [Graph 3 [Additional file 3] ]. There was no IVCF related mortality.
| Discussion|| |
The accepted indications for IVCF placement vary widely among institutions and various societies. In literature, the three society guidelines have been commonly referred to. ,,,,, They are (1) The Society of Interventional Radiology (SIR), (2) The Eastern Association for Surgery of Trauma (EAST), and more commonly (3) The American College of Chest Physicians (ACCP).
The SIR has recommended filters in patients with VTE and a contraindication, complication from, or a failure of, anticoagulation. Relative indications include prophylaxis in surgery, trauma with the latter generally only indicated if a patient has a documented VTE and has a contraindication to anticoagulation. ,,
The EAST, USA issued its guidelines in 2002. They found no level I evidence for the use of prophylactic filters in trauma patients, but have issued guidelines with level II/III evidence, recommending prophylactic filters in patients with a contraindication to anticoagulation and who are older (over 45 years of age), with Glasgow coma scale <8, complex pelvic fractures and associated lower extremity fractures, or incomplete spinal cord injury with paraplegia or quadriplegia. ,
The ACCP guidelines have more stringent criteria for IVCF placement. They recommend against the use of IVCF's in addition to anticoagulation (Grade 1B), recommend IVCF placement in cases of acute proximal DVT with contraindication for anticoagulation (Grade 1B). They also recommend initiating anticoagulation in a patient with the filter in situ, once contraindication to anticoagulation has passed (Grade 2B). They recommend against the use of IVCF for thromboprophylaxis in cases of trauma and spinal cord injury (Grade 2C). ,,,
The most established indications for IVCFs in patients are VTE and contraindication to anticoagulation. In our study 103 (56.59%) patients received IVCFs in accordance with this guideline. ,,,
The Prevention du Risque d'Embolie Pulmonaire par Interruption Cave (PREPIC) study, the only randomized controlled trial included in the Cochrane review on IVCFs, excluded patients who had a contraindication to anticoagulation. ,
Decousus et al., randomized 400 patients with proximal DVT to receive a vena cava filter (200 patients) or no filter (200 patients), and to receive low-molecular-weight heparin (enoxaparin 195, patients), or unfractionated heparin (205 patients).  The rates of recurrent VTE, death and major bleeding at day 12 and at 2-year were analyzed. They found that (1) IVCFs reduced the risk of pulmonary embolism (PE) in the short term (day 12 results).(2) In the long term, IVCFs increased the risk of recurrent DVT (2-year results).(3) The PREPIC trial, an 8-year follow-up, found them to have no effect on overall survival. ,
Decousus concluded that in high-risk patients with proximal DVT, the initial beneficial effect of IVCFs for the prevention of PE was counterbalanced by an excess of recurrent DVT, without any difference in mortality. 
Rajasekhar et al. found no additional benefit when anticoagulation was used in conjunction with an IVCF based on a small feasibility study in high-risk trauma patients (n = 34). 
In clinical practice, decisions to insert IVCFs for reasons outside the established guidelines are common. ,,,, In our study, three multi-trauma patients (1.64%) had IVCFs placed for VTE prophylaxis. One patient (0.55%) had a Cook Celect™ filter inserted overseas at 39 weeks 4 days gestation just prior to her delivery (fetal death in utero) for confirmed DVT. The device was retrieved successfully at our institution a month later.
In our study, the frequency of IVCF related adverse events was (7.69%) comparable to similar studies in the literature.  Sebunya et al. described total filter-related events in order of 9%, with six cases of caval penetration and five cases of filter tilt, resulting in three failed retrievals.
It is interesting to note that the retrieval rate of IVCFs declined as the time since insertion increased [Graph 4 [Additional file 4] ]. Our retrieval rate (43.95%) was comparatively lower than the study conducted by Sebunya et al. (56%). It could be due to the fact that our institution is a tertiary referral center. Patients are transferred across on to other hospitals as soon they are stable and hence are followed up elsewhere.
In summary, IVCFs have been ingrained in our practice for over 30 years.  While there has been a change of practice from using permanent to optional or temporary filters, over the years, there are potential problems with filters. 
Within the limitations of our study, it can be concluded that successful retrieval of optional IVCFs (Cook Celect™) is optimized and complication rates are minimized if prompt follow-up is performed within 1-month.
The authors recommend follow-up by the General Practitioner in the community and a direct referral to the radiology department for a check venogram and retrieval. Authors suggest that proceduralists (interventional radiologist or surgeon) have a database of filters for their institution with automatic follow-up reminders (for example at 1-month) post-insertion to prompt follow-up. A follow-up clinic along those lines would be ideal.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]