|Year : 2020 | Volume
| Issue : 4 | Page : 335-339
Inferior vena cava filter thrombosis: An overview
Murtuza Razi, He Xu, Gu Jianping, Mohammed Jameeluddin Ahmed
Department of Vascular and Interventional Radiology, Nanjing First Hospital Affiliated to Nanjing Medical University, Nanjing, Jiangsu, China
|Date of Submission||16-Aug-2020|
|Date of Decision||31-Aug-2020|
|Date of Acceptance||31-Aug-2020|
|Date of Web Publication||24-Dec-2020|
Department of Vascular and Interventional Radiology, Nanjing First Hospital Affiliated to Nanjing Medical University, Nanjing, Jiangsu
Source of Support: None, Conflict of Interest: None
The leading long term and undervalued impediment associated with inferior vena cava (IVC) filter placement is said to be increased risk of venous thrombosis within and below the IVC. Anticoagulation remains the mainstay treatment preference for the management of deep-vein thrombosis (DVT) and pulmonary embolism (PE). Now and then, it is not viable due to bleeding complications or, occasionally, breakthrough PE associated with this treatment method. In these patients, the development of vena cava filters was a significant advancement in their management. Patients with IVC filters predominantly the ones placed with permanent filters are considered to be at a greater risk for the development of recurrent DVT. Cautious applications of IVC filters, along with retrieval of temporary IVC filters in good time, significantly diminishe the risk of IVC thrombosis. The proof of connection of IVC thrombosis with each of the following factors is known: Population demographics, history of or preexisting hypercoagulable states/anticoagulation, the manner in which the thrombus is assessed, and the duration since the filter employment. Most cases of IVC filter thrombosis are asymptomatic. Contrast-enhanced computed tomography is a preferred imaging modality compared to Doppler sonography. Here in this article, we attempt to discuss briefly the present ideas concerned with the indications of IVC filters along with the prevalence, risks, and management of IVC filter thrombosis.
Keywords: Deep-vein thrombosis, inferior vena cava filter, inferior vena cava filter thrombosis, pulmonary embolism, venous thromboembolism
|How to cite this article:|
Razi M, Xu H, Jianping G, Ahmed MJ. Inferior vena cava filter thrombosis: An overview. Indian J Vasc Endovasc Surg 2020;7:335-9
| Introduction|| |
Venous thromboembolism is a name given to a group of disorders presenting as deep-vein thrombosis (DVT) and pulmonary embolism (PE), it is a serious, and perhaps, a life-threatening disease occurring in up to 5% of the general population. DVT is described as a condition in which formation of a blood clot occurs in the deep veins. Although it usually occurs in the deep veins of the distal limbs, it might also occur at other sites such as in the deep veins of the proximal limbs, the vena cava., PE transpires due to the migration of a piece of thrombus from the limb or the parts of the body to the lungs, which commonly occurs as a consequence to hospitalization postsurgery or trauma is known to be the third most common cause of death in hospitalized patients., Venous thromboembolism (VTE) is the most common cause of preventable in-hospital deaths with a morality rate ranging from 5% to 10%, with further increase in the incidence rates of venous thromboembolic events (VTEs) being noted with passing time.
A large number of patients with venous thromboembolism (VTE) are treated using anticoagulants, which successfully results in cessation of abnormal clotting process and thus prevents the progression of DVT as well as PE and recurrent VTE., In VTE patients where anticoagulation demonstrates ineffectiveness, contraindicated, or is accompanied by a serious risk of bleeding, inferior vena cava (IVC) filter placement is endorsed. In these cases, IVC filters have been shown to decrease the rates of fatal and nonfatal PE., Use of IVC filters has grown rapidly more so since the development of retrievable IVC filters. The goal of IVC filter placement is to decrease the rates of fatal PE., However, there is a risk of probable complications associated with IVC filter placements and one of the most common complication among them is thrombotic occlusion of IVC filter. All filters have been known to be associated with IVC thrombosis.
Retrievable IVC filters have reported the high rates of IVC filter thrombosis when compared with the permanent ones. Though not as common a complication as filter migration., Filter-induced thrombosis commences early, giving an added purpose for initiating anticoagulant management once it is deemed safe to do so after filter placement. Macroscopic evidence of thrombi in temporary IVC filters was noticed in 75% of patients only 5 days after the filter placement. These thrombotic evidences observed on filters may either originate from thrombus formation occurring at the site of filter implantation or could be due to thrombus propagation and migration of the emboli that are being trapped by the filter., Several filter thrombi could be asymptomatic while others may lead to acute, enormous swelling of the leg, chronic pain in the limb, and skin color and appearance changes, including venous leg ulcer. In patients who are anticoagulated after filter placement have reported usually less incidences of IVC filter thrombosis.,
| Indications of Inferior Vena Cava Filters|| |
IVC filters play an important role in the prevention and progression of DVT present in the lower limbs and the pelvic region into PE by acting as a mechanical barrier and stops the upward movement of the thrombus. However, then again, it does not play any role in dissolution of DVT itself. Following the development of retrievable IVC filters, a rise in IVC filter deployment has been observed. The indications for IVC filter placement have expanded over the years. With all the impediments of IVC filters in mind the indications of IVC filters are classified into three categories of absolute, relative, and prophylactic indications.
| Absolute Indications|| |
The absolute indication of IVC filter deployment includes (a) the presence of VTE and contraindication to anticoagulation, contraindications to anticoagulation include haemorrhagic stroke, active internal bleeding, bleeding diathesis and recent or multiple trauma to name a few, (b) failure of anticoagulation to prevent VTE, and (c) complication of anticoagulation. DVT and PE without any treatment are noted to be associated with comparatively high risk of recurrence which in turn is linked to high risk of morbidity and mortality. As per the guidelines published by the American college of chest physicians (ACCP), American Heart Association, British Committee for Standards in Hematology and Society of Interventional Radiology (SIR), patients with contradiction to, or failure of anticoagulation are commended for IVC filter placement.,, It is also important to confirm true failure of treatment in patients with failed anticoagulation as there may be few cases present which could have been inadequately treated rather than failure of anticoagulation. Systemic examination to exclude the disorders such as hypercoagulable syndromes, malignancy, and other various systemic cause of hypercoagulability is needed to be done in patients with confirmed failure of treatment before IVC filter is deployed. Moreover, anatomic variants, such as May–Thurner syndrome, must be considered if thrombotic events are repeatedly occurring at the same location and an IVC filter placement in this condition would not effectively address this problem.
The relative indications of IVC filter placement include conditions such as (a) Unstable patients with VTE or patients with poor cardiopulmonary reserves with VTE, (b) Massive PE treated with thrombolysis, (c) Ileocaval deep venous thrombosis, (d) Floating proximal DVT and (e) Prophylaxis in patients undergoing high risk surgeries such as bariatric surgeries or neurosurgical procedures or after major trauma. The previous ACCP guidelines established in 2012 along with the present SIR guidelines endorse considering the addition of IVC filter along with anticoagulation treatment in patients having unstable PE or in patients with poor or inadequate cardiopulmonary reserve who are receiving an ongoing anticoagulation treatment. Mismetti et al. conducted a study paralleling the use of IVC filter and anticoagulation therapy to anticoagulation therapy alone. IVC filter along with anticoagulation therapy were typically used in the scenarios of management of massive PE or VTE or anticoagulation failure, and not any difference in PE incidence rates at 90 days or 5 years, along with a tendency towards increased prevalence of DVT in the IVC filter and anticoagulation group. While many studies suggest minimal or no difference in PE incidence rates, there are few studies available such as a retrospective study conducted by, Kolbel et al. which inferred that evaluated catheter-directed thrombolysis with routine IVC filter use had found that 45% of filters revealed visible thrombi on venogram and no PE occurred, suggesting a protective benefit of utilising IVC filters.
On the whole, assumed the diversity of relative indications across different guidelines and contradictory data, the use of IVC filters for relative indications should be customized for each patient, weighing the risks and benefits of adding IVC filters.
| Prophylactic Indications|| |
Prophylactic indications of IVC filter placement are applicable in patients who are not confirmed VTE but are well thought-out high risk for VTE, with either a contraindication to anticoagulation or poor protection with anticoagulation. The prophylactic indications of IVC filter placements include (a) multiple trauma patients who are unable to undergo anticoagulation and are highly prone to DVT or PE formation. (b) History of DVT or PE with high risk surgeries such as bariatric surgery, hip surgery to name a few.
Trauma patients are generally more prone to develop VTE, particularly ones with multiple traumas involving pelvic or long bone fractures, and spinal trauma. The prevalence of DVT among these patients has been reported to be ranging as high as 50%–58%, presenting typically within the first few weeks of hospitalization, and of PE as high as 32%. Several nonrandomized observational trials conducted have assessed IVC filter use in trauma patients, and have made known a reduction in PE with a low complication rate.
| Prevalence of Inferior Vena Cava Filter Thrombosis|| |
IVC filter thrombosis has been reported to be a very prevalent and undesired complication in IVC filter placements, especially high incidence rates have been reported amongst the retrievable filters., It is proposed that filter thrombosis can be connected with reduced protection against PE, relocation of the filter, postthrombotic syndrome, chronic venous stasis and inability to retrieve the filter, vindicating it as an unwanted complication. Nonetheless, it should be well known that it is hard to determine if the thrombus contained by the filter is an outcome of successful trapping of lower limb thromboembolism or an in situ thrombus formation. As mentioned above sections, macroscopic indication of thrombi presence on temporary filters was revealed in up to about 75% of patients. Filter-induced thrombosis commences early, which is why it is further warranted for starting anticoagulant therapy the moment it is safe to do so post IVC filter deployment. In a clinical trial conducted by PREPIC study group showed that IVC thrombosis was seen in up to 13% of patients at 8 years post filter placement. These thrombi rise from either thrombosis at the place of filter implantation or it is connected to thrombus propagation from emboli that are trapped by the filter. Several IVC filter thrombi are asymptomatic, whereas the symptomatic cases present with symptoms that could lead to acute, huge leg swelling, chronic leg pain, and skin appearance changes which could include venous leg ulcers. Data of IVC filter thrombosis differ in publications, with overall prevalence rates range from 0.6% to 18%. Based on the study by Ahmad et al., it was reported that among 1718 patients placed with an IVC filter, undertook abdominal computed tomography imaging, about 19% of patients were found to be having some amount of IVC filter thrombosis, whereas 2% of the cases reported complete IVC occlusion. Based on the results of other studies, even higher rates of IVC filter occlusion were reported, and it was acknowledged that cylindrical or umbrella shaped filters appeared to be linked with the maximum rates of IVC thrombotic occlusion, with the incidence rated intensifying up to 65% at 9 years.
| Management of Inferior Vena Cava Filter Thrombosis|| |
There is no proper treatment strategy for the management of IVC filter occlusion. IVC filter thrombosis is a rare but highly fatal complication. Thrombosis within an IVC filter may range from being asymptomatic to being symptomatic with complete occlusion that may affect the lower extremities unilaterally or bilaterally.
Patients with complete IVC filter occlusion usually present with significant edema and pain of the lower extremities. Severe complications which may include sensory deficits, venous stasis, or ulceration may also present in a few cases. In cases of such clinical setting, the management depends on the capacity of the patient to undergo anticoagulation and/or thrombolysis.
Keeping all aspects and treatment modalities available endovascular management appears to be comparatively a safe and effective option in patients with IVC filter thrombosis, when compared to the results obtained with those reported for catheter-directed iliofemoral DVT treatment. Consequently, pulse-spray technique has become a more frequently used treatment modality at several institutions, ultimately growing into being utilised as a combination therapy by being used in combination with mechanical thrombectomy devices such as AngioJet. Even though pulse-spray and mechanical devices may have been successful in select patients, large thrombus present in the IVC still typically requires catheter-directed thrombolytic (CDT) infusion that may last 24–72 h. Technically, due to large thrombus and the possible involvement of bilateral iliofemoral veins, patients with IVC thrombosis time and again have need of larger thrombolytic doses when compared to patients with isolated extremity DVTs. Moreover, the indwelling IVC filter may cause a blockade for establishing a venous outflow, thereby creating additional probable difficulties for the endovascular procedure.
Use of CDT infusion post pulse-spray thrombolysis has also known to be useful. To achieve this, the catheter is favorably positioned or near the thrombosed venous segment so that thrombolytic agent can be infused directly into the thrombus. The thrombolytic agent preferred here is either tPA or urokinase, streptokinase is very rarely used due to some of its adverse effects. Systemic anticoagulation during thrombolysis is debatable, predominantly when concerned with if the patient should be completely or partially anticoagulated. Activated partial thromboplastin times of 60–90 s is desirable in completely anticoagulated patients when compared to partially anticoagulated patients who have been administered with sub therapeutic doses of heparin at 500 U/h. Though, on particular occasions, based on certain clinical factors such as severe thrombus burden or known cases of thrombophilia, complete heparinization may perhaps be necessary. In few particular situations, such as heparin induced thrombocytopenia, direct thrombin inhibitors could be used instead of heparin.
Another option pf treatment of IVC filter thrombosis is placement of a second IVC filter. Employment of a second filter downstream from the indwelling filter in the course of the initial thrombolysis process for IVC filter thrombosis is very much debateable. The supporters of introduction of a new filter normally quote a fear of the thrombus embolization in the course of thrombolysis. In several cases, the site of the initial filter is proximately below the level of the renal veins, and the IVC is generally patent at and above the filter; hence, placement of a new filter would be in a suprarenal location. If there is a large thrombus present above the initial filter, then the placement of the second filter is justified, and if a second filter is employed, it is preferred to place the filter at the suprarenal site, with intending to retrieving the new filter at the completion of thrombolysis.
Balloon venoplasty in IVC with filter placed in it can also be a treatment option in a few cases. A passage to permit the thrombolytics to interact better with thrombus is created through ballon dilatation of the IVC with filter placed in it, allowing more thrombolytic drug to be supplied to the thrombus through this created channel and have improved effects.,
In the end, in the event of CDT, mechanical thrombectomy, and/or balloon angioplasty without stent placement, the preexisting filter could stay in place and be totally functional. If it is a permanent filter, along with an adequate flow in the IVC and filter, the procedure may perhaps be concluded once determining the necessity for postprocedure anticoagulation. If the IVC filter is an optional type, post a successful endovascular procedure, it is preferred to recover the preexisting filter with or without employment of a new filter, depending on the clinical status of the patient.
| Conclusion|| |
Although not as common as a complication when compared to filter migration, IVC filter occlusion still is a prevalent and potentially fatal complication. IVC filter placement is commonly acknowledged and accepted in patients with acute VTE and absolute contraindications to anticoagulation or in patients who have failed adequate anticoagulation. Although, IVC filter is likely to have a role in the treatment of some high-risk patients. Endovascular management of a thrombosed IVC filter is in theory realistic, with high success and low complication rates. Development of newer endovascular devices allow interventional radiologists to treat by means of a number of methods that can be tailored on a case-by-case basis. Even though the presence of an IVC filter may perhaps add mechanical challenges to lower extremity and IVC thrombosis management, various present treatment options such as catheter directed thrombolysis, power pulse spray, the use of various mechanical devices, and astute use of tPA or stent placement will typically lead to a successful outcome. Long-standing clinical triumph depends upon not only by performing the thrombolysis but also in treatment of the underlying predisposing condition. More research is required to determine specifically, which groups of patients outside these stringent standards actually benefit from filter implantation.
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