Retrievable vena cava filters in trauma patients for high-risk prophylaxis and prevention of pulmonary embolism

doi:10.1016/j.amjsurg.2005.03.003

The American Journal of Surgery

Volume 189, Issue 6, June 2005, Pages 656-661

https://doi.org/10.1016/j.amjsurg.2005.03.003 Get rights and content

Abstract

Background

Venous thromboembolic (VTE) disease remains a significant cause of morbidity for trauma patients because many patients have injuries that may preclude effective VTE prevention and treatment. Retrievable vena cava filters may prove beneficial in this subset of trauma patients.

Methods

Trauma patients at risk for VTE were identified and managed by institutional protocol. Patients who required a vena cava filter were managed with a device that could be retrieved or left in situ. A retrospective review of medical records was used to identify the use, indications, and complications associated with a retrievable filter.

Results

Fifty-three retrievable filters were placed in 51 patients. Two of these patients received a second filter, and 1 received a filter in the superior vena cava. Thirty-two filters were placed prophylactically, whereas 21 were placed for demonstrated venous thromboembolism (VTE). Retrieval was successful in 24 of 25 attempts. Twenty-nine filters became permanent: 10 for continued contraindications to anticoagulation without known VTE, 12 for known VTE and continued contraindications to anticoagulation, 1 for technical reasons, and 6 because of patient death. There were no complications of bleeding, device migration or thrombosis, infection, or pulmonary embolism.

Conclusions

A retrievable vena cava filter appears safe and effective for the prevention of pulmonary embolism in the high-risk trauma patient who cannot receive anticoagulation.

Section snippets

Methods

This is a retrospective review of our experience with retrievable vena cava filters in the population of the traumatically injured. Our hospital is a 520-bed American College of Surgeons-verified level I trauma center that admits approximately 1,400 trauma patients/y. All multiply injured patients are admitted to the trauma service. At the time of admission and daily thereafter, each patient is assessed for risk of VTE according to institutional VTE protocol.

The trauma service protocol for VTE

Demographics

Between January 1, 2001 and September 30, 2003, 53 retrievable IVC filters—including 1 retrievable superior vena cava (SVC) filter—were placed in 51 trauma patients. The demographic and disposition details of the patients are listed in Table 1. All patients sustained multiple injuries (Table 2). Thirty-eight (75%) patients had multiple (>2) long-bone fractures; 29 (57%) had chest trauma; and 26 (51%) had traumatic brain injury.

During the 21 months of this study, 2,426 patients were admitted to

Comments

VTE remains a significant risk for hospitalized trauma patients. Prophylactic measures have been shown to decrease the incidence of DVT in general surgery, orthopedic, and trauma patients. However, VTE prophylaxis and treatment is often challenging in the multiply injured patient. Lower-extremity fracture or soft-tissue injury may prevent application of thigh-high sequential compression devices. Although some have suggested the use of foot-compression devices in these patients, no benefit was

References (30)

W.H. Geerts et al.
A prospective study of venous thromboembolism after major trauma
N Engl J Med
(1994)
R.J. Freeark et al.
Posttraumatic venous thrombosis
Arch Surg
(1967)
K.A. Kudsk et al.
Silent deep vein thrombosis in immobilized multiple trauma patients
Am J Surg
(1989)
M.D. Cipolle et al.
The role of surveillance duplex scanning in preventing venous thromboembolism in trauma patients
J Trauma
(2002)
M.H. Meissner
Deep venous thrombosis in the trauma patient
Semin Vasc Surg
(1998)
F.B. Rogers et al.
Routine prophylactic vena cava filter insertion in severely injured trauma patients decreases the incidence of pulmonary embolism
J Am Coll Surg
(1995)
F.B. Rogers et al.
Prophylactic vena cava filter insertion in severely injured trauma patientsindications and preliminary results
J Trauma
(1993)
J.L. Rodriguez et al.
Early placement of prophylactic vena caval filters in injured patients at high risk for pulmonary embolism
J Trauma
(1996)
S. Khansarinia et al.
Prophylactic Greenfield filter placement in selected high-risk trauma patients
J Vasc Surg
(1995)
D.A. Spain et al.
Venous thromboembolism in the high-risk trauma patientdo risks justify aggressive screening and prophylaxis?
J Trauma
(1997)

P.J. Offner et al.

The role of temporary inferior vena cava filters in critically ill surgical patients

Arch Surg

(2003)

C.S. Morris et al.

Current trends in vena caval filtration with the introduction of a retrievable filter at a level I trauma center

J Trauma

(2004)

C.G. Elliott et al.

Calf-thigh sequential pneumatic compression compared with plantar venous pneumatic compression to prevent deep-vein thrombosis after non-lower extremity trauma

J Trauma

(1999)

R. Wojcik et al.

Long-term follow-up of trauma patients with a vena caval filter

J Trauma

(2000)

M. Porcellini et al.

Intracardiac migration of nitinol TrapEase vena cava filter and paradoxical embolism

Eur J Cardiothorac Surg

(2002)

Cited by (57)

Practice Variation in Vena Cava Filter Use Among Trauma Centers in the NTDB
2020, Journal of Surgical Research
Citation Excerpt :
Haut et al.6 conducted a meta-analysis and concluded that VCF placement reduced PE and fatal PE with no difference in mortality and that the number needed to treat to prevent one PE was between 109 and 962. In two single-center retrospective studies, it was shown that prophylactic VCF prevents PE and it was recommended that institutions develop protocols to use prophylactic VCF routinely in trauma patients meeting specific indications.16,18 The consensus has shifted away from favoring the use of VCF.
Agreement regarding indications for vena cava filter (VCF) utilization in trauma patients has been in flux since the filter's introduction. As VCF technology and practice guidelines have evolved, the use of VCF in trauma patients has changed. This study examines variation in VCF placement among trauma centers.
A retrospective study was performed using data from the National Trauma Data Bank (2005-2014). Trauma centers were grouped according to whether they placed VCFs during the study period (VCF+/VCF−). A multivariable probit regression model was fit to predict the number of VCFs used among the VCF+ centers (the expected [E] number of VCF per center). The ratio of observed VCF placement (O) to expected VCFs (O:E) was computed and rank ordered to compare interfacility practice variation.
In total, 65,482 VCFs were placed by 448 centers. Twenty centers (4.3%) placed no VCFs. The greatest predictors of VCF placement were deep vein thrombosis, spinal cord paralysis, and major procedure. The strongest negative predictor of VCF placement was admission during the year 2014. Among the VCF+ centers, O:E varied by nearly 500%. One hundred fifty centers had an O:E greater than one. One hundred sixty-nine centers had an O:E less than one.
Substantial variation in practice is present in VCF placement. This variation cannot be explained only by the characteristics of the patients treated at these centers but could be also due to conflicting guidelines, changing evidence, decreasing reimbursement rates, or the culture of trauma centers.
Inferior Vena Cava Filters: Placement and Retrieval
2015, Journal of Radiology Nursing
The incidence of venous thromboembolism, including both deep venous thrombosis and pulmonary embolism, is approximately 100 per 100,000 patients in the United States. Although anticoagulation is the mainstay of treatment, increasing numbers of patients with absolute contraindications, treatment failures, and complications has led to rising numbers of inferior vena cava (IVC) filter placements. IVC filter placements, however, are not without potential early and long-term complications such as filter thrombosis, perforation, migration, fracture, and embolization. Although IVC filter removal is successful in many cases, retrieval may be technically challenging, and ultimately unsuccessful, due to associated thrombus, substantial filter tilting, filter fracture, and excessive tissue embedding surrounding the tip or struts. As a result of increasing prevalence of IVC filters, it is important that all members of the health care team be comfortable with these devices. The purpose of this article is to provide a comprehensive review of IVC filters, their placement, and retrieval.
Vena cava filters for management of venous thromboembolism: A clinical review
2013, Blood Reviews
Venous thromboembolism (VTE) is the common cause of morbidity and mortality. Vena cava filters (VCF) represent an important alternative to anticoagulation for management of VTE. VCF use has increased dramatically with the availability of retrievable filters. Since indiscriminate use of VCF can be associated with net patient harm, knowledge of the risks and benefits of these devices is essential to optimal evidence-based practice. In this review, we will examine the characteristics of available permanent and optional VCF, their efficacy and safety in management of VTE and discuss appropriate, extended and unsubstantiated indications for VCF use. We will also review the clinical outcomes of VCF in alternative placement sites (supra-renal inferior vena cava and superior vena cava) and in specialized patient populations (bariatric surgery, cancer, etc.), recommendations regarding anticoagulation for prevention of thrombosis as well as recommended follow up for patients with VCF.
Use of Vena Cava Filters and Venous Access Devices
2013, Consultative Hemostasis and Thrombosis: Third Edition
Improving retrieval rates of temporary inferior vena cava filters
2011, Journal of Vascular Surgery
Most studies have shown that the rate of inferior vena cava filter (IVCF) retrieval rarely exceeds 30%. A review of practices in our own institution revealed similar results (18%). Within the last year, few centers have demonstrated improved retrieval rates. Our hypothesis was that developing a dedicated program would improve IVCF retrieval. We report the results of an ongoing study following the development of this program.
This is a cohort of nontrauma consecutive patients who had an IVCF placed by the vascular service over a 12-month period (January 2010-January 2011) and were followed prospectively. A dedicated nurse practitioner was responsible in developing a database, maintaining contact with all the patients, and ensuring that arrangements were made for retrieval when indications for IVCF protection were no longer present. Demographics, indication for filter placement, timing to filter retrieval, and complications during placement and retrieval were prospectively collected. Retrieval rate was compared to the baseline institution data.
During the study period, 42 patients had an IVCF placed. There were 27 men and 15 women with a mean age of 58 (25 to 88 years old). Two patients were excluded (one due to mortality and one had multiple filters) leaving 40 patients in the study. Indications for IVCF placement were absolute in 23 of 40 patients (58%), relative in 10 of 40 patients (25%), while seven patients (17%) had an IVCF placed for prophylaxis as they were considered high risk for pulmonary embolism (PE) and could not receive any chemical regimen. During follow-up, five filters were converted to permanent. Therefore, retrieval was successful in 19 of 22 patients with an 86% success rate and no complications. Median time to retrieval was 21 days ranging from 4 to 140 days. Retrieval rate for IVCFs designated as temporary at the time of placement was 70% (19 of 27), which was significantly higher compared to our baseline data of 18% (P < .001).
Initial data show that a dedicated program that closely monitors patients with temporary IVCFs for ongoing need of filter prophylaxis can result in high retrieval rates. The endurance and long-term success of such a program needs to be further validated.
The use of retrievable inferior vena cava filters in severely injured military trauma patients
2009, Journal of Vascular Surgery
Important recent data on retrievable inferior vena cava filter (R-IVCF) used in civilian trauma centers suffer from poor follow-up in these transient patients. Because US military casualties can be more easily followed globally, our objective was to further characterize R-IVCF outcomes in a trauma population with improved follow-up.
From July 2003 to June 2007, trauma registry records were retrospectively reviewed for US soldiers injured in Iraq and Afghanistan who had R-IVCF placement. Indications, type of filter, complications, outcomes, and retrieval data were analyzed.
Seventy-two R-IVCFs were placed during the study period. Mean follow-up was 28.0 ± 12.0 months, in 61 (85%) patients. Mean injury severity score (ISS) was 36.3 ± 10.4 and mean patient age was 27.4 ± 6.4 years. Fifty-nine R-IVCFs (82%) were not retrieved due to: death (1, 1.3%), technical failure (2, 2.8%), lost to follow-up (11, 15.2%), or contraindications to retrieval (45, 62.5%). Thirteen R-IVCFs were successfully removed, an overall retrieval rate of 18%. Median dwell time of those removed was 47 days (range, 10-94). IVCF indications were prophylactic in 23 (32%) and therapeutic in 49 (68%) cases. Both retrieval failures were due to incorporation into the caval wall, attempted at 90 and 156 days. Deep vein thromboses at the insertion site or pulmonary embolism following R-IVCF placement or removal were not observed. To date, there have been no reports of IVC stenosis or occlusion.
R-IVCFs were safely and effectively used in severely injured military trauma patients with high ISS. Despite improved follow-up, overall retrieval remained low, reflecting the civilian experience. Indication, rather than follow-up losses, accounted for the low retrieval rate. Practice patterns for R-IVCF in trauma may need to be re-examined to optimize outcomes.

View all citing articles on Scopus

View full text

The American Journal of Surgery

Clinical surgeryRetrievable vena cava filters in trauma patients for high-risk prophylaxis and prevention of pulmonary embolism

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Demographics

Comments

A prospective study of venous thromboembolism after major trauma

N Engl J Med

Posttraumatic venous thrombosis

Arch Surg

Silent deep vein thrombosis in immobilized multiple trauma patients

Am J Surg

The role of surveillance duplex scanning in preventing venous thromboembolism in trauma patients

J Trauma

Deep venous thrombosis in the trauma patient

Semin Vasc Surg

Routine prophylactic vena cava filter insertion in severely injured trauma patients decreases the incidence of pulmonary embolism

J Am Coll Surg

Prophylactic vena cava filter insertion in severely injured trauma patientsindications and preliminary results

J Trauma

Early placement of prophylactic vena caval filters in injured patients at high risk for pulmonary embolism

J Trauma

Prophylactic Greenfield filter placement in selected high-risk trauma patients

J Vasc Surg

Venous thromboembolism in the high-risk trauma patientdo risks justify aggressive screening and prophylaxis?

J Trauma

The role of temporary inferior vena cava filters in critically ill surgical patients

Arch Surg

Current trends in vena caval filtration with the introduction of a retrievable filter at a level I trauma center

J Trauma

Calf-thigh sequential pneumatic compression compared with plantar venous pneumatic compression to prevent deep-vein thrombosis after non-lower extremity trauma

J Trauma

Long-term follow-up of trauma patients with a vena caval filter

J Trauma

Intracardiac migration of nitinol TrapEase vena cava filter and paradoxical embolism

Eur J Cardiothorac Surg

Practice Variation in Vena Cava Filter Use Among Trauma Centers in the NTDB

Inferior Vena Cava Filters: Placement and Retrieval

Vena cava filters for management of venous thromboembolism: A clinical review

Use of Vena Cava Filters and Venous Access Devices

Improving retrieval rates of temporary inferior vena cava filters

The use of retrievable inferior vena cava filters in severely injured military trauma patients

Clinical surgery
Retrievable vena cava filters in trauma patients for high-risk prophylaxis and prevention of pulmonary embolism