Review
Inferior Vena Caval Filters: Key Considerations

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ABSTRACT

Surgical interruption of the inferior vena cava (IVC) as a means to prevent pulmonary embolism and its consequences has been entertained since the end of the 19th century. Initial methods were crude, however, but their deficiencies led to the development of newer techniques. Despite increasing indications and use of permanent IVC filters there remains controversy regarding their efficacy and complications. The purpose of this article is to review the pertinent literature and, it is hoped, aid in the development of a rational approach to the use of IVC filters. The evolving data regarding the retrievable filters are also discussed.

Section snippets

Rationale for Use

Over the last 30 years, it has been demonstrated repeatedly that it is possible to insert a mechanical filter into the inferior vena cava (IVC) while maintaining patency and blood flow1., 2., 3., 4., 5. in an attempt to prevent consequences of embolic events from the lower extremity. An assumption underlying this use is that in a majority of cases, pulmonary emboli are manifestations of venous thrombi arising in the lower extremities, and that the risk of pulmonary embolization is increased

Indications for Inferior Vena Caval Filter Placement

According to the seventh ACCP Consensus Conference on Antithrombotic Therapy13 (Table 1), inferior vena caval filter placement is recommended when there is a contraindication or complication of anticoagulant therapy (including heparin induced thrombocytopenia) in an individual with a proximal vein thrombus or PE. It is also recommended for recurrent thromboembolism that occurs despite adequate anticoagulation, chronic recurrent embolism with pulmonary hypertension, and with the concurrent

Insertion of Inferior Vena Caval Filters

Insertion techniques have evolved from initial cut- down methods to the present-day percutaneous route using fluoroscopic guidance. Femoral, jugular, and basilic venous access sites have all been used. All sites involve standard venipuncture using the Seldinger technique for insertion of a catheter through which the filter is placed. Most uncomplicated procedures can be completed in less than 30 minutes with minimal fluoroscopy and contrast administration. The mortality rate from placement is

Types and Characteristics of Inferior Vena Caval Filters

Over the last 30 years, many designs of inferior vena caval filters have been introduced onto the market, although most of the experience has been with the stainless steel Greenfield filter15. Currently, there are at least 11 filters that are approved by the Food and Drug Administration and on the market for use in the United States. Design characteristics have undergone several technological changes and the characteristics of the ideal filter have been summarized.16 These features would

Efficacy

The most striking observation when reviewing the literature regarding IVC filters is the lack of randomized studies testing their efficacy and complications. Considering the issues raised above regarding the consequences of DVT, a controlled study involving such nontreated patients would certainly raise ethical concerns. There are, however, other significant shortcomings noted when reviewing articles dealing with IVC filters. Issues regarding diagnostic evaluations, appropriate descriptions of

Complications

Many of the same problems encountered when attempting to analyze articles commenting on the efficacy of mechanical filters are also found when reviewing data concerning complication rates: problems with study design, drop-out rate outcomes, and so on. With these limitations in mind, an attempt is made here to review what is known of the complications related to insertion of IVC filters.

Generally speaking, complications with a fatal outcome appear to be infrequent. As mentioned earlier, Becker

Removable Filters

With the above concerns regarding long-term safety, and realizing that contraindications to anticoagulation may be temporary in certain patients, there has been interest in the development of filters that are or can be removed after insertion. There are two categories of removable filters. The first is temporary, which by design must be removed after insertion as it is tethered to a catheter or wire at the insertion site. Currently no examples of this type are available for use in the United

Conclusion

Although randomized trials are limited, there is enough evidence in the literature to support the view that the consequences of untreated DVT/PE are significant and potentially fatal. The data do seem to indicate that there is protection against fatal complications early after insertion with acceptable morbidity but raises concerns about potential long-term complications. Any decision regarding permanent IVC filter placement must be based on an appreciation of these facts, even when following

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      Frequently, it is only a radiological finding which occurs when filter components extend more than 3 mm outside of the wall of the IVC [64]. More rarely, bleeding complications are associated with vena cava perforation, usually when the filter leg is withdrawn leaving an open hole; other severe consequences have been rarely reported [66,67]. The migration of the filter towards the heart is a potentially life-threatening complication of IVC filters, even if, in the majority of cases, migration is minor and does not result in any significant morbidity [30].

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      Vena cava perforation is a complication usually asymptomatic and without clinical importance; frequently it is only a radiological finding and occurs when filter components extending more than 3 mm outside of the wall of the IVC [51]. More rarely bleeding complications are associated with vena cava perforation, usually when the filter leg is withdrawn leaving an open hole; other severe consequences have been rarely reported [52]. The migration of the filter towards the heart is a potential life-threatening complication of IVC filters [24], even if in the majority of case migration is minor and does not result in any significant morbidity [12].

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      Standard demographic data, provider discipline, filter type, indications for placement, follow-up studies performed, and patient outcomes were collected. The indications for IVC filter placement were grouped as absolute, relative or prophylactic based upon previously published recommendations.4-9 Patients with documented VTE disease were categorized as having either absolute or relative indications, while patients at high risk but without any documented VTE disease were assigned to the prophylactic category (Table I).

    • Mid-term Experience with the ALN Retrievable Inferior Vena Cava Filter

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      Vena cava filters have been available widely to prevent life-threatening PE since the early seventies.3,4,10,11 The purpose of the modern retrievable filter is to avoid long-term device-related complications described with first-generation permanent filter, especially in patients who might benefit from PE prevention over a short period of time.8–16 The ALN filter is a stainless steel hydrodynamic retrievable IVC filter; few trials have recently investigated the efficacy and safety retrieval of the ALN device.5,6

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