Guidelines and the use of inferior vena cava filters: a review of an institutional experience

Summary.  Background and objectives:  Based on the American College of Chest Physicians 2004 antithrombotic therapy for venous thromboembolism (VTE) and the Eastern Association for the Surgery of Trauma 2002 guidelines, placement of an inferior vena cava (IVC) filter is indicated in patients who either have, or are at high risk for, VTE, but have a contraindication or failure of anticoagulation. Our aim is to compare clinical characteristics and outcomes of patients receiving IVC filters within-guidelines (WG) and outside-of-guidelines (OOG). Methods:  The 558 patients who received an IVC filter were divided into two groups called WG or OOG. The WG group met the criteria described above and the OOG group did not have a contraindication to or a failure of anticoagulation. Results:  The WG group had 362 patients and the OOG group had 196 patients. The OOG group had one (0.5%) patient with post-filter pulmonary embolism (PE), two (1%) with IVC thrombosis, and seven (3.6%) with deep vein thrombosis (DVT). The WG group had five (1.4%) patients with post-filter PE, 13 (3.6%) with IVC thrombosis, and 34 (9.4%) with DVT. All patients who developed post-filter PE had a DVT before filter placement, and patients who did not have a prior VTE event were at a significantly lower risk of developing post-filter IVC thrombosis and PE. Conclusion:  Our data do not support the use of an IVC filter outside of guidelines in patients without prior VTE who can tolerate anticoagulation because of the low risk of developing PE.     

Efficacy of inferior vena cava filters in anticoagulated patients

BACKGROUND AND OBJECTIVES: The benefit of an inferior vena cava (IVC) filter in addition to standard anticoagulation regimens is unknown. METHODS: We examined data for patients who received IVC filters with anticoagulation (AC-Filter) after an episode of venous thromboembolism (VTE) and compared them with data for those who received anticoagulation only (AC-Only). Outcome measures were new pulmonary embolism (PE), recurrent deep vein thrombosis (DVT), and mortality at 90 days and at 5 years. Demographic data included age, gender, and ethnicity/race, prior thromboembolic history, cancer, serum albumin, and time in therapeutic range. In addition, subsets matched for age, gender and race/ethnicity were examined in detail. RESULTS: AC-Filter patients (n = 251), when compared to AC-Only patients (n = 1377), did not differ significantly with regard to gender or cancer status, but white males in general had better outcomes. AC-Filter patients were more likely to have had a previous history of PE or VTE (P < 0.001). In comparison to AC-Only patients, AC-Filter patients had lower mean serum albumin levels (3.1 +/- 0.8 vs. 3.6 +/-0.8 mg dL(-1), P < 0.001) and were older (65 +/- 16.1 years vs. 60 +/- 17.5 years, P < 0.001). After stratification according to previous history of PE or VTE prior to the index VTE event, no differences in the outcome measures of new PE, recurrent DVT or mortality were identified between groups, but patients with a prior history of PE from either group were more likely to have a new PE (hazard ratio 1.9, P < 0.001). CONCLUSIONS: These data suggest that IVC filters may not provide any substantial additional benefit for patients who can tolerate anticoagulant therapy.     

下腔静脉滤器置人术预防肺动脉栓塞的临床应用

目的探讨置入下腔静脉滤器预防因下肢静脉血栓脱落引起肺栓塞的效果和安全性。方法15例下肢深静脉血栓患者置入钛质滤器Trap Ease Filter（REF）15例，其中临时性下腔静脉滤器置入3例，永久性下腔静脉滤器12例，全部滤器经股静脉穿刺置入，滤器位于双肾静脉水平以下的腔静脉内。随访3—19个月。结果本组15例患者滤器成功置入，临时性滤器体内置放两周后取出，未发现滤器移位和相关并发症，无肺动脉栓塞发生。结论置入下腔静脉滤器预防肺栓塞是安全有效的方法。     

Clinical review: Inferior vena cava filters in the age of patient-centered outcomes

Abstract

Inferior vena cava filter (IVCF) use continues to increase in the United States (US) despite questionable clinical benefit and increasing concerns over long-term complications. For this review we comprehensively examine the randomized, prospective data on IVC filter efficacy, compare relative rates of IVCF placement in the US and Europe, compare commonly considered guidelines for IVCF indications, and the current data on IVCF complications. Searches of MEDLINE and Cochrane databases were conducted for randomized prospective IVCF studies. Only three randomized prospective studies for IVCFs were identified. Commonly cited IVCF guidelines were reviewed with attention to their evolution over time. No evidence has shown a survival benefit with IVCF use. Despite this, continued rising utilization, especially for primary prophylactic indications, is concerning, given increasing evidence of long-term filter-related complications. This is particularly noted in the US where IVCF placements for 2012 are projected to be 25 times that of an equivalent population in Europe (224,700 versus 9,070). Pending much-needed randomized controlled trials that also evaluate long-term safety, we support the more stringent American College of Chest Physicians (ACCP) guidelines for IVCF placement indications and advocate a close, structured follow-up of retrievable IVCFs to improve filter retrieval rates.     

超声诊断左位下腔静脉引流入左上腔静脉1例

患者男,19岁,因"腰腿疼痛伴盗汗、乏力2月余"入院,临床诊断为L2、3腰椎结核.超声:心脏位置正常,心房正位,心室右袢,房室连接正常,右心房轻度增大,房间隔中部连续性中断(约6.4 mm);主动脉走行、位置正常,腹主动脉右侧未见下腔静脉;左右髂总静脉在左右髂总动脉分叉处左下方汇合后于腹主动脉左后方上行(图1A),穿过膈肌回流至左上腔静脉;下腔静脉肝后段缺如,肝左、肝右及肝中静脉直接汇入右心房(图1B);左颈内静脉、左锁骨下静脉汇入左上腔静脉,右无名静脉部分血流汇入右侧上腔静脉,另一部分于主动脉弓水平汇入左上腔静脉(图1C);左上腔静脉经冠状静脉窦回流至右心房;冠状静脉窦增宽,窦壁完整.     

Clinical outcome of patients with venous thromboembolism and recent major bleeding: findings from a prospective registry (RIETE)

BACKGROUND: Patients who have experienced a recent major bleeding episode are usually excluded from clinical studies of venous thromboembolism (VTE) treatment. Therefore, recommendations based on evidence from clinical trials may not be suitable for these patients. The Registro Informatizado de la Enfermedad TromboEmbolica (RIETE) is a multicenter, observational registry designed to gather and analyze data on VTE treatment practices and clinical outcomes in patients with acute VTE. OBJECTIVES: The aim of this analysis was to study outcomes of patients with VTE who had experienced recent major bleeding (< 30 days prior to VTE diagnosis). METHODS: Patients with objectively confirmed symptomatic acute VTE are consecutively enrolled into the RIETE registry. Patient characteristics, details of antithrombotic therapy, and clinical outcomes at 3 months were recorded. RESULTS: Of 6361 patients enrolled up to January 2004, 170 (2.7%) had experienced recent major bleeding: 69 (40.6%) gastrointestinal tract, 60 (35.3%) intracranial, 41 (24.1%) other. The incidences of major bleeding (4.1%) and recurrent pulmonary embolism (PE) (2.4%) were significantly higher in patients with recent major bleeding. Among them, patients with cancer had an increased incidence of major bleeding [odds ratio (OR) 10.0, 95% confidence interval (CI) 2.3, 50; P < 0.001] and fatal PE (OR 4.1, 95% CI 0.98, 17; P < 0.05). CONCLUSIONS: Patients with VTE and recent major bleeding prior to VTE diagnosis (2.7% of total enrolled patients) had poorer clinical outcomes compared with those who had not experienced recent major bleeding. In patients who had recent major bleeding prior to enrollment, those with cancer had a poorer clinical outcome than those without cancer.     

永久性下腔静脉滤器放置预防肺栓塞

目的评价永久性下腔静脉滤器置入术在下肢深静脉血栓形成(DVT)患者中预防肺栓塞(PE)的有效性和安全性。方法 48例下肢深静脉血栓形成(DVT)患者全部行永久性下腔静脉滤器置入术,采用B/BRAUN VENA TECHTM LP滤器,滤器均位于肾静脉水平以下的下腔静脉中。结果 48例滤器经健侧股静脉穿刺置入,手术均获成功,无滤器释放不全、穿孔、脱落、移位、出血和滤器释放通路血栓形成。术后随访48例,随访时间1~26个月,未出现滤器移位、倾斜、下腔静脉血栓形成和肺栓塞(PE)。结论永久性下腔静脉滤器置入术可以安全和有效预防肺栓塞(PE)的发生,且手术操作简便,并发症少。     

下腔静脉滤器置入联合导管溶栓术治疗深静脉血栓

目的探讨下腔静脉滤器(IVCF)置入联合导管溶栓术(CDT)治疗深静脉血栓的有效性与安全性。方法 80例下肢深静脉血栓患者分为观察组和对照组。观察组采用IVCF置入联合CDT,对照组则采用常规的抗凝、溶栓治疗。比较2组患者的疗效,分析大、小腿周径差及静脉通畅度评分情况。结果观察组总有效率显著高于对照组(P0.05)。2组患者的大、小腿周径差及静脉通畅度评分均显著降低(P0.01),且观察组各项指标均明显低于对照组(P0.01);观察组大、小腿消肿率明显高于对照组,患肢的溶栓率明显高于对照组(P0.01)。2组出血并发症发生率及肺动脉栓塞发生率比较有显著差异(P0.05)。结论 IVCF置入联合CDT治疗深静脉血栓安全有效,可显著改善患者的临床症状。     

Bilateral proximal deep vein thrombosis and COVID‐19 in a patient with absence of inferior vena cava: A case report and review of literature

Bilateral proximal deep vein thrombosis (DVT) in the lower extremities of young patients should raise suspicion over pro‐thrombotic conditions and venous anatomical abnormalities, even in the presence of other precipitating factors, such as viral infection. The authors present a 33‐year‐old man with bilateral DVT and absence of inferior vena cava (AIVC), who also had concurrent COVID‐19, and discuss the management of this patient.     

Radiofrequency catheter ablation of common atrial flutter in a patient with anomalous inferior vena cava and azygos continuation

We describe a case of isthmus-dependant atrial flutter ablation with a superior approach due to an anomalous inferior vena cava (IVC), azygos, and emiazygos continuation. A 56-year-old man was referred to our institution for the treatment of a common atrial flutter. Two years prior, the patient had an attempted electrophysiological study not performed due to the inability to advance the guidewire through IVC. A computed tomography of the abdominal venous system revealed the absence of the subrenal IVC, azygos, and emiazygos continuation. Following double puncture of the left subclavian vein, two catheters were inserted into the coronary sinus and into the right atrium. Programmed atrial stimulation was performed and a sustained isthmus-dependant right atrial tachycardia was obtained. After 11 applications of radiofrequency energy with an inversion technique, sinus rhythm was restored and a repeat atrial programmed stimulation failed to induce any arrhythmia.     

Treatment of catheter-induced thrombotic superior vena cava syndrome: a single institution's experience

 Thrombosis is the most frequent benign etiology of superior vena cava syndrome among cancer patients who have a long-term central venous catheter. In this paper, six cases of thrombotic superior vena cava syndrome are discussed. There were four women and two men. One patient was treated with streptokinase and five with urokinase. The mean age was 46 years (range 22–69), and the mean time for thrombosis development after catheter insertion was 125 days (range: 53–211 days). The mean time for resolution of thrombosis was 7 days (range 2–11) in five patients. One patient had no response to fibrinolysis. Published online: 20 April 2000     

Contrast-enhanced ultrasonography of intraluminal inferior vena cava leiomyosarcoma: A case report

Primary leiomyosarcoma of the inferior vena cava (IVC) is a rare and fatal disease. Imaging is the main diagnostic method. CT and MRI images of IVC leiomyosarcoma have been published, but ultrasonographic features have been scarcely described, especially with contrast-enhancement. We report the case of a patient in whom ultrasonography incidentally revealed a mass in the IVC. Contrast-enhanced ultrasonography showed heterogeneous enhancement in the arterial phase with some irregular non-enhanced areas, and mild clearance in the venous phase. The location and nature of the lesion as shown by ultrasonography were confirmed by CT and MRI.     

Retrievable inferior vena cava filter to prevent pulmonary embolism in patients with fractures and deep venous thrombosis of lower extremities: a single-center experience

ObjectiveTo evaluate the effectiveness of inserting a retrievable inferior vena cava filter (IVCF) to prevent pulmonary embolism (PE) in patients with bone fractures and acute deep venous thrombosis (DVT) before major orthopedic surgery.MethodsClinical data of patients with fractures and acute DVT who underwent IVCF insertion were analyzed. The patients were divided into above-knee DVT (AKDVT), popliteal vein thrombosis (PVT), and below-knee DVT (BKDVT) groups.ResultsAn IVCF was successfully implanted in 964 patients, among whom 929 were followed up (335, 470, and 124 in AKDVT, PVT, and BKDVT groups, respectively). There was no significant difference in the incidence of filter thrombosis among the groups (11.04%, 11.70%, and 8.06%, respectively). No symptomatic PE occurred during follow-up. The mean filter indwelling time was 18.4 ± 4.3 days, and the total filter removal rate was 76.87%. There was no significant difference in the rate of filter implantation, retrieval, complications, or mortality among the groups.ConclusionsRetrievable filters can effectively prevent PE before orthopedic surgery in patients with fractures and acute DVT of the lower limbs. AKDVT more readily forms a ≥1-cm thrombus in the IVCF than does BKDVT, and PVT more readily forms a <1-cm thrombus than does AKDVT.     

Compression of left inferior vena cava: a form of nutcracker syndrome

Left renal vein hypertension has been described in the literature as a cause of persistent hematuria. We report a case of nutcracker syndrome with hematuria involving the left inferior vena cava diagnosed with Doppler sonography and MRI.     

Manual aspiration thrombectomy for acute and subacute inferior vena cava thrombosis and lower extremity deep venous thrombosis

Deep vein thrombosis (DVT), which can lead to pulmonary embolism (PE), is a major contributor to the global disease burden and is the third most common cardiovascular pathology after coronary artery disease and stroke. Venous thromboembolic disease, which encompasses the disease entities of DVT and PE, affects up to 10 million cases every year and represents a serious and potentially life-threatening condition. Standard anticoagulation therapy alone is ineffective at promoting deep venous system thrombus removal. Many patients develop postthrombotic syndrome (PTS) despite being on adequate anticoagulation therapy. Aggressive therapy for rapid thrombus removal is important to prevent the development of PTS. Besides impeding the onset of PTS, rapid clearance of the thrombus is also required in the treatment of phlegmasia cerulea dolens, an uncommon but life-threatening complication of acute DVT that can lead to arterial insufficiency, compartment syndrome, venous gangrene, and limb amputation. Manual aspiration thrombectomy (MAT) can provide rapid and effective therapy that could be compared to the open surgical thrombectomy approach with minimal risk of morbidity, mortality, or recurrence after surgery. Though many devices have been developed to date for pharmacomechanical thrombolysis, the cost of the treatment using these devices is very expensive. MAT is simple to perform, easy to learn, inexpensive, and rapid. This review will outline and dissect several studies and case reports, sourced from the PubMed database, on the subject of the use of MAT in treating inferior vena cava thrombosis and lower extremity DVT, including in patients with compression of the iliac vein and phlegmasia cerulea dolens.     

Bilateral inferior vena cava: a vascular abnormality encountered during electrophysiologic study

In the course of clinical practice, the electrophysiologist may encounter a wide variety of vascular abnormalities, which are important to recognize, as they may potentially impact on the health and welfare of the patient. We describe a case of bilateral inferior vena cava and review its etiology, diagnosis, and significance to the cardiologist and electrophysiologist.     

下腔静脉滤器预防致死性肺栓塞

目的:评价置入下腔静脉滤器预防因下肢静脉血栓脱落引起肺栓塞的效果和安全性。材料和方法:40例下肢深静脉血栓患者,男23例,女17例,年龄31～79岁,中位年龄58岁。经下肢静脉造影证实有股髂静脉血栓,病变位于左下肢26例,右下肢10例,双下肢4例,同时16例经多普勒检查诊断。经股静脉或颈静脉穿刺置入下腔静脉滤器,术后分别于1,6,12个月摄腹部平片复查,以后每年复查腹部平片,观察滤器的位置、形态变化。结果:放置滤器42枚,经颈静脉穿刺4例,经右股静脉28例,经左股静脉10例,包括钛质Greenfieldfilter(TKG)14例,Bird'snestfilter(BNF)12例,Si-mon镍钛下腔静脉滤器10例,Tulip滤器3例(2枚已取出),Trapease滤器3例。滤器位于双肾静脉水平以下的腔静脉内。无严重并发症发生。随访发现2例TKG向足侧移位,1例TKG向头侧移位,2例BNF跨度增大,腹部CT,腔静脉造影发现一只脚穿透腔静脉壁,未出现任何症状,4例TKG和1例SNF发生滤器偏斜,角度小于15°。无1例发生腔静脉阻塞或复发肺栓塞。结论:置入下腔静脉滤器预防肺栓塞是安全、有效的方法。