Inferior Vena Cava Filters: When to Place and When to Remove

Abstract

Pulmonary embolism (PE) is a common and feared result of deep vein thrombosis. While anticoagulation is the mainstay of management, interruption of flow of thrombus from leg veins to the pulmonary circulation is frequently desired either in lieu of or in addition to anticoagulation. Inferior vena cava filters have become frequently used to prevent PE despite a paucity of evidence for efficacy and increasing concerns about the long-term complications of indwelling filters.

Role of Inferior Vena Cava Filter Retrieval in Patients on Chronic Anticoagulation Therapy

“…The IVCF has undergone evolution from the original Mobin-Uddin umbrella permanent filter in 1967 to the multitude of optional filters, which may be retrieved or left permanently, in use today [3]. The purpose of the IVCF remains to prevent significant PE by physically trapping venous emboli traveling from the lower extremities [20].…”

“…The FDA has recommended considering retrieval of IVCF as soon as clinically appropriate with an optimal time of retrieval between 29 and 54 days after placement, in order to maximize the benefits of filtration while minimizing the likelihood of complications, although, in practice, the decision to retrieve an IVCF and when is made on a patient-by-patient basis [3]. In order to facilitate this clinical decision-making, the SIR released guidelines for the use of optional IVCF in 2006 stating that an IVCF may be retrieved when an indication for permanent filtration is not present; the risk of clinically significant PE is acceptably low due to a proven ability to sustain appropriate primary therapy or a change in clinical status; the patient is not anticipated to return to a high-risk state for PE due to interruption in primary treatment, change in clinical management, or change in clinical condition; the life expectancy of the patient is long enough to benefit from retrieval of the filter; the filter may be safely retrieved or converted; and the patient agrees to have the filter retrieved or converted [20].…”

“…Routine IVCF retrieval, also known as standard, "snare and sheath," or "snareassisted" retrieval, refers to the use of a snare to engage the hook of the filter with subsequent collapsing of the filter into a sheath (Fig. 1) [3,32]. Routine retrieval techniques are used in 79-90.2% of retrieval procedures and have reported success rates of 73.2-100% [27•, 32, 34-36].…”

“…2), endobronchial forceps-assisted technique (Fig. 3), balloon displacement, and the Excimer laser sheath-assisted technique [3,[36][37][38][39]. Common reasons for routine retrieval failure with the subsequent need for advanced retrieval techniques include severe tilt, migration, penetration into the caval wall, caval occlusion (Fig.…”

“…Pulmonary embolism (PE) carries an 18-fold higher risk of early death when compared to patients with deep venous thrombosis (DVT) alone [2]. Approximately, 40% of all proximal DVT will cause PE without treatment [3]. Even with treatment, 1.5% of patients will have a fatal recurrent PE by 10 years [4•].…”