When do you use IVC

filters?

Jeffrey Wang MD

Horizon Vascular Specialists

Director of Vascular Research

Shady Grove Adventist Hospital

DVT and PE

DVT in the U.S.: • Symptomatic PE is the most important acute

complication of DVT

– 600,000 new DVT cases a year

– Responsible for 200,000 deaths (more than combined deaths from AIDS and breast cancer)

– Leading cause of preventable in-hospital mortality

• Diagnosis is confirmed in only 20-30% of ER patients with clinically suspected DVT

Sources:

• Society of Vascular Surgeons website, www.vascularweb.org, 1-6-06

• Schreiber, D. Deep venous thrombosis and thrombophlebitis.

www.emedicine.com/emerg/topic122.htm, last updated October 2005.

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Symptoms

• Dyspnea 78%

• Pleuritic chest pain 59%

• Cough 43%

• Leg pain 27%

• Hemoptysis 16%

• Palpitations 13%

• Wheezing 14%

• Angina like pain 6%

Signs

Tachypnea (20/min) 73%

Crackles 55%

Tachycardia (>100/min) 30%

Leg swelling 31%

Loud P2 23%

DVT 15%

Wheezes 11%

Diaphoresis 10%

Temperature (≥38.5°) 7%

Pleural rub 4%

Fourth heart sound 24%

Third heart sound 5%

Cyanosis 3%

Homans' sign 3%

Anticogaulation

• First line treatment of DVT and PE is

antigoagulation

• IVC interruption is an option if

anticoagulation is not possible

History

• 1893 Bottini-Ligates IVC

• 1959 Moretz- External clip of IVC

• 1973 Greenfield 1st IVC filter

Vena Cava Filter Indications

• Deep Venous Thrombosis and or

Pulmonary embolism

• Significant risk for falling

• Pt not able to tolerate anticoagulation

• Pt unable to tolerate additional PE

• New DVT or PE while on therapeutic

anticoagulation

Clinical Scenarios

• 84 yo female s/p right hip pining 1 wk

ago presents with right poplitial DVT

• 65 yo male with bilateral PE in ICU on

ventilator on pressors. O2 Sat 85%

• 68 yo female with GI Bleed and Left

Femoral DVT

• 72 yo male with atrial fibrillation on

therapeutic anticoagulation. Develops

a new right popliteal DVT. INR is 2.5

Some Other Controversial Indications

• BMI > 55 undergoing gastric bypass – There is data to suggest that prophylactic

filters reduce the amount of PEs

• Prior history of PE undergoing major orthopedic surgery – No evidence that once anticoagulation

treatment has been completed that there is additional benefit

• Oncologic Disorder with thromboembolic event – Effective in preventing PE but doesn’t seem

to convey a survival benefit

Some Other Controversial Indications

• Trauma and paraplegia or

quadriplegia

– There is a reduction in fatal PE, but higher

rate of recurrent DVT

– EAST recommends prophylactic filter in

high risk trauma patients

– ACCP does not recommend prophylactic

filters in the same group

• Hypercoagulable state

– Not appropriate for prophylaxisis

• Pregnancy

– IVC filter is safe in pregnancy

Some Other Controversial Indications

Normal Placement

List of available IVC filters

Retrievable

• Celect (Cook)

• Gunther Tulip (Cook)

• Denali(Bard)

• Optease(Cordis)

• ALN (ALN)

• SafeFlo (Rafael)

• Option (Rex)

• Crux (Crux)

Permanent

• Simon Nitinol (Bard)

• Vena Tech (Braun)

• Vena Tech LP (Braun)

• Greenfield (BSCI)

• Trapease (Cordis)

• Bird’s Nest (Cook)

Conclusion

• IVC Filters are very useful in many

situations

• Indications (Hard)

• Use your best clinical judgment (Soft)

• Retrievable filters are highly

recommended