Columbia University College of Physicians and Surgeons Classes of Filters and Complications John H. Rundback, MD, FAHA, FSVMB, FSIR The Interventional Institute at Holy Name Hospital Columbia University College of Physicians and Surgeons

John H. Rundback, MD DISCLOSURES Consulting Fees Honoraria ev3, Inc., Medtronic CardioVascular, Inc., Boston Scientific Corporation Honoraria Medtronic CardioVascular, Inc., Boston Scientific Corporation Grants/Contracted Research DSMC for VIVA (Abbott Trial), ev3, Inc., Abbott Vascular, C.R. Bard, Inc., Atrium Medical Corporation, W. L. Gore & Associates, Inc., Cordis, a Johnson & Johnson company, Terumo Medical Corporation

Classes of Filters Permanent Temporary Filter attached to tether Must be removed Optional – Retrievable Self-affixing to IVC wall Permanence is optional Optional – Convertible Self –affixing to IVC wall Device is permanent, but filtration is optional

NON-PERMANENT

Option Filter (Rex Medical) SafeFlo Filter (Rafael Medical) Crux Filter (Crux Biomedical) ALN Filter (ALN Implants)

IVC Filter Complications Death Caval Thrombosis Breakthrough PE Deep Venous Thrombosis Post-phlebitic syndrome Migration Embolization Caval Penetration Caval Injury with retrieval

SIR QI Guidelines (JVIR 2003)

Cardiac Migration Essentially no difference across permanent filter types Chest. 2009 Sep;136:877-87

Fracture and Cardiac Migration JVIR 2008 July

Caval Thrombosis and DVT

Decousus Study 400 patients with proximal DVT Randomized to anticoagulation vs. filter and anticoagulation Outcome measures: death, recurrent VTE, major bleeding Analysis at day 12 and 2 years NEJM February 2008

2 year f/u DVT: 20% with filter, 12% without (p<0.05) Recurrent PE, death: no difference

PREPIC 8-Year Update Recurrent DVT Filter: 57 (34.1%) 50% filter + DVT had filter thrombosis No filter: 41 (27.3%) Symptomatic PE Filter: 9 (6.2%), 2 fatal No filter: 24 (15.1%) 5 fatal Post–thrombotic syndrome: 56% in both groups Ulcers 5 filter, 15 non-filter No survival benefit with filter P=0.042 P=0.008 Circulation 2005;112:416

11 articles, 1552 patients, 4.5 yr mean f/u JVIR July 2008 11 articles, 1552 patients, 4.5 yr mean f/u One study reported no difference in PTS according to whether anticoagulation was initiated in addition to filter placement. No study reported rates of PTS according to use of elastic compression stockings after filter placement. Pooled Weighted Frequency of PTS Indication # pts Edema Trophic ∆‘s or ulcer Mean f/u 1o Prevention 302 20.2% 8.3% / 2% 2.1 y 2o Prevention 1103 51.2% 13.5% / 3.8% 5.6 y

JVIR Mar 2008 Recovery and Tulip Filters 15.5% of retrievable filters underwent attempted removal  70% successfully retrieved

Failed Retrieval

Conclusions There is an increasing trend towards the placement of optional IVC filters although most are not removed. No substantial differences in major complications exist across filter classes or types. Major risk is recurrent VTE which occurs in approximately 20% of cases.