1. Inferior Vena Cava Filter Placement Patterns: Our experience and a review of the literature
Jaideep Patel, Stephanie Detterline, M.D., Robert Ferguson, M.D.
ACP Internal Medicine 2010 – Toronto,
April 24th, 2010

2. Available data  case reports, with few animal or in vitro studies, reviews, and prospective studies
Only 1 RTC available  Decousus et al
Pts with DVT (w/ or w/o PE) randomized to receive  Filter vs no filter
Also all patients were anticoagulated for 3 months.
filter group had a significantly lower incidence of PE during the first 12 days than the non-filter group.
May benefit patients with high risk PE
 overlooked that IVC filters have their own inherent risks and complications and may not be the best management strategy for every patient

3. Concerning because it has great implications for both patient safety and proper utilization of resources.

4. National Hospital Discharge Survey (1979-1999)
Numbers begin to increase sharply in 1988
Increasing use of filters, with development in filter technology (Nonthromogenic, High filtering efficiency , Retrievable)
large and small emboli (without impedance of flow) Secure fixation within the vena cava Rapid percutaneous insertion Smaller caliber Amenable to repositioning Simple release mechanism MRI compatible Low cost Retrievable
Stein PD, Kayali F, Olson RE. Twenty-one-year trends in the use of inferior vena cava filters. Arch Intern Med 2004; 164:

5. Objective Review our institutional practices
regarding IVC filter placement and
compare this to available published
guidelines to better understand our
compliance with the available evidence.
Want to ensure we are appropriately placing IVC filters because according to the NEJM study, having an IVC filter shows no effect on survival
WANTED TO ASSES OUR USE of IVC FILTERS IN OUR INSTITUTION

6. Methods
Retrospective review of patients undergoing temporary or permanent IVC filter implantation from 2001 to 2009.
Demographics, clinical presentation, indications for placement according to ACCP (2008) and extended guidelines, filter type, and hypercoagulable risk factors were collected for each case.

7. Methods
In each case, indications for IVC filter placement were determined to be either:
Indicated by absolute guidelines (G)
Indicated by relative guidelines (EG)
Met neither criteria for placement (NG)
Also on a case by case basis, IVC filter placement was determined to be

8. Absolute Guidelines for IVC Filter Placement - ACCP(2008)
Proven VTE with contraindications for anticoagulation
Proven VTE with complications of anticoagulation treatment
Recurrent VTE despite anticoagulation treatment (failure of anticoagulation)
Adapted from Chest 1,2

9. Relative extended guideline indications for IVF Filter placement
Recent VTE and operative procedure requiring prolonged withholding of anticoagulation
Patients with DVT and limited cardiopulmonary reserve or COPD
Patients with DVT who have cancer, burns or are pregnant
Large/free floating iliofemoral thrombus in high risk patient
Following thrombectomy/embelectomy/thrombolysis of a DVT
Propagating iliofemoral thrombus while anticoagulated
High risk surgical patients with anticoagulation contraindication
Major abdominal surgery within the past 2 days
Gastrointestinal or genitourinary bleeding within the past 14 days
Chronic PE in patient with pulmonary hypertension and cor pulmonale
Malignant hypertension
Infective endocarditis
Adapted from Blood , J Vasc Interv Radio , Am J Med
 Unfortunately, the ACCP Guidelines, are not clear in the definitions of what a contraindications or complications are, and for that reason
 many who argue there are other compelling reasons for filter placement
 Other than the ABSOLUTE recommended guidelines, there is also a list of RELATIVE guidelines
 Often mentioned, but not widely agreed upon and include - read off two of them
keep in mind NOT absolute  once again NOT ABSOLUTE

10. Total Filters Placed During Study Period
Results:
Total Filters Placed During Study Period
Overall INCRESING trend in total number of filters placed
* Data collected until September 2009

11. Results
Fully 50% of our filters were guideline indicated, and the remaining ½ were either EG or NG
Of our 50% that followed absolute guidelines for placement , 50% were placed in patients who had an acute VTE and a contraindication for IVC placement

12. Contraindications to Anticoagualtion Therapy
If we break down the contraindications to IVC filter placement in our study
Major risk of falling n= %
Overt GI bleed/guiac positive stools n= %
1/3 of these filters were not placed due to patient having a high risk of fall
This was followed closely by patients being heme positive

13. Complications of Anticoagulation Therapy
97% of patients encountered bleeding as their complication to AC therapy, and hence received a filter

14. Results
27% of our patients had filters placed according to the Relative Guidelines for IVC Filter placement

15. Relative Indications for Placement
In regards to RELATIVE Guidelines, 27%
71% of our patients had an IVC filter placed due to the fact that they were undergoing an operative procedure which required holding of AC
Attribute it to Union being a surgical center, with a stellar orthopedic unit

16. Conclusions 50% Indicated by absolute guidelines (G)
27% Indicated by relative guidelines
(EG)
23% Met neither criteria for placement (NG)
In summary, 50% of our patients had IVC filters placed according to current ACCP guideline
What was concerning to us though was the 23% of patients who met neither criteria for IVC filter placement
Concerning from a safety standpoint, given that IVC filters have shown no effect on survival

17. Conclusion Our practices our comparable Limitations
Physician understanding
Unclear recommendations/guidelines
Poor dictation
Patient follow-up
Kalva (2006) – study from Mass General – 28% prophylaxis; 72% G
Moris (2004) – study from U. of Vermont - 48% prophylaxis; 52% G
Dorvish et all (2005) – 27% prophylaxis; 73% G – Israeli multicenter study
Hammond et al (2008) – 57% G; 37% R; 6% prophylaxis – UK multicenter study
Ivette (2007) – 13.6% Prophylaxis; 71% G; 12.2% R – Chilean study
Singh et al (2009) - 65% WG, 35% OOG - US
Given this data, we seem to fall within the range at which other hospitals are placing IVC filters outside of the accepted guidelines
However, we feel a great need for more research on the proper indications, and greater attention to enforce those already in existence
Future studies
Patient follow-up