1. Optional IVC Filters: Indications for Placement and Retrieval
Adam J. Doyle, M.D. Assistant Professor of Surgery Division of Vascular Surgery University of Rochester Medical Center
Thank you for the opportunity to present today. Today I will be discussing optional IVC filters, indications for placement and removal.

2. No Disclosures
I have nothing to disclose.

3. Objectives Review indications for placement
Review indications for removal
Suggestions for surveillance of IVC filters that cannot be removed via endovascular techniques
The objectives of the talk include reviewing indications for placement, reviewing indications for removal, and suggestion for surveillance of IVC filters that cannot be removed by endovascular techniques.

4. Following the publication of the results of the PREPPIC, trial the use of IVC filters has skyrocketed. This trial showed a significant reduction in the rate of pulmonary embolism in the group of patients randomized to IVC filter placement, however there was no Difference in mortality rate.

5. You can see on table on the left the rate of IVC filter insertion has increased consistently since On the right-hand side table you see the absolute number of filters inserted, and on the bottom you see an estimate of the high in the low number of IVC filter retrievals. As you can see the majority of filters being place, While felt to be temporary at the time, Turn out to be permanent.

6. The High Risk Trauma Patient
< 25% of Patients had IVC filters retrieved
Several other societies have recommendations regarding placement of IVC filters in high risk trauma patients based upon expert opinion. You can see from the results of this review of the national trauma Registry, that the filter related complications exceeded the rate of pulmonary embolism in this patient population.

7. But one more PE might kill the patient...* mm
In this trial publishing JAMA 2015 that Studied the effect of IVC filter placement in addition to therapeutic anticoagulation.

8. Severe cardiopulmory disease CVA with paralysis Iliocaval DVT
- Randomized high risk DVT/PE patients to anticoagulation alone vs anticoagulation + IVCF
Age > 75
Active CA
Severe cardiopulmory disease
CVA with paralysis
Iliocaval DVT
Signs of RV dysfunction or MI
It randomized High-risk DVT/PE patient to anticoagulation alone versus anticoagulation and IVC filter place placement.

9. The results of the study showed there was no benefit to placement of IVC filters.

10. Over the past few years there’s been a rapid increase in rates of reporting of device related complications for IVC filters. This article from the journal of vascular surgery showed that there was a statistically significant increase rate of device related complications overtime with the use of temporary IVC filters as compared to permanent IVC filters.

11. Device Related Complications
A quick Google search yields these direct to patient advertisements regarding device related complications.

12. Device Related Complications
Notably several filters have been pulled off the market, and in other cases, the filters have been redesigned.

13. In the case of the Cook celect filter a redesign was released A few years ago.

14. Cook’s CIVC trial which has yet to be published: https://www
This prospective, multicenter, single-arm clinical study will further evaluate the safety and effectiveness of specifically, the Günther Tulip Vena Cava Filter and Cook Celect Vena Cava Filters in patients in need of temporary or permanent IVC filter placement for the prevention of pulmonary embolism. 
The clinical trial evaluating the safety and efficacy of this filter has completed enrollment, but the results have not yet been reported.

15. Over the past few years there is mounting evidence about risk factors for IVC filter non-removal. Some of these are listed here.

16. Additionally, Other studies have shown that the dwell time of the filter is directly related to failure to retrieve. In the study by glocker et al, 90% of filters were able to be removed at 120 days, while less than 40% were able to be removed at 300 days.

17. You can see from this picture of a removed filter, in some cases the filter becomes incorporating into the vena cava.

18. What is the evidence and what are the indications?
The ninth edition of the ACCP antithrombbotic guidelines Make recommendations on the placement of IVC filters. I will review these.

19. Chest Guidelines
In patients with acute DVT of the leg we recommend against the use of an IVC filter in addition to anticoagulation. In patients with acute proximal DVT of the leg and contraindication to anticoagulation we recommended the use of an IVC filter.

20. Chest Guidelines
In patients with acute proximal DVT of the leg and an IVC filter inserted as an alternative to anticoagulation, we suggest a conventional course of anticoagulation therapy if their risk of bleeding resolves.

21. Chest Guidelines
In patients with acute PE were treated with anticoagulants we recommend against the use of an IVC filter. In patients with acute PE and contraindication to anticoagulation we recommend the use of an IVC filter.

22. Here are a few pictures of the patient of mine who had a prophylactic temporary IVC filter placed seven years ago.

23. As you can see from these pictures the filter has perforated vena cava up to 11 mm.

24. Compare this to another one of my patients who had a permanent IVC filter placed seven years ago in the setting of an acute recurrent DVT/PE while on therapeutic anticoagulation, and massive G.I. bleeding. In the case of the permanent filter there is minimal evidence of IVC perforation.

25. FDA: Inferior Vena Cava (IVC) Filters: Initial Communication: Risk of Adverse Events with Long Term Use. 2010
“If a patient has a retrievable IVC filter that should be removed based on his or her individual risk/benefit profile, the primary care physician and/or those providing ongoing patient care should refer the patient for IVC filter removal when feasible and clinically indicated.”
In 2010 the FDA released an initial communication regarding the risk of adverse events with long-term use of temporary IVC filters. It stated that if a retrievable IVC filter has been placed, that it should be removed based on his or her individual risk/benefit profile, the primary care physician and/or those providing ongoing patient care should refer the patient for IVC filter removal when feasible and clinically indicated.

26. Since then several studies have looked into ways to improve IVC filter retrieval rates.

27. . In this study out of Boston they were only able to improve their retrieval rates from 11% to 54%.

28. Their suggested algorithm for surveillance, and removal is listed here.

29. As you can see from this graph filters can easily be removed within the first hundred days, After which the rates of success begin to decreased significantly.

30. An alternate algorithm for considering IVC filter removal is presented here. Practically speaking, all attempts should be made to remove IVC filters as soon as there is no longer a contraindication to anticoagulation, no evidence of acute DVT, and the patient has returned to ambulatory status.

31. I this recent analysis of patients with a history of IVC filters placed in the Kaiser northern California system the authors examined long term device related complications in patients who had CT scans to review.

32. The indications for placement in these patients was acceptable in the majority.

33. While the number of patients in this study was low, the rates of IVC and retroperitoneal perforations was strikingly high in the temporary group when compared to the permanent group (70 vs 15 % and 53 % vs 5% respectively)

34. Lastly, in situations where an IVC filter cannot be removed, and has caused a complication, referral for open surgical removal should be considered.

35. Take Home Points IVC Filters are an effective tool when used correctly
Indications for placement:
Acute DVT or PE with contraindication/intolerance of therapeutic anticoagulation
Recurrent PE while on therapeutic anticoagulation
Consider the use of permanent IVC filter given lower rates of device related complications if it is unlikely the filter will be removed
Patients should be started on therapeutic anticoagulation as soon as able after IVC filter placement
Attempt removal of all temporary filters as soon as possible
Consider surveillance imaging of all IVC filters to assess for device related complications
Consider open surgical removal of IVC filters in patients with complications
In conclusion IVC filters are an effective tool when used correctly. The indications for replacement are: Acute DVT or PE with contraindication to therapeutic anticoagulation, or recurrent PE while on therapeutic anticoagulation. One must consider the use of permanent IVC filters, given the lower rates of device related complications, if it is unlikely that the filter will be removed. Patients should be started on therapeutic anticoagulation as soon as able after IVC filter is place. Attempted removal of all temporary IVC filters should be made. In the event where IVC filters cannot be removed, then surveillance imaging should be considered to evaluate for device related complications. In situations where there is a complication related to an IVC filter, the patient should be referred to a surgeon for consideration of open surgical removal.