1. Case 2: IVC Filters 44 y/o male “preaching pastor” 10/23Generalized seizure Large AVM 2/12Embolization, left frontal craniotomy and resection c/b right hemiplegia/aphasia 2/22Right leg pain/swelling US: popliteal and calf DVT 44 y/o male “preaching pastor” 10/23Generalized seizure Large AVM 2/12Embolization, left frontal craniotomy and resection c/b right hemiplegia/aphasia 2/22Right leg pain/swelling US: popliteal and calf DVT

2. No heparin, no way!

3. Case 2 2/24Doing well 2/266AMSeizure Cardiac arrest Brief CPR, Intubation, Pressors 2/24Doing well 2/266AMSeizure Cardiac arrest Brief CPR, Intubation, Pressors

4. What is most likely diagnosis? 1) ICH: get a head CT 2) MI: get ECG, enzymes, and echo 3) PE: get CTA chest 4) Bleed: get CBC 5) Sepsis: get cultures, start antibiotics What is most likely diagnosis? 1) ICH: get a head CT 2) MI: get ECG, enzymes, and echo 3) PE: get CTA chest 4) Bleed: get CBC 5) Sepsis: get cultures, start antibiotics Case 2

5. What is most likely diagnosis? 1) ICH: get a head CT 2) MI: get ECG, enzymes, and echo 3) PE: get CTA chest 4) Bleed: get CBC 5) Sepsis: get cultures, start antibiotics What is most likely diagnosis? 1) ICH: get a head CT 2) MI: get ECG, enzymes, and echo 3) PE: get CTA chest 4) Bleed: get CBC 5) Sepsis: get cultures, start antibiotics Case 2 All of em

10. What should you do next? 1)Cardiac CT 2)CV surgery: remove the embolized filter 3)IR: remove the embolized filter 4)Cardiac MRI 5)Plain film What should you do next? 1)Cardiac CT 2)CV surgery: remove the embolized filter 3)IR: remove the embolized filter 4)Cardiac MRI 5)Plain film Case 2

17. Ultrasound Assessment Upper Extremity:Cephalic vein thrombi bilaterally Lower Extremity: Right popliteal and femoral DVT Upper Extremity:Cephalic vein thrombi bilaterally Lower Extremity: Right popliteal and femoral DVT

18. What is the rate of PE after IVC filter placement at one year? 1) 0% 2) 3 - 5% 3) 20 – 25% 4) 50% 5) There is no data on this topic What is the rate of PE after IVC filter placement at one year? 1) 0% 2) 3 - 5% 3) 20 – 25% 4) 50% 5) There is no data on this topic Case 2

19. What is the rate of PE after IVC filter placement at one year? 1) 0% 2) 3 - 5% 3) 20 – 25% 4) 50% 5) There is no data on this topic What is the rate of PE after IVC filter placement at one year? 1) 0% 2) 3 - 5% 3) 20 – 25% 4) 50% 5) There is no data on this topic Case 2

20. IVC Filters in Patients with Proximal DVT Filter (n = 200) Filter (n = 200) No Filter (n = 200) No Filter (n = 200) LMW-H (n = 195) LMW-H (n = 195) UF-H (n = 205) UF-H (n = 205) Characteristic @ Baseline Characteristic @ Baseline Upper limit of DVT Popliteal Femoral Iliac Caval Symptomatic PE Asymptomatic PE n (%) 13(6) 113(56) 70(35) 4(2) 77(38) 25(12) 10(5) 105(52) 77(38) 8(4) 68(34) 27(14) 15(8) 102(52) 74(38) 4(2) 68(35) 24(12) 8(4) 116(57) 73(36) 8(4) 77(38) 28(14) N Engl J Med 98;338:409

21. IVC Filters in Patients with Proximal DVT Filter (n = 200) Filter (n = 200) No Filter (n = 200) No Filter (n = 200) Odds Ratio (95%CI) Odds Ratio (95%CI) P Value P Value Event number (%) 6 (3.4) 37(20.8) 17(8.8) 43(21.6) 12(6.3) 21(11.6) 22(11.8) 40(20.1) 0.5 (0.19 - 1.33) 0.5 (0.19 - 1.33) NS 0.02 NS N Engl J Med 98;338:409 Symptomatic PE Recurrent DVT Major Bleed Death 1.87 (1.10 - 3.20) 1.87 (1.10 - 3.20) 0.77 (0.41 - 1.45) 0.77 (0.41 - 1.45) 1.10 (0.72 - 1.70) 1.10 (0.72 - 1.70)

22. A population-based study of the efficacy of IVC filter use among VTE patients Objective: Determine the 1 year cumulative incidence of re-hospitalization for DVT or PE following IVC filter placement Patients/methods: 1991 – 1995 ICD9 discharge codes 3632 with IVC filters 64333 without IVC filters Objective: Determine the 1 year cumulative incidence of re-hospitalization for DVT or PE following IVC filter placement Patients/methods: 1991 – 1995 ICD9 discharge codes 3632 with IVC filters 64333 without IVC filters

23. Re-hospitalization for DVT % White RH. Arch Int Med 2000;160:2033 0 0 2 2 4 4 6 6 8 8 10 100 200 300 Days 0 0 Filter No Filter 400 12 Re-hospitalization for Venous Thrombosis among Recipients of IVC Filters Re-hospitalization for Venous Thrombosis among Recipients of IVC Filters

24. Re-hospitalization for PE % White RH. Arch Int Med 2000;160:2033 0 0 2 2 4 4 6 6 8 8 10 100 200 300 Days 0 0 Filter No Filter 400 12 Re-hospitalization for Pulmonary Embolism among Recipients of IVC Filters Re-hospitalization for Pulmonary Embolism among Recipients of IVC Filters

25. Case 2: Bottom Line IVC Filters: Does not eliminate possibility of large PE –Rate ~ 3 – 5% at one year Use “pretest probability of disease” to assess the probability of PE –Even if IVC filter is in place IVC Filters: Does not eliminate possibility of large PE –Rate ~ 3 – 5% at one year Use “pretest probability of disease” to assess the probability of PE –Even if IVC filter is in place