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Correspondence |

Management of Retrievable Inferior Vena Cava Filters FREE TO VIEW

Eric K. Hoffer, MD
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

Section of Interventional Radiology, Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH

CORRESPONDENCE TO: Eric K. Hoffer, MD, Department of Radiology, Dartmouth-Hitchcock Medical Center, One Medical Center Dr, Lebanon, NH 03756-1000


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;150(4):979-980. doi:10.1016/j.chest.2016.07.038
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Published online

In their recent article in CHEST (May 2016) regarding the management of inferior vena cava (IVC) filters, Drs Arous and Messina recommend that filters be implanted on the basis of best available evidence, and be removed at 25 to 54 days postimplantation. By not distinguishing between high-risk and low-risk populations that receive IVC filters, the authors propagate an often inappropriate case report-driven obsession for filter removal. The patients at higher risk for pulmonary embolism (PE) are those who have filters placed for DVT, and the patients at lower risk are those who have filters placed because they had a transient elevated risk for the development of DVT. Differentiating these groups is important in any consideration on filter removal. In the cost/benefit analysis of whether to remove a filter, the costs, or complication risk of a filter over time, may be similar between those groups, but the benefit of a filter is different, as it is dependent on the risk of a patient developing a PE.

The benefit of filters, a reduced long-term PE risk, was demonstrated in the two prospective randomized trials the authors report (although they question the applicability of the demonstrated benefit). The costs, or risks, were less well defined; the authors employ reports of complications from even further down the evidentiary food chain. The concern regarding complications is derived from lawsuits, case reports, and registries—which provide a sense of risk but lack a denominator to quantify it. The authors do not mention the larger population-based series that evaluated the long-term performance of retrievable IVC filters and that generally found a low incidence of clinically relevant complications.,,,

While concern regarding long-term potential complications may justify removal of filters from patients who are not at elevated risk for PE (as per the US Food and Drug Administration [FDA] statement), there is little evidence to support removal from patients with a history of VTE. The “best available evidence” recommendations for IVC filter placement includes patients with proximal DVT in whom anticoagulation is contraindicated or has failed. The FDA recommendation for removal refers to a different population: those patients who never had a DVT or PE and whose transient risk for PE had passed.

The former population, those who have had a proximal DVT, are at higher risk for recurrent VTE than the patients who have not had DVT. Without a VTE event, the risk of developing one is less than 0.3%. After a VTE, the risk ranges from 3%/y after a “provoked” event to 10%/y after an “unprovoked” or “idiopathic” VTE. In the VTE population with an IVC filter, the available evidence indicates that the beneficial reduction in PE outweighs the filter complication risk.

References

Arous E.J. .Messina L.M. . Temporary inferior vena cava filters: how do we move forward? Chest. 2016;149:1143-1145 [PubMed]journal. [CrossRef] [PubMed]
 
Morales J.P. .Li X. .Irony T.Z. .Ibrahim N.G. .Moynahan M. .Cavanaugh K.J. Jr.. Decision analysis of retrievable inferior vena cava filters in patients without pulmonary embolism. J Vasc Surg Venous Lymphat Disord. 2013;1:376-384 [PubMed]journal. [CrossRef] [PubMed]
 
Angel L.F. .Tapson V. .Galgon R.E. .Restrepo M.I. .Kaufman J. . Systematic review of the use of retrievable inferior vena cava filters. J Vasc Interv Radiol. 2011;22:1522-1530 [PubMed]journal. [CrossRef] [PubMed]
 
Hoffer E.K. .Mueller R.J. .Luciano M.R. .Lee N.N. .Michaels A.T. .Gemery J.M. . Safety and efficacy of the Gunther tulip retrievable vena cava filter: midterm outcomes. Cardiovasc Intervent Radiol. 2013;36:998-1005 [PubMed]journal. [CrossRef] [PubMed]
 
An T. .Moon E. .Bullen J. .et al Prevalence and clinical consequences of fracture and fragment migration of the Bard G2 filter: imaging and clinical follow-up in 684 implantations. J Vasc Interv Radiol. 2014;25:941-948 [PubMed]journal. [CrossRef] [PubMed]
 
Vijay K. .Hughes J.A. .Burdette A.S. .et al Fractured Bard recovery, G2, and G2 express inferior vena cava filters: incidence, clinical consequences, and outcomes of removal attempts. J Vasc Interv Radiol. 2012;23:188-194 [PubMed]journal. [CrossRef] [PubMed]
 
Kearon C. .Kahn S.R. .Agnelli G. .Goldhaber S. .Raskob G.E. .Comerota A.J. . American College of Chest Physicians Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133:454S-545S [PubMed]journal. [CrossRef] [PubMed]
 
Kearon C. . Natural history of venous thromboembolism. Circulation. 2003;107:I22-I30 [PubMed]journal. [PubMed]
 

Figures

Tables

References

Arous E.J. .Messina L.M. . Temporary inferior vena cava filters: how do we move forward? Chest. 2016;149:1143-1145 [PubMed]journal. [CrossRef] [PubMed]
 
Morales J.P. .Li X. .Irony T.Z. .Ibrahim N.G. .Moynahan M. .Cavanaugh K.J. Jr.. Decision analysis of retrievable inferior vena cava filters in patients without pulmonary embolism. J Vasc Surg Venous Lymphat Disord. 2013;1:376-384 [PubMed]journal. [CrossRef] [PubMed]
 
Angel L.F. .Tapson V. .Galgon R.E. .Restrepo M.I. .Kaufman J. . Systematic review of the use of retrievable inferior vena cava filters. J Vasc Interv Radiol. 2011;22:1522-1530 [PubMed]journal. [CrossRef] [PubMed]
 
Hoffer E.K. .Mueller R.J. .Luciano M.R. .Lee N.N. .Michaels A.T. .Gemery J.M. . Safety and efficacy of the Gunther tulip retrievable vena cava filter: midterm outcomes. Cardiovasc Intervent Radiol. 2013;36:998-1005 [PubMed]journal. [CrossRef] [PubMed]
 
An T. .Moon E. .Bullen J. .et al Prevalence and clinical consequences of fracture and fragment migration of the Bard G2 filter: imaging and clinical follow-up in 684 implantations. J Vasc Interv Radiol. 2014;25:941-948 [PubMed]journal. [CrossRef] [PubMed]
 
Vijay K. .Hughes J.A. .Burdette A.S. .et al Fractured Bard recovery, G2, and G2 express inferior vena cava filters: incidence, clinical consequences, and outcomes of removal attempts. J Vasc Interv Radiol. 2012;23:188-194 [PubMed]journal. [CrossRef] [PubMed]
 
Kearon C. .Kahn S.R. .Agnelli G. .Goldhaber S. .Raskob G.E. .Comerota A.J. . American College of Chest Physicians Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133:454S-545S [PubMed]journal. [CrossRef] [PubMed]
 
Kearon C. . Natural history of venous thromboembolism. Circulation. 2003;107:I22-I30 [PubMed]journal. [PubMed]
 
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