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Editorials: Point and Counterpoint |

Rebuttal From Drs Funaki and Haskal FREE TO VIEW

Brian Funaki, MD; Ziv J. Haskal, MD
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following: B. F. is on the Data Safety Monitoring Committee for Novate and the SENTRY Trial; and Z. J. H. does consulting and is on the speakers bureau at Penumbra, WL Gore, and CR Bard.

aVascular and Interventional Radiology, Department of Radiology, University of Chicago Medicine, Chicago, IL

bDepartment of Radiology and Medical Imaging/Interventional Radiology, University of Virginia School of Medicine, Charlottesville, VA

CORRESPONDENCE TO: Brian Funaki, MD, Vascular and Interventional Radiology, Department of Radiology, University of Chicago Medicine, 5840 S Maryland, MC 2026, Chicago, IL 60637


Copyright 2016, . All Rights Reserved.


Chest. 2016;150(6):1184-1185. doi:10.1016/j.chest.2016.08.1479
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Lessne and Sing raise important considerations regarding the utilization of inferior vena cava (IVC) filters in the United States. A key premise of their argument concerns indications for caval filtration, and they maintain that most filters are currently placed for prophylactic reasons. The references to support this contention are nebulous, and given the huge variability of filter insertion even within similar geographic areas, we doubt that this is known. One of the references cited to support this contention is a review which further cited several studies which also do not prove the contention. In fact, one of the references in this review is from the University of Chicago (one of the author’s institution) in which prophylactic filters comprise < 20% of filters inserted. Incidentally, this same study also reported an 87% retrieval rate showing that with good follow-up, the contention that “optional filters are infrequently removed” is inaccurate. The use of prophylactic filters appears to be decreasing, even in bariatric patients and in trauma centers where prophylactic filter placement is expected to be high., A final complicating factor of this topic is the definition of prophylactic. Does this mean absence of DVT and pulmonary embolism (PE), or DVT but no PE? We favor the former definition, but this is not universal in the published literature.

Several additional points merit mention. First, level 1 evidence does exist for retrievable filters. These devices were used (and retrieved) in the Prevention du Risque d'Embolie Pulmonaire par Interruption Cave (PREPIC) 2 trial and demonstrated very low complication rates with similar outcomes to the first trial. We do believe that newer iterations of retrievable filters can represent the best of both worlds, provided they are used properly. Clearly though, any device, if used improperly, will have dubious benefit. Second, the absence of level 1 evidence is not the same as absence of evidence. We concede that prophylactic indications for caval filtration are controversial and there is no consensus even among expert panels. That being said, it would be naïve to assume that there are no legitimate prophylactic indications. A recent meta-analysis of prophylactic filter insertion in trauma patients found that current controlled studies “support the association of IVC filter placement with a lower incidence of PE and fatal PE in trauma patients.”

Much is left to be learned about caval filtration, and studies are ongoing to improve our understanding of this therapy. Nonetheless, the benefits outweigh the risks for most patients under consideration for IVC filters.

References

Lessne M.L. .Sing R.F. . Counterpoint: Do the benefits outweigh the risks for most patients under consideration for inferior vena cava filters? No. Chest. 2016;150:1182-1184 [PubMed]journal. [CrossRef]
 
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]
 
Piano G. .Ketteler E.R. .Prachand V. .et al Safety, feasibility, and outcome of retrievable vena cava filters in high-risk surgical patients. J Vasc Surg. 2007;45:784-788 [PubMed]journal. [CrossRef] [PubMed]
 
Gruner J. .Tatum D. . Current national trends in inferior vena cave filter use. Crit Care Med. 2015;43:198-199 [PubMed]journal
 
Afthinos J.N. .Gibbs K.E. . Trends in prophylactic IVC filter placement among bariatric operations. Surg Endosc. 2016;:S458- [PubMed]journal
 
Mismetti P. .Laporte S. .Pellerin O. .et al Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism: a randomized clinical trial. JAMA. 2015;313:1627-1635 [PubMed]journal. [CrossRef] [PubMed]
 
Haut E.R. .Garcia L.J. .Shihab H.M. .et al The effectiveness of prophylactic inferior vena cava filters in trauma patients: a systematic review and meta-analysis. JAMA Surg. 2014;149:194-202 [PubMed]journal. [CrossRef] [PubMed]
 

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References

Lessne M.L. .Sing R.F. . Counterpoint: Do the benefits outweigh the risks for most patients under consideration for inferior vena cava filters? No. Chest. 2016;150:1182-1184 [PubMed]journal. [CrossRef]
 
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]
 
Piano G. .Ketteler E.R. .Prachand V. .et al Safety, feasibility, and outcome of retrievable vena cava filters in high-risk surgical patients. J Vasc Surg. 2007;45:784-788 [PubMed]journal. [CrossRef] [PubMed]
 
Gruner J. .Tatum D. . Current national trends in inferior vena cave filter use. Crit Care Med. 2015;43:198-199 [PubMed]journal
 
Afthinos J.N. .Gibbs K.E. . Trends in prophylactic IVC filter placement among bariatric operations. Surg Endosc. 2016;:S458- [PubMed]journal
 
Mismetti P. .Laporte S. .Pellerin O. .et al Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism: a randomized clinical trial. JAMA. 2015;313:1627-1635 [PubMed]journal. [CrossRef] [PubMed]
 
Haut E.R. .Garcia L.J. .Shihab H.M. .et al The effectiveness of prophylactic inferior vena cava filters in trauma patients: a systematic review and meta-analysis. JAMA Surg. 2014;149:194-202 [PubMed]journal. [CrossRef] [PubMed]
 
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