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Editorials: Point and Counterpoint |

Rebuttal From Drs Lessne and Sing FREE TO VIEW

Mark L. Lessne, MD; Ronald F. Sing, DO, FCCP
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following: R. F. S. has received educational grant support from CR Bard, Cook Medical, Volcano Medical, and Argon Medical. None declared (M. L. L.).

aVascular and Interventional Specialists of Charlotte Radiology, Carolinas HealthCare System, Charlotte, NC

bDepartment of Trauma Surgery, Carolinas HealthCare System, Charlotte, NC

CORRESPONDENCE TO: Mark L. Lessne, MD, 1701 East Blvd, Charlotte, NC 28203


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


Chest. 2016;150(6):1185-1186. doi:10.1016/j.chest.2016.08.1482
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Published online

Our exceptionally worthy opponents justifiably argue that patients with VTE who cannot receive anticoagulation should not be denied a surrogate form of protection with caval filtration. This point is uncontested, and no one advocates for rounding up all inferior vena cava (IVC) filters and tossing them out with the bath water. Unfortunately, this no longer represents the 90% indication, with most filters placed for prophylactic use, where the clinical benefit remains largely unsubstantiated.,

As previously discussed, the Prevention du Risque d'Embolie Pulmonaire par Interruption Cave (PREPIC) trial addresses an interesting, but nearly irrelevant, issue regarding the benefits of IVC filters in concomitantly anticoagulated patients. The study by Fullen et al, referenced by our colleagues in their argument, and published during the Nixon administration, randomized patients with hip fractures to receive filters (under pyelographic guidance, no less) and also, not surprisingly, maintains little relevance to today’s practices. In that study, no patient was anticoagulated, despite an average hospital stay > 1 month; moreover, pulmonary embolism was often diagnosed using chest radiograph alone because Dr Hounsfield’s then 2-year old CT scanner was not yet readily available. Therefore, this study confidently demonstrated a benefit of IVC filters over allowing a patient with an acute long bone fracture to wallow sedentary in a hospital bed for > 30 days without anticoagulation. Today’s standard would be to initiate anticoagulation quickly after surgery, not to place an IVC filter. This recommendation undoubtedly benefits patients, lowers health-care costs, and reserves these potentially lifesaving devices for those who genuinely require them.

More work is required to define the high-risk population genuinely requiring caval filtration. Published guidelines, although imperfect, help identify these patients, with one study demonstrating that prophylactic filters placed in trauma patients resulted in a benefit only when their use adhered to Eastern Association for the Surgery of Trauma criteria. Additionally, providers caring for patients at risk for pulmonary embolism should consider IVC filters an ephemeral replacement for anticoagulation, which should be resumed when no longer contraindicated, allowing for expeditious filter removal. Also, many patients are erroneously labeled as having a contraindication to anticoagulation, which otherwise could have obviated long-term caval filtration and mitigated subsequent complications.

We emphatically agree with our colleagues, Drs Funaki and Haskal, that it is critically important for the clinician placing IVC filters to take ownership of the device and responsibility for the patient. Implementation of mechanisms for tracking patients with filters, including creation of an IVC filter clinic, has proven successful in increasing filter retrieval rates once the device’s utility has expired.

To conclude, the benefits do not outweigh the risks for most patients under consideration for IVC filters. Nonetheless, IVC filters will continue to play a crucial role protecting the most vulnerable. Careful selection of the patients who will benefit most (and suffer least harm) from IVC filter placement is critical to its efficacious use: although none of us want our patients skydiving without a parachute, we need not provide one before they go scuba diving.

References

Funaki B. .Haskal Z.J. . Point: Do the benefits outweigh the risks for most patients under consideration for inferior vena cava filters? Yes. Chest. 2016;150:1181-1182 [PubMed]journal. [CrossRef]
 
Alkhouli M. .Bashir R. . Inferior vena cava filters in the United States: Less is more. Int J Cardiol. 2014;177:742-743 [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.e3 [PubMed]journal. [CrossRef] [PubMed]
 
Fullen W.D. .Miller E.H. .Steele W.F. .McDonough J.J. . Prophylactic vena caval interruption in hip fractures. J Trauma. 1973;13:403-410 [PubMed]journal. [PubMed]
 
Falck-Ytter Y. .Francis C.W. .Johanson N.A. .et al Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141:e278S-e325S [PubMed]journal. [CrossRef] [PubMed]
 
Wehrenberg-Klee E. .Stavropoulos S.W. . Inferior vena cava filters for primary prophylaxis: When are they indicated? Semin Intervent Radiol. 2012;29:29-35 [PubMed]journal. [CrossRef] [PubMed]
 
Minocha J. .Idakoji I. .Riaz A. .et al Improving inferior vena cava filter retrieval rates: impact of a dedicated inferior vena cava filter clinic. J Vasc Interv Radiol. 2010;21:1847-1851 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Funaki B. .Haskal Z.J. . Point: Do the benefits outweigh the risks for most patients under consideration for inferior vena cava filters? Yes. Chest. 2016;150:1181-1182 [PubMed]journal. [CrossRef]
 
Alkhouli M. .Bashir R. . Inferior vena cava filters in the United States: Less is more. Int J Cardiol. 2014;177:742-743 [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.e3 [PubMed]journal. [CrossRef] [PubMed]
 
Fullen W.D. .Miller E.H. .Steele W.F. .McDonough J.J. . Prophylactic vena caval interruption in hip fractures. J Trauma. 1973;13:403-410 [PubMed]journal. [PubMed]
 
Falck-Ytter Y. .Francis C.W. .Johanson N.A. .et al Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141:e278S-e325S [PubMed]journal. [CrossRef] [PubMed]
 
Wehrenberg-Klee E. .Stavropoulos S.W. . Inferior vena cava filters for primary prophylaxis: When are they indicated? Semin Intervent Radiol. 2012;29:29-35 [PubMed]journal. [CrossRef] [PubMed]
 
Minocha J. .Idakoji I. .Riaz A. .et al Improving inferior vena cava filter retrieval rates: impact of a dedicated inferior vena cava filter clinic. J Vasc Interv Radiol. 2010;21:1847-1851 [PubMed]journal. [CrossRef] [PubMed]
 
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