Use of vena cava filters

Bassam M. Hassan Al-Alosi

Traditionally, vena cava filters (IVF) have been indicated for patients with acute pulmonary embolism PE, in the presence of contraindications or complications related to the use of anticoagulants. ^(1-3) They are also used in relapses of pulmonary thromboembolism (PTE), despite adequate anticoagulation, as well as in the presence of massive PTE and in surgical cases of embolectomy.⁽²⁾ More recently, especially with the advent of removable filters, their indication has been extended to patients with proximal DVT at temporary high risk for PTE.⁽⁴⁾ In recent years, due to the higher prevalence of thrombi originating in the upper extremities, filters have also been installed in the superior vena cava.⁽⁵⁾

There is only one randomized, controlled study that seeks to demonstrate the efficacy and safety of IVFs in preventing pulmonary thromboembolism PTE in patients with proximal venous thrombosis.⁽⁶⁾ IVFs were implanted in 200 patients with proximal DVT, at risk of PTE, while another 200 individuals did not use the filters. All 400 patients were treated with heparin and coumarins in the traditional way. It was demonstrated that, although the group that used IVF had a lower incidence of PTE, there was a greater number of DVT recurrences, however, without an increase in mortality. This same group of researchers carried out a second analysis, with the same patients, studied 8 years later^.(7) At the end of the period, in addition to the heparin administered in the acute phase, 50% of the patients were still using coumarins. In the initial phase, IVFs reduced the risk of PTE. In the medium and long term, IVF were sufficient to reduce the occurrence of PTE, despite the increase in the incidence of DVT. The higher number of DVT cases did not translate into a higher incidence of post-thrombotic syndrome. There was no impact on reducing mortality.

Complications with the use of permanent vena cava filters are common. Early complications include puncture site thrombosis, as well as late DVT recurrence and post-thrombotic syndrome. Inferior vena cava occlusion occurs in 22% of patients after 5 years and in 33% after 9 years, regardless of anticoagulation use and duration.⁽⁸⁾

The systematic use of vena cava filters at a therapeutic level is not indicated for unselected patients with DVT who are candidates for the use of anticoagulants. They should be used in patients with a contraindication to the use of anticoagulants or who experience recurrence despite adequate pharmacological treatment .Patients with permanent filters, after the contraindication of anticoagulants, should receive this therapy additionally.

Removable filters should be used for patients with temporary contraindications to the use of anticoagulants, which should remain in place for approximately 2 weeks.

The use of vena cava filters should be considered in the preoperative period of patients who are candidates for surgery and affected by a thrombotic event in the last 30 days, for whom anticoagulation needs to be discontinued.^(9,10) Removable filters should be considered in the presence of vena cava filters. of a temporary contraindication to anticoagulation.

References

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2. Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ, et al. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl):454S-545S.

3. Girard P, Stern JB, Parent F. Medical literature and vena cava filters: so far so weak. Chest. 2002;122(3):963-7.

4. Pacouret G, Alison D, Pottier JM, Bertrand P, Charbonnier B. Free-floating thrombus and embolic risk in patients with angiographically confirmed proximal deep venous thrombosis. A prospective study. Arch Intern Med. 1997;157(3):305-8.

5. Spence LD, Gironta MG, Malde HM, Mickolick CT, Geisinger MA, Dolmatch BL. Acute upper extremity deep venous thrombosis: safety and effectiveness of superior vena caval filters. Radiology. 1999;210(1):53-8.

6. Decousus H, Leizorovicz A, Parent F, Page Y, Tardy B, Girard P, et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group. N Engl J Med. 1998;338(7):409-15.

7. PREPIC Study Group. Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d'Embolie Pulmonaire par Interruption Cave) randomized study. Circulation. 2005;112(3):416-22.

8. Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, et al. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2008;29(18):2276-315.

9. Levine MN, Raskob G, Landefeld S, Kearon C. Hemorrhagic complications of anticoagulant treatment. Chest. 1998;114(5 Suppl):511S-523S.

10. Kearon C, Hirsh J. Management of anticoagulation before and after elective surgery. N Engl J Med. 1997;336(21):1506-11.