Inferior Vena Cava Filters in Pregnancy: A Systematic Review

REVIEW ARTICLE

Inferior Vena Cava Filters in Pregnancy: A Systematic Review Sally A. Harris, MBChB, BSc, Rahul Velineni, BSc, MBBS, MRCS, and Alun H. Davies, MA, DM, DSc, FRCS, FEBVS, FACPH

ABSTRACT During pregnancy, patients have an increased risk of venous thromboembolism (VTE). This is an important cause of maternal mortality. Inferior vena cava (IVC) filters can be used to prevent pulmonary embolism in complicated cases of VTE during pregnancy. The present systematic review includes all patients reported in the literature who had an IVC filter placed during pregnancy. The indications for IVC filters are discussed, along with practical considerations for placement during pregnancy, filter effectiveness, and maternal and fetal mortality and morbidity. IVC filters can be used safely when appropriate during pregnancy, with complication rates similar to those in nonpregnant patients.

ABBREVIATIONS DVT = deep vein thrombosis, IVC = inferior vena cava, MeSH = Medical Subject Heading, PE = pulmonary embolism, VTE = venous thromboembolism

During pregnancy, patients are more predisposed to thromboembolic events because of hypercoagulability caused by adaptations in the hemostatic system in preparation for the hemostatic challenge of delivery, venous stasis caused in part by the pressure effect of the enlarging uterus, and vascular endothelial damage caused by distension or surgical injury. Venous thromboembolism (VTE) is the third most common direct cause of maternal mortality in the United Kingdom, occurring in 0.79 per 100,00 maternities in 2005–2008 (1). The standard treatment is anticoagulation with low molecular weight heparin until at least 6 weeks postpartum (2). Warfarin is avoided in pregnancy because it can cross the placental barrier and lead to fetal complications, including malformations and death (3). There are now increasing numbers of reported use of inferior vena cava (IVC) filters during pregnancy.

From the Department of Academic Surgery (S.A.H., R.V., A.H.D.), and Section of Vascular Surgery (R.V., A.H.D.), Imperial College London, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, United Kingdom. Received July 27, 2015; final revision received October 31, 2015; accepted November 1, 2015. Address correspondence to A.H.D.; E-mail: [email protected] Table E1 is available online at www.jvir.org. None of the authors have identified a conflict of interest. & SIR, 2015 J Vasc Interv Radiol 2015; XX:]]]–]]] http://dx.doi.org/10.1016/j.jvir.2015.11.024

The first reported IVC filter placed in a pregnant patient occurred in 1981 (4). Initially, permanent filters were used. However, in pregnancy, the patient normally has a long life expectancy and the increased risk of VTE is generally temporary, so removable filters are attractive (5). The present systematic review will collate the information on the use of IVC filters during pregnancy.

MATERIALS AND METHODS This systematic review was performed in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (6). The focus of the review was pregnant patients who had an IVC filter placed during pregnancy, excluding those who had an IVC filter before conception or in the postpartum period. Outcome measures included maternal and fetal morbidity and mortality. PubMed, Cochrane database, Embase and Ovid Medline databases were searched using a search strategy developed to identify all papers about IVF filter placement in pregnancy regardless of study design as follows: (filter, inferior vena cava [Medical Subject Heading (MeSH) Terms]) AND (pregnancy [MeSH Terms]) OR (obstetrics [MeSH Terms]). The search included all articles published through December 2014. The titles and abstracts of the resulting articles were reviewed and screened for relevance. Duplicate publications, articles not published in English, and abstracts from conferences were removed. All references of included

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manuscripts were manually searched to identify related articles that had not been identified. Data were extracted to compile a database of all reported pregnancies in which an IVC filter was placed. When possible, patient age, parity, indication for IVC filter placement, IVC filter position, gestation at insertion, filter type, time of retrieval, mode of delivery, fetal outcome, and maternal morbidity and mortality were recorded.

RESULTS The database search located 332 publications. After screening, 52 publications were located. After review of their references, a further three were found. Full texts were then examined for eligibility. This resulted in 11 exclusions: conference abstracts, reports of postpartum IVC filter insertion and superior vena cava filter insertion, and inability to identify the pregnant patients in a series. The remaining 44 articles were case reports or case series from a particular institution. There were no randomized controlled trials, and consequently no studies were amenable to pooling for meta-analysis. From these manuscripts, 135 pregnancies in which an IVC filter was inserted were identified. However, a case series of 18 patients (7) overlapped with and included all 11 patients in an earlier series (8). Therefore, the present review includes a total of 124 pregnancies (Table E1, available online at www.jvir.org) (4,5,7–48).

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risk of PE is particularly high (51). This is not acknowledged as a relative indication specifically by SIR but could be considered an extension of “high risk of complication of anticoagulation” (49). Other publications referred to the relative indications of unstable, floating, large DVTs near the time of delivery (4,7,8,15,32,33,36–43) or threatened preterm labor (16) and those with clots in or extending into the IVC (44). More recently, IVC filters have been inserted as protection against PE during endovascular procedures (45–47) or thrombolysis (48) carried out during pregnancy. No prophylactic indications have been reported, but one group (17) suggested that, in patients with high-risk thrombophilias, prophylactic placement of a temporary IVC filter could be performed before labor; however, we are aware of no studies that support this. The British Society for Haematology IVC filter guidelines (52) state that “insertion may be considered in pregnant patients who have contraindications to anticoagulation and develop extensive VTE shortly before delivery (within 2 weeks).” This does not encompass the range of indications seen in the present review. The Royal Society of Obstetricians and Gynaecologists VTE guidelines (2) recommend to “consider use of a temporary IVC filter in the peripartum period for patients with iliac vein VTE or in patients with proven DVT and who have recurrent PE despite adequate anticoagulation,” which is more reflective of the current literature.

Indications

Placement

The Society of Interventional Radiology (SIR) recognizes absolute and relative indications for filter placement in confirmed VTE in addition to prophylactic indications (49). In the cases identified, the rationale for IVC filter placement is not always clear, but the most common indications were selected and considered in these categories. As in nonpregnant patients, IVC filters were inserted for the absolute indications of failure of medical therapy for VTE despite adequate anticoagulation (5,8,10–23) and complications of anticoagulation, including heparininduced thrombocytopenia (7,15,23,24), heparin allergy (25), significant bleeding during anticoagulation (7,8,20, 23,26), and contraindication to anticoagulation as a result of recent neurosurgery (27). In some articles, the only stated reason for IVC filter placement was extensive deep vein thrombosis (DVT) during pregnancy with concerns about the risk of pulmonary embolism (PE) during delivery, when anticoagulation was to be stopped (13,26,28–35). This was particularly true when the clot was ileofemoral and delivery was in the following 2–3 weeks (7). This centers on the need to discontinue anticoagulation medication during vaginal and caesarean delivery to reduce the risk of bleeding and epidural hematoma (50) at a time when the

IVC filters have been placed in primigravid and multigravid women with success, and patients with filters left in situ have gone on to have successful pregnancies (16). IVC filters have been placed in all trimesters of pregnancy, ranging from 7 weeks’ (20) to 41 weeks’ gestation (34), and even during the latent stage of labor (39). The gravid uterus has not been found to prevent accurate IVC filter placement via the jugular (5) or femoral route (36). A patient in latent labor at 39 weeks’ gestation had an IVC angiogram demonstrating complete effacement of the infrarenal IVC by the gravid uterus; however, with the patient positioned in the left lateral decubitus position, the infrarenal IVC was decompressed and the filter was successfully deployed infrarenally with no filter complications (39). In one patient, the planned infrarenal placement was not possible because of IVC compression by the gravid uterus (12). For a number of reasons, it is often thought that suprarenal placement is preferred in pregnancy and in young women who have the potential to become pregnant. Below the level of the renal veins, the IVC can be compressed by the gravid uterus, which could displace the filter particularly when contracting, leading to migration or fracture of the filter or damage to the IVC wall (32).

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Suprarenal placement also provides additional protection from thrombus that has developed in the dilated ovarian veins (32). Additionally, with the volume of renal blood flow, there is the added advantage of accelerated venous flow, which should promote lysis of trapped thrombi (27). Of the patients included in the present review, 69 (55.6%) had IVC filters placed in the suprarenal position and 32 (25.8%) had filters placed in the infrarenal position; placement was in an unknown position in 23 cases (18.5%). There was no reported renal dysfunction, in line with larger studies in the nonpregnant population (53).

Effectiveness No fatal PE occurred after filter placement in the publications reviewed. One patient who had a Greenfield filter required a second filter as a result of a recurrent symptomatic pulmonary embolus (25). In this case, a venogram showed a large thrombus extending from the filter. No other cases of symptomatic pulmonary emboli were reported after filter placement, for a 0.81% rate of symptomatic PE after filter insertion. There have been no randomized controlled trials to investigate the effectiveness of IVC filter placement in pregnant women. It is possible to detect thrombus in the filter on imaging, and, with the advent of retrievable filters, it is possible to see the trapped thrombus and evaluate it when the filter has been removed (12,45). However, it cannot be known whether these thrombi would have caused a clinically significant event. One retrospective observational study (8) compared a group of patients whose pregnancy was complicated with a DVT of the lower extremity and had permanent IVC filters placed with a lower dose of heparin versus patients who received only full-dose heparin over the same time period. This study showed no immediate major complications in the 11 patients with a filter but, among the 15 patients without filters, there were two cases of PE and a retroperitoneal hematoma. However, there was no randomization, and, although the investigators reported both groups being comparable regarding age and VTE risk factors, filters were placed at the discretion of the treating physician. Additionally, this study was conducted in a very small pool of patients.

Fetal Morbidity and Mortality There was no recorded fetal morbidity or mortality, and, when reported, all neonates were healthy except for two with mild respiratory distress (23). There is limited information on long-term outcomes in the children. The placement of an IVC filter requires radiation exposure, which can cause multiple effects in a developing fetus depending on the dose and the stage of fetal development. The International Commission on Radiological Protection has recommended that no “deterministic effects of practical significance” would be expected in

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the developing human fetus at doses lower than 100 mGy (54). In the publications that documented the amount of total radiation, doses of 12 Gy (19) and 0.05 rad (equivalent to 0.5 Gy) (34) were reported. Techniques employed to minimize the amount of radiation exposure to the fetus include the use of a lead abdominal shield (16) and ultrasound (US) imaging for the diagnosis of DVT in pregnancy (34). IVC filters have been placed with the use of intravascular US guidance (55) and, because it eliminates the need for fluoroscopy, it has been proposed as a potential method in pregnant patients (34). However, we are aware of no reports of this technique in pregnant patients to demonstrate feasibility, filter placement has always been in an infrarenal location, and the enlarged uterus will complicate visualization.

Maternal Morbidity and Mortality One maternal death was identified in the included publications. In 1990, a patient who was 2 months pregnant experienced an air embolism during insertion of a Greenfield filter into the internal jugular vein through a cutdown approach (10). However, percutaneous techniques are now in use with smaller sheaths, the femoral insertion route is more commonly used, and this specific filter is no longer in use. There was no comment on whether the early pregnancy had any impact on the occurrence (10). Two mothers had threatened preterm labor immediately subsequent to IVC filter placement at 30 weeks’ gestation and 26 weeks’ gestation and required tocolysis, which was successful in both cases (4,24). Another patient had varying uterine activity in the 48 hours following insertion, but this resolved spontaneously (21). There were also reports of leg pain and swelling after filter insertion, but this was transient and required no further intervention (9), so it was not considered significant. Other reported cases of maternal morbidity not directly attributable to the IVC filter included a wound hematoma after caesarean section (37) and diarrhea with fever (31). One patient had a retroperitoneal hematoma leading to paralytic ileus following IVC filter placement, but this was thought to have resulted from excessive heparinization (4). Of expressed concern was the risk of infection of the filter at delivery as a result of prolonged rupture of the membranes or other sources of sepsis (9), but we are aware of no reports of this in the available literature. One patient in the series did have premature rupture of membranes at 31 weeks (26), but there was no evidence of IVC filter infection. The Table (13–16,18,25,28,34,43) details complications directly related to the IVC filter itself. Of the 124 patients included in the review, 11 had a complication related to their filter, for a complication rate of 8.87%. If the reported maternal mortality and cases of threatened

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Gestation: Insertion/ Study, Year

Delivery

Complication

Filter (Type)

Delivery (wk)

Method

Placement

Arbogast et al (25), 1994

Cephalad propagation of large thrombus from filter required second filter placed

Greenfield (permanent)

14 and 32/36

Caesarean

Suprarenal

Kelly and Boyd (28),

Migration of filter into right atrium after tethering

Tempofilter* (temporary)

34/34

Caesarean

Suprarenal

1999 Cheung et al (13),

catheter buckled, removed after 5 d in situ Caudal migration of filter and filter fracture, partially

Recovery nitinol

37/38

Vaginal

Infrarenal

Recovery* (retrievable)

26/37

Caesarean

Suprarenal

ALN vena cava filter

40/41

Vaginal

Suprarenal

2005 Ganguli et al (14), 2006 Sendon et al (15), 2006 Gupta et al (16), 2008

Sparrow (18), 2009

retrieved, one leg hook retained (patient asymptomatic at 18-mo follow-up) Fracture of one strut and migration of filter led to

(retrievable)

Review: Inferior Vena Cava Filters in Pregnancy

Table . Filter-Related Complications in Previous Publications (13–16,18,25,28,34,43)

failed retrieval at 167 d, no problems reported at 3mo follow-up Filter migration to right renal vein led to failed retrieval, patient remained asymptomatic

(retrievable)

Failed retrieval: inability to snare

Günther Tulip (retrievable)

34/38

Caesarean

Unknown

Failed retrieval: inability to snare

Günther Tulip

30/34

Caesarean

Unknown

Failed retrieval after 73 d in situ, despite successfully

(retrievable) Günther Tulip

30/40

Vaginal

Suprarenal

snaring retrieval hook, struts would not collapse,

(retrievable)

thought due to adherence of retaining hooks to IVC wall McConville et al (43), 2009 Liu et al (34), 2012

Failed retrieval 28 d after insertion due to filter tilt

OptEase (retrievable)

38/39

Vaginal

Suprarenal

causing hook to become embedded in IVC Failed retrieval 28 d after insertion due to filter tilt

OptEase (retrievable)

38/39

Caesarean

Suprarenal

Occlusion of filter with thrombus that could not be

OptEase (retrievable)

37/37

Caesarean

Suprarenal

eliminated by thrombolytic therapy IVC ¼ inferior vena cava. *Indicates a filter no longer in use in the United Kingdom. Harris et al ’

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premature labor requiring tocolysis are included, a complication arose in 14 patients (11.3%). In the present series, 80 patients received a retrievable filter. Eight had a failed attempted retrieval (14– 16,18,34,43) and one had a filter only partially retrieved (13), yielding a failure-to-retrieve rate of 11.25%. The retrieval failures resulted from a combination of inability to snare the filter, filter fracture, filter migration, filter tilt, and large trapped thrombi. This rate is comparable to those reported in nonpregnant populations, with a 12.1% unsuccessful retrieval rate in 223 attempted retrievals reported in a recent study (56). There was one additional patient who did not have a retrievable filter removed as planned, but this was not related to the filter itself and was a result of extensive DVT still present 9 days after full heparin anticoagulation (38). One patient had a large thrombus that failed to dissolve with thrombolysis, and the retrievable filter was replaced with a permanent filter (32). An additional patient had a retrievable filter replaced with a permanent one after it was decided not to lyse a large trapped thrombus (17), meaning 15% of the 80 patients with retrievable filters were left with a filter in situ postpartum. It has been generally recommended that filters are removed as soon as possible or within 14 days after delivery to avoid incorporation into the caval wall (16,34). In a group of eight patients from one center (42), three had minor filter tilt between 51 and 171, but all filters were successfully retrieved, and these cases were not included as complications, with the greatest tilt requiring only a longer duration of fluoroscopy (42). There are limited long-term follow-up data for this patient group. The longest follow-up is from a series of 18 patients with permanent Greenfield filters (7), with a mean of 78 months of follow-up (range, 10–142 mo). There was no reported PE or filter-related complications, but four patients had significant leg swelling as a result of partial resolution of DVT, which was treated conservatively in all cases (7).

Method of Delivery In one case series, the delivery method was based on obstetric factors alone (16), but others recommended caesarean section for those with IVC filters (34). The reasons given for elective caesarean section include a shorter time without anticoagulation and difficulties in vaginal delivery as a result of swelling of the lower extremities (34). It is not clear if contractions experienced during a trial of labor are more likely to cause filter complications such as migration, tilt, or fracture, but some groups have speculated this (14). Of the eight patients who had a failed filter removal (excluding the patient whose filter was not removed as a result of clot in the filter), four had vaginal deliveries and four had caesarean sections, two of which were elective, which does mean that 75% of patients with such

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filter complications experienced labor. It is not possible to state that these complications are more common with a trial of labor, as not all studies indicated whether this occurred. Indeed, tilting of the filter was seen in one center in a patient with an induced vaginal birth and another with an elective caesarean section (43). This is a potential area for further research.

DISCUSSION Since the first occurrence in 1981, considerable experience has been amassed with the placement of IVC filters in pregnancy. Permanent and retrievable filters have been used successfully and safely in pregnancy, but, in recent years, the majority of filters placed have been retrievable, reflecting the temporarily increased risk of VTE in pregnancy. The indications for use appear similar to the current absolute and relative indications in the general population, although it may be that a relative indication to consider, unique to pregnant women, is the challenge of labor. Retrieval and complication rates appear comparable to those in the general population, but some groups have theorized that it may be more difficult to snare retrievable filters in patients with the anatomic and physiologic changes of pregnancy such as pressure from the uterus causing angulation or distortion of the IVC filter (16). As complications arose in suprarenal and infrarenal placement, this theory may be purely hypothetical. It has been postulated that excess neointimization and adherence of retaining hooks to the IVC wall could be exacerbated by increased abdominal and intracaval pressures associated with labor at vaginal delivery (18). Although frequently cited as a possible factor, it is unclear whether venous dilatation or exertion during labor contributes to filter migration and fracture, which can also lead to failed retrieval (14). It has been theorized that anatomic changes in the configuration of the IVC during pregnancy can lead to tilting, with the IVC being displaced laterally by the gravid uterus so that, when it returns to its normal position after delivery, the filter is tilted (43). This could be compounded by the increase in intravascular volume during pregnancy causing an increase in IVC diameter that returns to normal after delivery (43). There is great variance in the types of filters inserted, and technology is rapidly progressing. Consequently, better IVC filters may be developed for use in clinical practice, which may mean the conclusions drawn from the present review are less relevant and applicable. This review considered a very heterogeneous group of IVC filters collectively as a result of the small numbers of cases, and may not appreciate the individual features that may contribute to complications, as it is known that reported adverse events differ among filter brands (57). Another weakness in the present review is that not all

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cases of IVC filter use in pregnancy are reported, and it is possible that cases in which something went wrong are more likely to be published in the medical literature, perhaps yielding an overestimation of adverse events. Additionally, because of the nature of studying VTE in pregnancy, there are no randomized controlled trials as a result of ethical and practical difficulties. Although one group (8) attempted to compare their experience with filters versus a cohort of patients without filters, it is not possible to draw any meaningful conclusions from this. There is also a lack of long-term follow-up data. It is therefore not known what long-term impact having an IVC filter has, particularly at a young age. This is an especially important consideration because as many as 11.25% of patients with retrievable filters placed had a failed retrieval, and recent randomized control trial data (58) suggest that, at 8 years, IVC filters placed in male and female patients with proximal DVT are associated with an increased rate of DVT and no effect on survival.

Conclusions IVC filters can be used effectively in pregnancy to prevent PE. The use of retrievable filters is particularly attractive because of the transient increase in VTE risk in a young patient. However, there is currently not enough evidence to suggest that IVC filters should be routinely used in pregnancy in patients with DVT, and, until further studies are carried out, their use should be considered for the same absolute indications as in the nonpregnant population or in individuals in whom there are concerns surrounding delivery. Rates of complications in pregnant patients are comparable to those in the nonpregnant population, and there is no significant fetal morbidity or mortality. Suprarenal and infrarenal positioning can be used, although there are more theoretical benefits to suprarenal placement. There may be an advantage to patients having an elective caesarean section, as contractions during labor may contribute to filter complications, but this requires further investigation. There is limited long-term follow-up information, but it does appear that IVC filters can be used safely, when appropriate, during pregnancy.

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30. Reddy K, Reginald PW, Charig MJ. Insertion of an inferior venocaval filter in a pregnant woman at risk for pulmonary embolism–a challenging management. J Obstet Gynaecol 2003; 23:198. 31. Ioakeimidou C, Aziz AI. To filter or not to filter the inferior vena cava in pregnancy? Case report. J Obstet Gynaecol 2005; 25:310. 32. Kawamata K, Chiba Y, Tanaka R, Higashi M, Nishigami K. Experience of temporary inferior vena cava filters inserted in the perinatal period to prevent pulmonary embolism in pregnant women with deep vein thrombosis. J Vasc Surg 2005; 41:652–656. 33. Milford W, Chadha Y, Lust K. Use of a retrievable inferior vena cava filter in term pregnancy: Case report and review of literature. Aust N Z J Obstet Gynaecol 2009; 49:331–333. 34. Liu Y, Sun Y, Zhang S, Jin X. Placement of a retrievable inferior vena cava filter for deep venous thrombosis in term pregnancy. J Vasc Surg 2012; 55:1042–1047. 35. Nakajima Y, Masaoka N, Tsuzuki Y, Morooka M, Sakai M. May-Thurner syndrome resulting in acute iliofemoral deep vein thrombosis during the second trimester of pregnancy. J Obstet Gynaecol Res 2012; 38: 1106–1110. 36. Narayan H, Cullimore J, Krarup K, Thurston H, Macvicar J, Bolia A. Experience with the Cardial inferior vena cava filter as prophylaxis against pulmonary embolism in pregnant women with extensive deep venous thrombosis. Br J Obstet Gynaecol 1992; 99:637–640. 37. Owen RJ, Krarup KC. Case report: the successful use and removal of the Gunther Tulip inferior vena caval filter in pregnancy. Clin Radiol 1997; 52:241–243. 38. Adams E, Maguire N, Richmond D, Rowlands P. Retrievable inferior vena cava filter for thrombolic disease in pregnancy. Br J Obstet Gynaecol 1998; 105:1039. 39. Clark SL, Blatter DD, Jackson GM. Placement of a temporary vena cava filter during labor. Am J Obstet Gynecol 2005; 193:1746–1747. 40. Jamjute P, Reed N, Hinwood D. Use of inferior vena cava filters in thromboembolic disease during labor: case report with a literature review. J Matern Fetal Neonatal Med 2006; 19:741–744. 41. Opara E, Gile J, Zaidi J. Inferior vena cava filter thrombo-prophylaxis in high-risk twin pregnancy. Int J Gynaecol Obstet 2007; 98:62–63. 42. Köcher M, Krcova V, Cerna M, Prochazka M. Retrievable Günther Tulip Vena Cava Filter in the prevention of pulmonary embolism in patients with acute deep venous thrombosis in perinatal period. Eur J Radiol 2009; 70:165–169. 43. McConville RM, Kennedy PT, Collins AJ, Ellis PK. Failed retrieval of an inferior vena cava filter during pregnancy because of filter tilt: report of two cases. Cardiovasc Intervent Radiol 2009; 32:174–177. 44. Brenner C, Molloy M, McEniff N. Use of inferior vena cava filters in thromboembolic disease two case reports with a literature review. Ir Med J 2001; 94:267–268.

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45. Neri E, Civeli L, Benvenuti A, et al. protected iliofemoral venous thrombectomy: in a pregnant woman with pulmonary embolism and ischemic venous thrombosis. Tex Heart Inst J 2002; 29:130–132. 46. Yamagami T, Yoshimatsu R, Okubo T. Symptomatic deep venous thrombosis of the lower extremity in a pregnant woman successfully treated with endovascular procedures. J Obstet Gynaecol Res 2013; 39: 1059–1064. 47. DeStephano CC, Werner EF, Holly BP, Lessne ML. Diagnosis and management of iliac vein thrombosis in pregnancy resulting from MayThurner Syndrome. J Perinatol 2014; 34:566–568. 48. Lonjaret L, Lairez O, Galinier M, Minville V. Thrombolysis by recombinant tissue plasminogen activator during pregnancy: a case of massive pulmonary embolism. Am J Emerg Med 2011; 29:694.e1-e2. 49. Kaufman JA, Kinney TB, Streiff MB, et al. Guidelines for the use of retrievable and convertible vena cava filters: report from the Society of Interventional Radiology multidisciplinary consensus conference. J Vasc Interv Radiol 2006; 17:449–459. 50. Royal College of Obstetricians and Gynaecologists. Reducing the risk of thrombosis and embolism during pregnancy and the puerperium. Green-top guideline no 37a. 2009. Available at: https://www. rcog.org.uk/globalassets/documents/guidelines/gtg-37a.pdf. Accessed December 17, 2015. 51. Sultan AA, West J, Tata LJ, Fleming KM, Nelson-Piercy C, Grainge MJ. Risk of first venous thromboembolism in and around pregnancy: a population-based cohort study. Br J Haematol 2012; 156:366–373. 52. Baglin TP, Brush J, Streiff M. Guidelines on use of vena cava filters. Br J Haematol 2006; 134:590–595. 53. Greenfield LJ, Proctor MC. Suprarenal filter placement. J Vasc Surg 1998; 28:432–438, discussion 438. 54. International Commission on Radiological Protection. The 2007 recommendations of the International Commission on Radiological Protection. ICRP Publication 103. Ann ICRP 2007; 37:1–332. 55. Hodgkiss-Harlow K, Back MR, Brumberg R, et al. Technical factors affecting the accuracy of bedside IVC filter placement using intravascular ultrasound. Vasc Endovascular Surg 2012; 46:293–299. 56. Cohoon KP, McBride J, Friese JL, McPhail IR. Retrievable inferior vena cava filters can be placed and removed with a high degree of success: initial experience. Catheter Cardiovasc Interv 2014. 57. Andreoli JM, Lewandowski RJ, Vogelzang RL, Ryu RK. Comparison of complication rates associated with permanent and retrievable inferior vena cava filters: a review of the MAUDE database. J Vasc Interv Radiol 2014; 25:1181–1185. 58. 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; 112:416–422.

7.e1

Table E1 . Details of All Patients with an IVC Filter Placed during Pregnancy (4,5,7–48)

Indication

Location

G2P0

Left IF DVT

Unstable clot

Infrarenal

Jugular

Permanent Greenfield

26

–

36

Vaginal

Threatened preterm labor requiring tocolysis at 26 wk, retroperitoneal hematoma, and ileus

Twins, alive

Barnes et al (9), 1981 2 38

G6P5

PE

PE, patient concerned about risk of heparin

Infrarenal

Jugular

Permanent Greenfield

13

–

40

Vaginal

Pain and swelling in left leg for 2 wk after placement

Alive (8,9)

Hux et al (23), 1986 3 22

G2P1

Bilateral DVT and thrombi in vena cava

Heparin induced thrombocytopenia

Suprarenal

Jugular

Permanent Greenfield

33

–

35

Vaginal

None at 7 mo after delivery

Alive with mild respiratory distress

4

41

G6P4

Left thigh DVT

PE on therapeutic anticoagulation (heparin)

Unknown

Femoral

Permanent Greenfield

26

–

Term

Vaginal

None at 4-y follow-up

Alive

5

33

G3P2

Bilateral DVT and thrombi in vena cava

Significant bleeding on heparin (gastrointestinal)

Unknown

Jugular

Permanent Greenfield

22

–

35

Caesarean

None at 2.5-y followup

Alive with mild respiratory distress

6

25

G2P1

Left IF DVT

PE on therapeutic anticoagulation (heparin)

Unknown

Jugular

Permanent Greenfield

32

–

Term

Caesarean

None at 2-y follow-up

Alive

7

32

G6P5

Bilateral DVT

PE on therapeutic anticoagulation (heparin)

Unknown

Jugular

Permanent Greenfield

25

–

Term

Vaginal

None at 3-y follow-up

Alive

Left IF DVT

PE on therapeutic anticoagulation (heparin)

Unknown

Jugular

Permanent Greenfield

30 þ 2

–

38

Vaginal

None

Alive

Right DVT calf and thigh

PE on therapeutic anticoagulation (heparin)

Unknown

Jugular

Permanent Greenfield

9*

–

NA

NA

Narayan et al (36), 1992 10 26 G1P0

Left IF DVT

Unstable clot

Infrarenal

Femoral

Permanent Cardial

24

–

Miscarriage

NA

Miscarriage before filter insertion, edema of left leg slow to resolve

Twin fetuses died before filter at 23/ 40 wk

11

22

G1P0

Left IF DVT

Extensive thrombus

Infrarenal

Femoral

Permanent Cardial

39

–

40 þ 6

Vaginal

None

Alive

12

25

G1P0

Left IF DVT

Extensive thrombus

Infrarenal

Femoral

Permanent Cardial

37 þ 3

–

42

Vaginal

None

Alive

Banfield et al (21), 1990 8 28 G1P0

Eagle and Davies (10), 1990 9 35 Unknown

Filter Type

Delivery Gestation

Delivery Mode

Maternal Complications

Review: Inferior Vena Cava Filters in Pregnancy

VTE

Age (y)

Time in Situ (d)

’

GP

Scurr et al (4), 1981 1 30

Pt. No.

Insertion Gestation (wk)

Fetal Outcome (Apgar score 1 min, 5 min)

Insertion Route

Death of air embolus Maternal death in at filter placement first trimester

Harris et al ’

JVIR

(Continued)

Indication

Location

Left IF DVT

Extensive thrombus

Infrarenal

Femoral

Permanent Cardial

32

–

NA

Delivery Mode NA

None: not delivered at time of report

Not delivered at time of report

Left CF and right popliteal to IVC DVT

Heparin-induced thrombocytopenia

Unknown

Jugular

Permanent Bird’s nest

30

–

37

Vaginal

Threatened preterm labor requiring tocolysis at 30 wk

Alive (9,10)

PE

PE on therapeutic anticoagulation (heparin), heparin allergy

Suprarenal

Femoral and jugular

Permanent Greenfield

14 and 32

–

36

Caesarean

Cephalad propagation of large thrombus from filter, second filter placed, further symptomatic PE leading to delivery

Alive

Right IF and left iliac DVT

After neurosurgery, anticoagulation contraindicated

Suprarenal

Jugular

Permanent Greenfield

33

–

36

Vaginal

None at 6-mo followup

Alive

Thomas et al (20), 1997 17 26 G3P1

Unknown

Recurrent DVT, PE, and thrombophlebitis on heparin

Unknown

Unknown

Permanent Greenfield

31

–

38

Caesarean

None

Alive

18

29

G5P4

Unknown

DVT PE on heparin

Unknown

Unknown

33

–

36

Vaginal

None

Alive

19

34

G12P9

Unknown

Recurrent DVT, heparin failure and bleeding

Unknown

Unknown

Permanent Greenfield Permanent Greenfield

11

–

38

Vaginal

None

Alive

20

29

G2P1

Unknown

PE during pregnancy, possibility for recurrence

Unknown

Unknown

Permanent Greenfield

11

–

37

Vaginal

None

Alive

21

28

G2P1

Unknown

DVT with multiple PEs

Unknown

Unknown

24

–

38

Caesarean

None

Alive

22

21

G4P3

Unknown

DVT

Unknown

Unknown

11

–

38

Vaginal

None

Alive

23

30

G5P4

Unknown

DVT and PE

Unknown

Unknown

Permanent Greenfield Permanent Greenfield Permanent Greenfield

7

–

34

Vaginal

None

Alive

Neill et al (5), 1997 24 18

G1P0

Left IF DVT

PE on heparin

Infrarenal

Femoral

Retrievable Günther Tulip

37 þ 3

8

38

Caesarean

None

Alive

Geary et al (11), 1997 25 33

G1P0

Left IF DVT

Unstable clot extending during anticoagulation

Unknown

Jugular

Temporary filter

34 þ 6

6

34 þ 6

Caesarean

None

Alive

Owen and Krarup (37), 1997 26 37 G1P0

Left IF DVT

Recent extensive thrombosis and imminent delivery

Infrarenal

Femoral

Retrievable Günther Tulip

37 þ 3

12

37 þ 3

Caesarean

Wound hematoma

Alive

Number X

VTE

G1P0

Quayle et al (24), 1994 14 21 G1P0

Delivery Gestation

’

GP

28

Filter Type

Time in Situ (d)

Fetal Outcome (Apgar score 1 min, 5 min)

Age (y)

Pt. No. 13

Insertion Gestation (wk)

Maternal Complications

Insertion Route

Volume XX

Table E1. Details of All Patients with an IVC Filter Placed during Pregnancy (4,5,7–48) (continued )

’ ’

2015

Ricciotti et al (27), 1995 16 31 G3P1

Month

Arbogast et al (25), 1994 15 25 G1P0

(Continued)

7.e2

7.e3

Table E1. Details of All Patients with an IVC Filter Placed during Pregnancy (4,5,7–48) (continued )

Left IF DVT

Extensive unstable clot

Infrarenal

Jugular

Retrievable Günther Tulip

25

Not removed

37

Vaginal

Filter not removed, extensive clot still present after 9 d full anticoagulation

Alive

Left IFP DVT

Extension into iliac veins, perceived high risk of PE

Suprarenal

Jugular

Temporary Tempofilter

34

5

34

Caesarean

Migration of filter having buckled

Alive

Jugular

Permanent Greenfield

Unknown

–

Unknown

Unknown

None at long-term follow-up (mean, 78 mo) apart from 4 patients with significant leg swelling due to partial resolution of DVT, treated conservatively

Alive

30

Jugular

31

Jugular

32

Jugular

33

Jugular

34

Jugular

35

Jugular

36

Jugular

37

Jugular

38

Jugular

39

Jugular

40

Jugular

41

Jugular

42

Jugular

43

Jugular

44

Jugular

Permanent Greenfield Permanent Greenfield Permanent Greenfield Permanent Greenfield Permanent Greenfield Permanent Greenfield Permanent Greenfield Permanent Greenfield Permanent Greenfield Permanent Greenfield Permanent Greenfield Permanent Greenfield Permanent Greenfield Permanent Greenfield Permanent Greenfield

Kelly and Boyd (28), 1999 28 24 Unknown

Aburahma et al (7,8), 1999 and 2001 29 Mean, 25 Unknown 14 IFP, 4 femoro(range, popliteal (left, n = 19–31) 13; right, n = 5)

PE during therapeutic Infrarenal (n = antico10), suprarenal agulation (n = 3), (n = 8) significant bleeding during anticoagulation (n = 2), freefloating iliofemoral DVT (n = 4), heparin-induced thrombocytopenia (n = 2), iliofemoral popliteal DVT 1–3 wk before labor (n = 7)

Filter Type

Delivery Mode

Maternal Complications

–

Alive

–

Alive

–

Alive

–

Alive

–

Alive

–

Alive

–

Alive

–

Alive

–

Alive

–

Alive

–

Alive

–

Alive

–

Alive

–

Alive

–

Alive

Harris et al

Location

GP

Delivery Gestation

Review: Inferior Vena Cava Filters in Pregnancy

Indication

Age (y)

Time in Situ (d)

’

VTE

Pt. No.

Adams et al (38), 1998 27 20 G1P0

Insertion Gestation (wk)

Fetal Outcome (Apgar score 1 min, 5 min)

Insertion Route

’

JVIR

(Continued)

Pt. No.

Age (y)

GP

VTE

Indication

Location

Insertion Route

46

Jugular

Brenner et al (44), 2001 47 29 Unknown

Delivery Mode

Maternal Complications

Fetal Outcome (Apgar score 1 min, 5 min)

–

Alive

–

Alive

PE and IVC thrombus

IVC thrombus posing high risk of PE during labor

Suprarenal

Femoral

Retrievable Günther Tulip

33

8

33 þ 1

Vaginal

None

Alive

Unknown

DVT resistant to anticoagulation with heparin, high peripartum PE risk

Suprarenal

Jugular

Temporary Tempofilter

31–37

21⫾ 6

14–18 d after insertion

Caesarean

None

Alive

Temporary Tempofilter Temporary Tempofilter Temporary Tempofilter

Caesarean

None

Alive

Caesarean

None

Alive

Caesarean

None

Alive

Jugular

50

Unknown

Infrarenal

Jugular

51

Unknown

Infrarenal

Jugular

Neri et al (45), 2002 52 22

Unknown

Left ischemic VTE and possible PE

Ischemic venous thrombosis and possible PE before surgical thrombectomy

Unknown

Jugular

Retrievable Prolyser

11

2

Term

Vaginal

None at 18-mo follow-up

Alive

PE

PE and thrombophilia, prophylactic

Infrarenal

Subclavian

Permanent Bird’s Nest

26

–

31

Caesarean

Premature rupture of membranes

Alive

Unknown

Left IF DVT

Failure of anticoagulation

Suprarenal

Subclavian

Retrievable Günther Tulip

35

19*

37

Vaginal

None

Alive

Ishikawa et al (29), 2003 55 29 Unknown

Left IF DVT

Occlusive DVT, high risk of PE

Infrarenal

Subclavian

Temporary Neuhaus Protect

32 þ 3

15

32 þ 3

Caesarean

Edematous leg at 15mo follow-up

Alive

Right FP DVT

Persistent symptoms despite anticoagulation and imminent labor

Unknown

Jugular

Retrievable Günther Tulip

35 þ 3

14

36

Caesarean

None

Alive

Deep veins of both legs

Growing clot and symptomatic of PE on therapy

Suprarenal

Not stated

Removable Zontik filter

33

5

33 þ 3

Caesarean

None

Alive

IF DVT (unilateral)

Extensive DVT near time of labor

Infrarenal

Jugular

Removable Tulip

39*

2

39

Vaginal

None

Alive

Hynek et al (26), 2002 53 36 Unknown

54

30

Reddy et al (30), 2003 56 17

G1P0

Burov and Kapranov (22), 2005 57 40 G3P0

Clark et al (39), 2005 58 21

G1P0

7.e4

(Continued)

2015

Infrarenal

’

Unknown

Month

49

’

Ferraro et al (12), 2001 48 Mean 29 ⫾ Unknown 8 (SD)

Filter Type Permanent Greenfield Permanent Greenfield

Delivery Gestation

Number X

Jugular

Time in Situ (d)

’

45

Insertion Gestation (wk)

Volume XX

Table E1. Details of All Patients with an IVC Filter Placed during Pregnancy (4,5,7–48) (continued )

7.e5

Table E1. Details of All Patients with an IVC Filter Placed during Pregnancy (4,5,7–48) (continued )

GP

Kawamata et al (32), 2005 60 27 G1P0

VTE

Indication

Location

Left CF, great saphenous and popliteal

Extensive DVT

Infrarenal

Jugular

Retrievable Günther Tulip

38 þ 1

19

38 þ 2

Caesarean

Feverish diarrhea (treated with erythromycin)

Alive

Right EI DVT

DVT developed during pregnancy History of DVT, on anticoagulation when not pregnant DVT developed during pregnancy DVT developed during pregnancy

Suprarenal

Jugular

Antheor rIVC

Unknown

9

36

Caesarean

None

Alive

Suprarenal

Unknown

Antheor rIVC

11

37

Vaginal

None

Alive

Suprarenal

Cubital

Antheor rIVC

7

38

Vaginal

None

Alive

Suprarenal

Cubital

Antheor rIVC

14

33

Caesarean

Alive

Suprarenal

Cubital

Antheor rIVC

3

40

Vaginal

Large thrombus captured in filter not dissolved by thrombolysis, temporary filter changed and permanent filter placed None

Alive

Suprarenal Suprarenal

Cubital Cubital

Antheor rIVC Antheor rIVC

4 6

38 39

Vaginal Vaginal

None None

Alive Alive

Suprarenal

Cubital

Antheor rIVC

8

37

Vaginal

None

Alive

Suprarenal

Jugular

4

37

Vaginal

None

Alive

Suprarenal

Jugular

Neuhaus protect rIVC Antheor rIVC

7

37

Vaginal

None

Alive

Suprarenal

Jugular

Antheor rIVC

5

37

Vaginal

None

Alive

Infrarenal

Jugular

40 þ 2

10

40 þ 3

Vaginal

None

Alive

Infrarenal

Femoral

Günther temporary Recovery nitinol IVC filter

37

75

38

Vaginal

Filter migration and fracture; leg hook retained at removal, patient remained asymptomatic

Alive

Unknown

Jugular

Retrievable

36

13

36

Vaginal

None

Alive

26

Attempt at 167

37

Caesarean

Failed retrieval, inferior migration, two struts in right renal vein, tilting, fractured strut in right hepatic lobe

61

32

G3P3

Left EI DVT

62

30

G0P0

Left CI DVT

63

32

G1P1

Left CI DVT

64

33

G2P2

Left CI DVT

65 66

24 39

G1P1 G0P0

Right EI DVT Right femoral DVT

67

27

G1P0

IVC

68

28

G2P1

IVC

69

33

G0P0

Left CI DVT

70

34

G2P2

Left EI DVT

Cheung et al (13), 2005 71 30 G1P0 72

29

Left femoral DVT

G2P1

Left IF DVT

Jamjute et al (40), 2006 73 34 G1P0

Left IF DVT

DVT developed during pregnancy Floating thrombi DVT developed during pregnancy DVT developed during pregnancy Floating thrombi DVT developed during pregnancy History of DVT, on anticoagulation when not pregnant Occlusive DVT (concern of labor and delivery) Extension of occlusive DVT despite anticoagulation

Extensive DVT and onset of labor 24 h after presentation

Filter Type

Delivery Gestation

Delivery Mode

Maternal Complications

Review: Inferior Vena Cava Filters in Pregnancy

Age (y)

Time in Situ (d)

’

Pt. No.

Ioakeimidou and Aziz (31), 2005 59 18 G1P0

Insertion Gestation (wk)

Fetal Outcome (Apgar score 1 min, 5 min)

Insertion Route

OptEase Ganguli et al (14), 2006 74 40 G1P0

PE

Suprarenal

Femoral

Recovery

Harris et al

Recurrent PE on therapeutic anticoagulation

’

JVIR

(Continued)

GP

VTE

Indication

Location

G1P0

Bilateral femoral DVT

Extensive mobile clot

Infrarenal

Jugular

Delivery Mode

Fetal Outcome (Apgar score 1 min, 5 min)

38 þ 5

Vaginal

None

Alive twins

6

38

Vaginal

None

Alive

Number X

Age (y)

Maternal Complications

’

Pt. No.

Opara et al (41), 2006 85 29

Insertion Route

40

3

40

Caesarean

None

Alive

ALN

37

3

37

Caesarean

None

Alive

ALN

36

3

37

Vaginal

None

Alive

ALN

38

9

38

Caesarean

None

Alive

ALN

39

6

39

Caesarean

None

Alive

ALN

40

–

41

Vaginal

Failed retrieval

Alive

ALN

36

30

39

Vaginal

None

Alive

ALN

36

22

39

Vaginal

None

Alive

ALN

37

5

37

Vaginal

None

Alive

Attempt at 6 or 38 d

38

Caesarean

Alive (9,9)

34

Caesarean

Filter Type

Insertion Gestation (wk)

Time in Situ (d)

Delivery Gestation

Retrievable

37 þ 5

14

ALN

38

ALN

Günther Tulip Sendon et al (15), 2008 75 Unknown Unknown

Unknown

77

VTE near time of labor

Suprarenal

Jugular

78

Suprarenal

Jugular

Suprarenal

Jugular

80

Failed medical treatment Heparin-induced thrombocytopenia VTE near time of labor

Suprarenal

Jugular

81

VTE near time of labor

Suprarenal

Jugular

82

Failed medical treatment Failed medical treatment VTE near time of labor

Suprarenal

Jugular

Suprarenal

Jugular

Suprarenal

Jugular

79

83 84 Gupta et al (16), 2008 86 25

P0

IF DVT

DVT, threatened preterm labor

Unknown

Jugular

Retrievable

34

87

22

P1

PE

Massive PE

Unknown

Jugular

Retrievable

30

88

23

P0

DVT

Unknown

Jugular

Permanent

11

NA

37

Caesarean

89

35

P0

IF DVT

DVT recurrent during anticoagulation DVT, threatened preterm labor

Threatened preterm labor requiring tocolysis at 34 wk; failed retrieval, inability to snare filter Failed retrieval, inability to snare filter None

Unknown

Jugular

Permanent

35

NA

41

Vaginal

None

Alive (9, 9)

Hidaka et al (17), 2008 90 35

GP0

Left FP DVT

VTE on anticoagulation

Infrarenal

Jugular

Retrievable Neuhaus Protect

37 þ 0

12

37 þ 5

Vaginal

Large trapped embolus not lysed, temporary filter exchanged for permanent filter

Alive (8, 9)

Sparrow (18), 2009 91 27

P1G0

Left IF DVT

Possible PE (refused CT) on LMWH

Suprarenal

Unknown

Retrievable Günther Tulip

30

Attempt at 73

40

Vaginal

Failed retrieval

Alive

IF DVT

Main criterion for filter insertion was fresh nonorganized or floating thrombus in iliac veins or IVC at time of delivery

Suprarenal

Jugular

Retrievable Günther Tulip

Unknown

Mean, 11 (range, 9–12)

Unknown

Caesarean

None (three had minor tilt of 51–171, all successfully retrieved)

Alive

Köcher et al (42), 2009 92 Mean 27.4 Unknown (range 20-42)

2015

Jugular

’

Suprarenal

Retrievable filter Retrievable filter Retrievable filter Retrievable filter Retrievable filter Retrievable filter Retrievable filter Retrievable filter Retrievable filter Retrievable filter

Month

Jugular

’

Suprarenal

76

Failed medical treatment VTE near time of labor

Volume XX

Table E1. Details of All Patients with an IVC Filter Placed during Pregnancy (4,5,7–48) (continued )

Alive (5,10) Alive (9,9)

7.e6

(Continued)

7.e7

Table E1. Details of All Patients with an IVC Filter Placed during Pregnancy (4,5,7–48) (continued )

IF DVT

Suprarenal

Jugular

94

IF DVT

Suprarenal

Jugular

95

IF DVT

Suprarenal

Jugular

96

IF DVT

Suprarenal

Jugular

97

IF DVT

Suprarenal

Jugular

98

IF DVT

Suprarenal

Jugular

99

IF DVT

Suprarenal

Jugular

Pt. No.

Age (y)

Milford et al (33), 2009 100 31

GP

G2

McConville et al (43), 2009 101 34 G1P0

102

32

G2P1

Lonjaret et al (48), 2011 103 33 G3P1

VTE

Indication

Filter Type

Time in Situ (d)

Delivery Gestation

Retrievable Günther Tulip Retrievable Günther Tulip Retrievable Günther Tulip Retrievable Günther Tulip Retrievable Günther Tulip Retrievable Günther Tulip Retrievable Günther Tulip

Delivery Mode

Maternal Complications

Fetal Outcome (Apgar score 1 min, 5 min)

Caesarean

Alive

Caesarean

Alive

Caesarean

Alive

Caesarean

Alive

Caesarean

Alive

Caesarean

Alive

Caesarean

Alive

Suprarenal

Jugular

Retrievable Cook Celect

39 þ 5

7

40 þ 0

Vaginal

None

Alive

Bilateral

Extensive floating thrombus

Suprarenal

Unknown

Retrievable OptEase

38 þ 2

Attempt at 28

39

Vaginal

Failed retrieval, filter tilt

Alive

Left IF DVT

Free-floating thrombus

Suprarenal

Unknown

Retrievable OptEase

38

Attempt at 28

39

Caesarean

Failed retrieval, filter tilt

Alive

PE and left IF DVT

Massive PE requiring thrombolysis

Unknown

Jugular

Retrievable

31 þ 0

Unknown

38

Vaginal

None (minor epistaxis)

Alive

Retrievable OptEase Retrievable OptEase Retrievable OptEase Retrievable OptEase

39

13

39

Caesarean

None at 12 mo

Alive

39

15

39

Caesarean

None at 12 mo

Alive

38

12

38

Caesarean

None at 12 mo

Alive

40

14

40

Caesarean

Alive

Retrievable OptEase Retrievable OptEase Retrievable OptEase

39

12

39

Caesarean

Unilateral leg swelling with partial resolution of DVT at 3 mo, nothing else at 48 mo None at 12 mo

Alive

38

14

38

Caesarean

None at 12 mo

Alive

41

14

41

Caesarean

Unilateral leg swelling with partial resolution of DVT at 3 mo, nothing else at 28 mo

Alive

Liu et al (34), 2012 104 26

G1P0

Left IFP DVT

Extensive DVT

Suprarenal

Jugular

105

29

G1P1

Left IFP DVT

Extensive DVT

Suprarenal

Jugular

106

20

G1P0

Left PF DVT

Extensive DVT

Suprarenal

Jugular

107

31

G1P0

Left IFP DVT

Extensive DVT

Suprarenal

Jugular

108

28

G1P0

Right IFP DVT

Extensive DVT

Suprarenal

Jugular

109

27

G1P0

Left PF DVT

Extensive DVT

Suprarenal

Jugular

110

33

G1P1

Left IFP DVT

Extensive DVT

Suprarenal

Jugular

’

Extensive DVT

Harris et al

Left IF DVT

Review: Inferior Vena Cava Filters in Pregnancy

93

Insertion Gestation (wk)

’

Location

Insertion Route

JVIR

(Continued)

Delivery Mode

Maternal Complications

Fetal Outcome (Apgar score 1 min, 5 min)

Caesarean

None at 12 mo

Alive

39

Caesarean

None at 12 mo

Alive

12

38

Caesarean

None at 12 mo

Alive

37

NA

37

Caesarean

Alive

Retrievable OptEase Retrievable OptEase Retrievable OptEase Retrievable OptEase

39

14

39

Caesarean

Device not retrieved as device occluded with thrombus, unilateral leg swelling with partial resolution of DVT at 3 mo, nothing else at 18 mo None at 12 mo

Alive

39

12

39

Caesarean

None at 12 mo

Alive

41

13

41

Caesarean

None at 9 mo

Alive

40

14

40

Caesarean

None at 6 mo

Alive

GP

VTE

Indication

Location

111

31

G1P0

Left IFP DVT

Extensive DVT

Suprarenal

Jugular

112

25

G1P0

Left PF DVT

Extensive DVT

Suprarenal

Jugular

113

28

G1P0

Right IFP DVT

Extensive DVT

Suprarenal

Jugular

114

41

G1P1

Left gastrocnemius vein DVT

Extensive DVT

Suprarenal

Jugular

115

35

G1P1

Left IFP DVT

Extensive DVT

Suprarenal

Jugular

116

26

G1P0

Left IFP DVT

Extensive DVT

Suprarenal

Jugular

117

32

G1P0

Left PF DVT

Extensive DVT

Suprarenal

Jugular

118

29

G1P0

Left PF DVT

Extensive DVT

Suprarenal

Jugular

Nakajima et al (35), 2012 119 27 G1P0

Left IF DVT

Extensive thrombosis, risk of PE at delivery

Infrarenal

Jugular

Temporary filter

36

19

37þ5

Vaginal

None at 12 mo (patient had MTS)

Alive (8, 9)

Right EI to intramuscular veins of gastrocnemius DVT

Phlebothrombosis, extensive DVT on anticoagulation

Infrarenal

Unknown

Permanent TrapEase

30þ0

NA

37þ0

Vaginal

None

Alive

Left calf vein to left CI DVT

Extensive DVT and planned endovascular procedures

Suprarenal

Jugular

Retrievable Günther Tulip

34 þ 0

30

35 þ 1

Caesarean

IVC filter exchanged twice postpartum while endovascular DVT treatment was carried out (successfully removed)

Alive

Left calf vein to left CI DVT/PE (asymptomatic, seen on CT) Left calf vein to left CI DVT

Percutaneous PMT for ongoing pain/risk for PTS

Suprarenal

Unknown

Retrievable

18 þ 2

64

39 þ 3

Caesarean

None (patient had MTS)

Alive (8, 9)

Percutaneous PMT for ongoing pain/risk for PTS

Suprarenal

Unknown

Retrievable

30 þ 5

Unknown

37 þ 6

Vaginal

Alive (9, 9)

Percutaneous PMT for ongoing pain/risk for PTS

Suprarenal

Unknown

Retrievable

35 þ 1

66

38 þ 4

Vaginal

None related to IVC filter (partial rethrombosis of DVT and pain, patient had MTS) None (patient had MTS)

Pt. No.

G1P0

124

18

G1P0

Left IFP DVT/PE (asymptomatic, seen on CT)

14

39

39

9

38

2015

30

39

Filter Type

’

123

Retrievable OptEase Retrievable OptEase Retrievable OptEase Retrievable OptEase

Month

DeStephano et al (47), 2014 122 28 G6P0

Delivery Gestation

’

Yamagami et al (46), 2013 121 24 Unknown

Time in Situ (d)

Number X

Valadares et al (19), 2013 120 27 G2P1

Insertion Gestation (wk)

’

Age (y)

Insertion Route

Volume XX

Table E1. Details of All Patients with an IVC Filter Placed during Pregnancy (4,5,7–48) (continued )

Alive (9, 9)

CF ¼ common femoral; CI ¼ common iliac; CIV ¼ common iliac vein; DVT ¼ deep vein thrombosis; EI ¼ external iliac; GP ¼ gravidity/parity; IF ¼ ileofemoral; IFP ¼ ileofemoropopliteal; IVC ¼ inferior vena cava; LMWH ¼ low molecular weight heparin; NA ¼ not applicable; PE ¼ pulmonary embolism; PF ¼ popliteal–femoral; MTS ¼ May–Thurner syndrome; PMT ¼ pharmacomechanical thrombectomy; PTS ¼ postthrombotic syndrome; VTE ¼ venous thromboembolism. n

Approximate.

7.e8