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Inferior Vena Cava Filter Placement and Retrieval: A Survey of Vascular Specialists Practices
806 Abstracts
JOURNAL OF VASCULAR SURGERY September 2015
Inferior Vena Cava Filter Placement and Retrieval: A Survey of Vascular Specialists Practices Anand Brahmandam, MD1, Laura Skrip, MPH2, Bauer Sumpio, MD, PhD1, Jeffrey Indes, MD1, Alan Dardik, MD, PhD1, Timur Sarac, MD1, John Rectenwald, MD3, Cassius Iyad Ochoa Chaar, MD, MS1. 1Yale School of Medicine, New Haven, Conn; 2Yale School of Public Health, New Haven, Conn; 3University of Michigan School of Medicine, Ann Arbor, Mich
Fig. Receiver operator characteristic (ROC) curve analysis using common femoral vein (CFV) to predict >50% stenosis by intravascular ultrasound (IVUS).
Conclusions: The current study highlights the validity of VDUS in diagnosing iliac vein stenosis. Stent placement and pentoxyphylline were found to reduce the risk of recurrence. Author Disclosures: A. Mousa: None; M. Broce: None; M. Yacoub: None; J. Kazil: None; S. AbuHaliamh: None; A. Nanjundappa: None; P. Stone: None; M. Bates: None; A. AbuRahma: None. National Incidence and Ten-Year Trends in Deep Vein Thrombosis Following Total Knee and Total Hip Replacement Anahita Dua, MD1, Sapan S. Desai2, Jennifer A. Heller, MD3. 1Medical College of Wisconsin, Milwaukee, Wisc; 2Southern Illinois University, Springfield, Ill; 3Johns Hopkins University, Baltimore, Md Objectives: Total knee replacement (TKR) and total hip replacement (THR) are associated with an increased risk of deep vein thrombosis (DVT). Advances in DVT prophylaxis over the past decade have led to a decrease in DVT-related morbidity, but gender, racial, and other demographic factors that contribute to a higher risk of DVT are incompletely characterized. This study aimed to determine the incidence of DVT over the past decade and identify factors that were associated with an increased risk of DVT. Methods: Patients who underwent TKR or THR between 2001 and 2011 were identified using the National Inpatient Sample. Demographics (including age, gender, and race), comorbidities, and subsequent outcomes (including length of stay [LOS] and mortality) were determined for patients who developed a DVT. Differences between patients who did and did not develop a DVT were determined using multivariate regression analysis. A Mann-Kendall analysis was done to evaluate all trends. Results: Between 2001 and 2011, 1.1 million patients underwent TKR, and 550,000 underwent THR. The overall incidence of DVT decreased for TKR from 0.86% in 2001 to 0.45% in 2011 and decreased for THR from 0.55% to 0.24% for the same period. Patients who developed a DVT after TKR were older (67.7 vs 66.8 years; P < .001) and were more likely to be male (37.9% vs 36.4%; P < .001), African American (P < .001), and to have significant comorbidities, including congestive heart failure, peripheral artery disease, and end-stage renal disease. Findings were similar for patients who developed a DVT after THR. Mortality was significantly greater for patients who developed a DVT (0.4% after TKR and 1.7% after THR), with an almost double LOS. Conclusions: A focus on DVT prophylaxis has decreased national rates of DVT after TKR and THR. However, older patients, men, African Americans, and patients with more comorbidities appear to be especially at risk for DVT. Mortality was almost eight times higher than in patients who did not develop DVT, and a LOS double that of unaffected patients significantly affects the quality of care. A focus on DVT prophylaxis, and perhaps more aggressive management of the at-risk population, may help decrease the rate of DVT. Author Disclosures: A. Dua: None; S. S. Desai: None; J. A. Heller: None.
Objectives: The frequency of inferior vena cava filter (IVCF) placement continues to rise. Vascular specialists (VSs) adopt different practices based on local expertise. This study was performed to assess the attitudes of VSs toward the placement and retrieval of IVCFs. Methods: An online survey of 28 questions related to practice patterns regarding IVCFs was administered to a group of vascular surgeons and interventional radiologists. VSs were categorized as low volume (LV) if they place fewer than three IVCFs per month and as high volume (HV) if they place at least 3 IVCF per month. The responses of HV and LV were compared and analyzed using c2 tests. Results: A total of 259 VSs completed the survey. There were 199 vascular surgeons (74%) and 69 interventional radiologists (26%). Most responders (67%) were in academic practice and worked in tertiary care centers (73%). The temporary IVCF of choice was Celect (27%), followed by Denali (20%). The permanent IVCF of choice was a temporary IVCF left in situ indefinitely (42%), followed by Titanium Greenfield (17%). Eightytwo percent preferred placing the tip of the IVCF at or just below the lowest renal vein. Thirty-one percent obtained a venous duplex of the lower extremities before retrieval, and 34% did not do any imaging. VSs were divided into 132 LV (51%) and 127 HV (49%). HV responders were significantly more likely to have procedural time for IVCF retrieval of <30 minutes compared with LV responders (57% vs 42%; P ¼ .026). There was a trend for HV responders to have fewer unsuccessful attempts at IVCF retrieval but that did not reach statistical significance (P ¼ .061). HV responders were more likely to have attempted multiple times to retrieve an IVCF (66% vs 33%; P < .001) and to have used a bronchoscopy forceps (32% vs 14%; P ¼ .001) or a laser sheath (14% vs 2%; P < .001) for IVCF retrieval. In general, VSs were not comfortable using a bronchoscopy forceps (65%) or a laser sheath (90%) for IVCF retrieval. Conclusions: This study underscores significant variability in VS practice patterns regarding IVCFs. More studies and societal guidelines are needed to define the best practices. Author Disclosures: A. Brahmandam: None; L. Skrip: None; B. Sumpio: None; J. Indes: None; A. Dardik: None; T. Sarac: None; J. Rectenwald: None; C. Ochoa Chaar: None. Is Pulmonary Embolism Predictable in Patients With Deep Vein Thrombosis? Nancy Huynh, BS, Wassim Fares, MD, MPH, Kirstyn Brownson, MD, Anand Brahmandam, MD, Alfred I. Lee, MD, PhD, Alan Dardik, MD, PhD, Timur Sarac, MD, Cassius Iyad Ochoa Chaar. Yale School of Medicine, New Haven, Conn Objectives: The Caprini model estimates patients risk for venous thromboembolism (VTE) based on 30 different factors. Hemodynamically significant (HS) pulmonary embolism (PE), defined as high risk (massive) or intermediate (submassive) PE, is the most dreaded complication. This study tests whether the Caprini model correlates with the prevalence of PE and HS PE in patients with deep vein thrombosis (DVT). Methods: A retrospective review of the records of all consecutive patients diagnosed with DVT between January 2013 and August 2014 in a tertiary care center was performed. Patient demographics and risk factors based on the Caprini model were noted. Multivariable analysis was used to determine predictors of PE, and HS PE. Stata software was used for all analysis. Results: There were 838 patients (50.95% women) with DVT; 217 patients (25.89%) had a concomitant PE at presentation and 135 had HS PE (101 submassive PE, 34 massive PE). The mean age was 65 years. There was no significant relation between age or gender and the occurrence of PE or HS PE. Patients with PE were less likely to have undergone major surgery (18.43% vs 81.57%; P ¼ .001), to have inflammatory bowel disease (3.69% vs 96.31%; P ¼ .001), and to have sepsis (4.61% vs 95.39%; P ¼ .002) but were more likely to be overweight (body mass index >25 kg/ m2; 74.65% vs 24.42%; P ¼ .007). On multivariable analysis, only major surgery (P ¼ .001) and sepsis (P ¼ .008) remained statistically significant. The Caprini score had statistically significant inverse relation with occurrence of PE, in that patients with a higher score were less likely to develop PE (P ¼ .047). Patients with DVT after major surgery were less likely to have HS PE (13.33% vs 86.67%; P ¼ .011). There was no association between Caprini score and HS PE (P ¼ .171).
JOURNAL OF VASCULAR SURGERY September 2015
Inferior Vena Cava Filter Placement and Retrieval: A Survey of Vascular Specialists Practices Anand Brahmandam, MD1, Laura Skrip, MPH2, Bauer Sumpio, MD, PhD1, Jeffrey Indes, MD1, Alan Dardik, MD, PhD1, Timur Sarac, MD1, John Rectenwald, MD3, Cassius Iyad Ochoa Chaar, MD, MS1. 1Yale School of Medicine, New Haven, Conn; 2Yale School of Public Health, New Haven, Conn; 3University of Michigan School of Medicine, Ann Arbor, Mich
Fig. Receiver operator characteristic (ROC) curve analysis using common femoral vein (CFV) to predict >50% stenosis by intravascular ultrasound (IVUS).
Conclusions: The current study highlights the validity of VDUS in diagnosing iliac vein stenosis. Stent placement and pentoxyphylline were found to reduce the risk of recurrence. Author Disclosures: A. Mousa: None; M. Broce: None; M. Yacoub: None; J. Kazil: None; S. AbuHaliamh: None; A. Nanjundappa: None; P. Stone: None; M. Bates: None; A. AbuRahma: None. National Incidence and Ten-Year Trends in Deep Vein Thrombosis Following Total Knee and Total Hip Replacement Anahita Dua, MD1, Sapan S. Desai2, Jennifer A. Heller, MD3. 1Medical College of Wisconsin, Milwaukee, Wisc; 2Southern Illinois University, Springfield, Ill; 3Johns Hopkins University, Baltimore, Md Objectives: Total knee replacement (TKR) and total hip replacement (THR) are associated with an increased risk of deep vein thrombosis (DVT). Advances in DVT prophylaxis over the past decade have led to a decrease in DVT-related morbidity, but gender, racial, and other demographic factors that contribute to a higher risk of DVT are incompletely characterized. This study aimed to determine the incidence of DVT over the past decade and identify factors that were associated with an increased risk of DVT. Methods: Patients who underwent TKR or THR between 2001 and 2011 were identified using the National Inpatient Sample. Demographics (including age, gender, and race), comorbidities, and subsequent outcomes (including length of stay [LOS] and mortality) were determined for patients who developed a DVT. Differences between patients who did and did not develop a DVT were determined using multivariate regression analysis. A Mann-Kendall analysis was done to evaluate all trends. Results: Between 2001 and 2011, 1.1 million patients underwent TKR, and 550,000 underwent THR. The overall incidence of DVT decreased for TKR from 0.86% in 2001 to 0.45% in 2011 and decreased for THR from 0.55% to 0.24% for the same period. Patients who developed a DVT after TKR were older (67.7 vs 66.8 years; P < .001) and were more likely to be male (37.9% vs 36.4%; P < .001), African American (P < .001), and to have significant comorbidities, including congestive heart failure, peripheral artery disease, and end-stage renal disease. Findings were similar for patients who developed a DVT after THR. Mortality was significantly greater for patients who developed a DVT (0.4% after TKR and 1.7% after THR), with an almost double LOS. Conclusions: A focus on DVT prophylaxis has decreased national rates of DVT after TKR and THR. However, older patients, men, African Americans, and patients with more comorbidities appear to be especially at risk for DVT. Mortality was almost eight times higher than in patients who did not develop DVT, and a LOS double that of unaffected patients significantly affects the quality of care. A focus on DVT prophylaxis, and perhaps more aggressive management of the at-risk population, may help decrease the rate of DVT. Author Disclosures: A. Dua: None; S. S. Desai: None; J. A. Heller: None.
Objectives: The frequency of inferior vena cava filter (IVCF) placement continues to rise. Vascular specialists (VSs) adopt different practices based on local expertise. This study was performed to assess the attitudes of VSs toward the placement and retrieval of IVCFs. Methods: An online survey of 28 questions related to practice patterns regarding IVCFs was administered to a group of vascular surgeons and interventional radiologists. VSs were categorized as low volume (LV) if they place fewer than three IVCFs per month and as high volume (HV) if they place at least 3 IVCF per month. The responses of HV and LV were compared and analyzed using c2 tests. Results: A total of 259 VSs completed the survey. There were 199 vascular surgeons (74%) and 69 interventional radiologists (26%). Most responders (67%) were in academic practice and worked in tertiary care centers (73%). The temporary IVCF of choice was Celect (27%), followed by Denali (20%). The permanent IVCF of choice was a temporary IVCF left in situ indefinitely (42%), followed by Titanium Greenfield (17%). Eightytwo percent preferred placing the tip of the IVCF at or just below the lowest renal vein. Thirty-one percent obtained a venous duplex of the lower extremities before retrieval, and 34% did not do any imaging. VSs were divided into 132 LV (51%) and 127 HV (49%). HV responders were significantly more likely to have procedural time for IVCF retrieval of <30 minutes compared with LV responders (57% vs 42%; P ¼ .026). There was a trend for HV responders to have fewer unsuccessful attempts at IVCF retrieval but that did not reach statistical significance (P ¼ .061). HV responders were more likely to have attempted multiple times to retrieve an IVCF (66% vs 33%; P < .001) and to have used a bronchoscopy forceps (32% vs 14%; P ¼ .001) or a laser sheath (14% vs 2%; P < .001) for IVCF retrieval. In general, VSs were not comfortable using a bronchoscopy forceps (65%) or a laser sheath (90%) for IVCF retrieval. Conclusions: This study underscores significant variability in VS practice patterns regarding IVCFs. More studies and societal guidelines are needed to define the best practices. Author Disclosures: A. Brahmandam: None; L. Skrip: None; B. Sumpio: None; J. Indes: None; A. Dardik: None; T. Sarac: None; J. Rectenwald: None; C. Ochoa Chaar: None. Is Pulmonary Embolism Predictable in Patients With Deep Vein Thrombosis? Nancy Huynh, BS, Wassim Fares, MD, MPH, Kirstyn Brownson, MD, Anand Brahmandam, MD, Alfred I. Lee, MD, PhD, Alan Dardik, MD, PhD, Timur Sarac, MD, Cassius Iyad Ochoa Chaar. Yale School of Medicine, New Haven, Conn Objectives: The Caprini model estimates patients risk for venous thromboembolism (VTE) based on 30 different factors. Hemodynamically significant (HS) pulmonary embolism (PE), defined as high risk (massive) or intermediate (submassive) PE, is the most dreaded complication. This study tests whether the Caprini model correlates with the prevalence of PE and HS PE in patients with deep vein thrombosis (DVT). Methods: A retrospective review of the records of all consecutive patients diagnosed with DVT between January 2013 and August 2014 in a tertiary care center was performed. Patient demographics and risk factors based on the Caprini model were noted. Multivariable analysis was used to determine predictors of PE, and HS PE. Stata software was used for all analysis. Results: There were 838 patients (50.95% women) with DVT; 217 patients (25.89%) had a concomitant PE at presentation and 135 had HS PE (101 submassive PE, 34 massive PE). The mean age was 65 years. There was no significant relation between age or gender and the occurrence of PE or HS PE. Patients with PE were less likely to have undergone major surgery (18.43% vs 81.57%; P ¼ .001), to have inflammatory bowel disease (3.69% vs 96.31%; P ¼ .001), and to have sepsis (4.61% vs 95.39%; P ¼ .002) but were more likely to be overweight (body mass index >25 kg/ m2; 74.65% vs 24.42%; P ¼ .007). On multivariable analysis, only major surgery (P ¼ .001) and sepsis (P ¼ .008) remained statistically significant. The Caprini score had statistically significant inverse relation with occurrence of PE, in that patients with a higher score were less likely to develop PE (P ¼ .047). Patients with DVT after major surgery were less likely to have HS PE (13.33% vs 86.67%; P ¼ .011). There was no association between Caprini score and HS PE (P ¼ .171).