- Email: [email protected]
Initial Experience with Fourth Generation Inferior Vena Caval Filters
Case Reports
INITIAL EXPERIENCE WITH FOURTH GENERATION INFERIOR VENA CAVAL FILTERS Umesh Gupta From the Department of Vascular Surgery, Apollo Surgical Sciences Centre, Indraprastha Apollo Hospitals, New Delhi 110 044, India. Correspondence to: Dr. Umesh Gupta, Consultant Vascular Surgeon, Team leader-JCI DICE, Indraprastha Apollo Hospitals, New Delhi 110 044, India. E-mail: [email protected] The fourth generation temporary inferior vena cava (IVC) filter was used with good outcomes in two patients of deep vein thrombosis (DVT) with high likelihood of life threatening pulmonary embolism (PE). Key words: Deep vein thrombosis, Pulmonary embolism, Inferior vena caval filter
Patient 2
INFERIOR Vena Caval Filters (IVC) have been used since 1967 for the prevention of life threatening pulmonary embolism in deep vein thrombosis (DVT). As all filters have the potential to lead to caval thrombosis, all patients with IVC filters require lifelong anticoagulant therapy. Filters have now been developed that can be removed after varying periods of time. These fourth generation filters have the advantage of providing protection against PE and then can be removed. Thus, patients can discontinue anticoagulants after 6-12 months. My initial experience with two such patients is described.
A 47-year male patient presented with right painful swelling of the lower limb for the last 3 days. He is a smoker, diabetic and hypertensive. Except for smoking, no major risk factors for DVT were identified. Venous Doppler revealed DVT of the right ileo-femoral vein with extension into the IVC. He was immediately given a bolus of 8000 units of heparin I/V (100 units/Kg) and an infusion of 1400 units/hr (18 units/Kg/hr). The heparin infusion was titrated to keep the PTT at 2.5-3 times the control. On third day of admission, he developed mild pain on the right side of the chest. Lung examination and a chest X-ray were clear. ABG was unremarkable and ventilation-perfusion lungs scan showed high probability of PE in the right upper lung field. A temporary IVC filter (Tempo Filter II, B Braun) was inserted via the right internal jugular vein till just below the renal veins. The filter was explanted after six weeks without further episodes of PE or any other complications. A repeat ventilation-perfusion lungs scan before discharge did not reveal any new areas of mismatch. He continues to do well 4 months after the episode.
CASE REPORTS Patient 1 A 36-year male patient presented to the emergency room with two-week-old head injury and consequent intra-cranial hematoma. The intra-cranial hematoma did not require any surgical intervention and had been managed conservatively by the neurosurgeon. The patient had developed swelling of the whole of the right lower limb 2 days before presentation. On examination, he was conscious, alert and oriented with no neurological deficit. Vital signs were stable and systemic examination was unremarkable. The whole of the right lower limb was swollen till the groin. Venous Doppler interrogation revealed DVT of the right ileo-femoral vein and the thrombus extending into the IVC. Due to the recent head injury with an intracranial hematoma, anti-coagulation was contra-indicated. On the other hand, the thrombus extending into the IVC placed the patient at high risk for a life threatening thrombus. After discussing all options with the patient and family, a temporary IVC filter (Tempo Filter II, BBraun) was inserted via the right internal jugular vein till just below the renal veins. The filter was removed after six weeks. He continues to do well without further complications.
DISCUSSION The concept of interrupting the flow in the inferior vena cava (IVC) to prevent PE originated in the 1930s and 1940s with the performance of common femoral vein and superficial femoral vein ligation. These methods were used in parallel with anticoagulation methods when heparin and warfarin became available in 1935 and 1948 respectively. Later, ligation of the IVC was performed, initially in patients harboring thrombi above the superficial femoral veins. Eventually, it replaced lower-level venous ligation. The operative mortality rate of 2-15% was not significantly different from that of femoral vein ligation, but a lower rate for recurrent PE was reported. The optimal level of ligation was located immediately below the renal veins to prevent 69
Apollo Medicine, Vol.1 September 2004
Case Reports
thrombosis due to venous stasis between the interrupted IVC and the renal veins. However, 10-16% of these patients had immediate lower-extremity swelling.
insufficiency. Implanting and then explanting the temporary filter after 6 weeks has resulted in prevention of mortality as well as an anticoagulation free life.
In the 1960s, various methods of partially interrupting the flow in the IVC were developed to lessen the effect of venous stasis. The procedures provided emboli trapping with preservation of blood flow through the lumen. The procedures include suture plication and caval clips (Moretz clip, Miles clip, Adams-DeWeese clip). The rates for operative mortality and recurrent PE were similar to those of caval ligation, yet the rate for limb edema was reduced. Despite the fact that these procedures partially interrupted flow in the IVC, caval occlusion rates of 30-40% were reported.
The second patient with documented PE despite adequate anticoagulation was a classical indication for IVC filter placement. Again, a temporary filter has resulted in prevention of further PE and an anticoagulation free life after 4 months of therapy. Both the cases demonstrate the effectiveness of the temporary filters and a good quality of life afterwards. The main drawback of the temporary filters is the lack of long-term results and complication data of these filters. Till such data is available, the fourth generation IVC filters should be used very selectively and under close monitoring.
In 1967, the Mobin-Uddin umbrella filter was developed as a replacement for surgical ligation, caval plication, and caval clips and partially to interrupt the flow in the IVC and to prevent PE. Since then, several filters have been introduced. Currently, filters represent the standard of care when partial interruption of IVC flow is indicated to prevent the occurrence of PE. The classical indications for IVC filters are contraindication to anticoagulation or recurrent PE despite adequate anticoagulation [1,2]. Less frequent indications include prophylaxis and perioperative coverage.
REFERENCES 1. Vaughn BK, Knezevich S, Lombardi AV Jr, Mallory TH. Use of the Greenfield filter to prevent fatal pulmonary embolism associated with total hip and knee arthroplasty. J Bone Joint Surg Am 1989 Dec; 71(10): 1542-1548. 2. Wittenberg G, Kueppers V, Tschammler A, et al. Long-term results of vena cava filters: experiences with the LGM and the Titanium Greenfield devices. Cardiovasc Intervent Radiol 1998 May-Jun; 21(3): 225-229. 3. Thomas JH, Cornell KM, Siegel EL, et al. Vena caval occlusion after bird’s nest filter placement. Am J Surg 1998 Dec; 176(6): 598-600.
All IVC Filters have the potential to cause IVC thrombosis [3,4]. Further, patients with IVC filters require lifelong anticoagulation. Other uncommon complications of permanent filters include IVC perforation, filter migration etc. [5-8].
4. Starok MS, Common AA. Follow-up after insertion of Bird’s Nest inferior vena caval filters. Can Assoc Radiol J 1996 Jun; 47(3): 189-194.
Fourth generation IVC filters were developed to overcome the complication of IVC thrombosis as these filters can be removed after the period of greatest chances of occurrence of PE is over, usually six weeks. Further, as the filter is removable, patients do not require lifelong anticoagulation with its attendant expenses and complications. These filters are further classified as removable or retrievable. Difference is that the retrievable filters can be either left inside or removed depending on the continued indication for the filter. Removable filters have a tethering catheter and the filter must be removed within six weeks of insertion.
5. Athanasoulis CA, Kaufman JA, Halpern EF, et al: Inferior vena caval filters: review of a 26-year single-center clinical experience. Radiology 2000 Jul; 216(1): 54-66. 6. Awh MH, Taylor FC, Lu CT. Spontaneous fracture of a VenaTech inferior vena caval filter. AJR Am J Roentgenol 1991 Jul; 157(1): 177-178. 7. LaPlante JS, Contractor FM, Kiproff PM, Khoury MB. Migration of the Simon nitinol vena cava filter to the chest. AJR Am J Roentgenol 1993 Feb; 160(2): 385-386. 8. Teitelbaum GP, Jones DL, van Breda A, et al. Vena caval filter splaying: potential complication of use of the titanium Greenfield filter. Radiology 1989 Dec; 173(3): 809-814.
Patients of polytrauma or those requiring urgent surgery and also have DVT, require prophylactic coverage for prevention of PE as anticoagulation is contraindicated [9-12]. Such patients are ideally suited for the fourth generation IVC filters.
9. Gosin JS, Graham AM, Ciocca RG, Hammond JS. Efficacy of prophylactic vena cava filters in high-risk trauma patients. Ann Vasc Surg 1997 Jan; 11(1): 100-105. 10. Greenfield LJ, Proctor MC, Michaels AJ, Taheri PA. Prophylactic vena caval filters in trauma: the rest of the story. J Vasc Surg 2000 Sep; 32(3): 490-5; discussion 496-497.
Anticoagulation was contraindicated in the first patient due to recent head injury with concomitant intracranial hemorrhage. The DVT was extending to his IVC and hence, he had a real threat of developing life threatening PE. As the patient is a young man with a long life ahead of him, a conventional IVC filter would have meant possible IVC thrombosis with subsequent bilateral chronic venous Apollo Medicine, Vol.1 September 2004
11. Langan EM 3rd, Miller RS, Casey WJ 3rd, et al. Prophylactic inferior vena cava filters in trauma patients at high risk: followup examination and risk/benefit assessment. J Vasc Surg 1999 Sep; 30(3): 484-488. 12. Rogers FB, Shackford SR, Ricci MA, et al. Prophylactic vena cava filter insertion in selected high-risk orthopaedic trauma patients. J Orthop Trauma 1997 May; 11(4): 267-272. 70
INITIAL EXPERIENCE WITH FOURTH GENERATION INFERIOR VENA CAVAL FILTERS Umesh Gupta From the Department of Vascular Surgery, Apollo Surgical Sciences Centre, Indraprastha Apollo Hospitals, New Delhi 110 044, India. Correspondence to: Dr. Umesh Gupta, Consultant Vascular Surgeon, Team leader-JCI DICE, Indraprastha Apollo Hospitals, New Delhi 110 044, India. E-mail: [email protected] The fourth generation temporary inferior vena cava (IVC) filter was used with good outcomes in two patients of deep vein thrombosis (DVT) with high likelihood of life threatening pulmonary embolism (PE). Key words: Deep vein thrombosis, Pulmonary embolism, Inferior vena caval filter
Patient 2
INFERIOR Vena Caval Filters (IVC) have been used since 1967 for the prevention of life threatening pulmonary embolism in deep vein thrombosis (DVT). As all filters have the potential to lead to caval thrombosis, all patients with IVC filters require lifelong anticoagulant therapy. Filters have now been developed that can be removed after varying periods of time. These fourth generation filters have the advantage of providing protection against PE and then can be removed. Thus, patients can discontinue anticoagulants after 6-12 months. My initial experience with two such patients is described.
A 47-year male patient presented with right painful swelling of the lower limb for the last 3 days. He is a smoker, diabetic and hypertensive. Except for smoking, no major risk factors for DVT were identified. Venous Doppler revealed DVT of the right ileo-femoral vein with extension into the IVC. He was immediately given a bolus of 8000 units of heparin I/V (100 units/Kg) and an infusion of 1400 units/hr (18 units/Kg/hr). The heparin infusion was titrated to keep the PTT at 2.5-3 times the control. On third day of admission, he developed mild pain on the right side of the chest. Lung examination and a chest X-ray were clear. ABG was unremarkable and ventilation-perfusion lungs scan showed high probability of PE in the right upper lung field. A temporary IVC filter (Tempo Filter II, B Braun) was inserted via the right internal jugular vein till just below the renal veins. The filter was explanted after six weeks without further episodes of PE or any other complications. A repeat ventilation-perfusion lungs scan before discharge did not reveal any new areas of mismatch. He continues to do well 4 months after the episode.
CASE REPORTS Patient 1 A 36-year male patient presented to the emergency room with two-week-old head injury and consequent intra-cranial hematoma. The intra-cranial hematoma did not require any surgical intervention and had been managed conservatively by the neurosurgeon. The patient had developed swelling of the whole of the right lower limb 2 days before presentation. On examination, he was conscious, alert and oriented with no neurological deficit. Vital signs were stable and systemic examination was unremarkable. The whole of the right lower limb was swollen till the groin. Venous Doppler interrogation revealed DVT of the right ileo-femoral vein and the thrombus extending into the IVC. Due to the recent head injury with an intracranial hematoma, anti-coagulation was contra-indicated. On the other hand, the thrombus extending into the IVC placed the patient at high risk for a life threatening thrombus. After discussing all options with the patient and family, a temporary IVC filter (Tempo Filter II, BBraun) was inserted via the right internal jugular vein till just below the renal veins. The filter was removed after six weeks. He continues to do well without further complications.
DISCUSSION The concept of interrupting the flow in the inferior vena cava (IVC) to prevent PE originated in the 1930s and 1940s with the performance of common femoral vein and superficial femoral vein ligation. These methods were used in parallel with anticoagulation methods when heparin and warfarin became available in 1935 and 1948 respectively. Later, ligation of the IVC was performed, initially in patients harboring thrombi above the superficial femoral veins. Eventually, it replaced lower-level venous ligation. The operative mortality rate of 2-15% was not significantly different from that of femoral vein ligation, but a lower rate for recurrent PE was reported. The optimal level of ligation was located immediately below the renal veins to prevent 69
Apollo Medicine, Vol.1 September 2004
Case Reports
thrombosis due to venous stasis between the interrupted IVC and the renal veins. However, 10-16% of these patients had immediate lower-extremity swelling.
insufficiency. Implanting and then explanting the temporary filter after 6 weeks has resulted in prevention of mortality as well as an anticoagulation free life.
In the 1960s, various methods of partially interrupting the flow in the IVC were developed to lessen the effect of venous stasis. The procedures provided emboli trapping with preservation of blood flow through the lumen. The procedures include suture plication and caval clips (Moretz clip, Miles clip, Adams-DeWeese clip). The rates for operative mortality and recurrent PE were similar to those of caval ligation, yet the rate for limb edema was reduced. Despite the fact that these procedures partially interrupted flow in the IVC, caval occlusion rates of 30-40% were reported.
The second patient with documented PE despite adequate anticoagulation was a classical indication for IVC filter placement. Again, a temporary filter has resulted in prevention of further PE and an anticoagulation free life after 4 months of therapy. Both the cases demonstrate the effectiveness of the temporary filters and a good quality of life afterwards. The main drawback of the temporary filters is the lack of long-term results and complication data of these filters. Till such data is available, the fourth generation IVC filters should be used very selectively and under close monitoring.
In 1967, the Mobin-Uddin umbrella filter was developed as a replacement for surgical ligation, caval plication, and caval clips and partially to interrupt the flow in the IVC and to prevent PE. Since then, several filters have been introduced. Currently, filters represent the standard of care when partial interruption of IVC flow is indicated to prevent the occurrence of PE. The classical indications for IVC filters are contraindication to anticoagulation or recurrent PE despite adequate anticoagulation [1,2]. Less frequent indications include prophylaxis and perioperative coverage.
REFERENCES 1. Vaughn BK, Knezevich S, Lombardi AV Jr, Mallory TH. Use of the Greenfield filter to prevent fatal pulmonary embolism associated with total hip and knee arthroplasty. J Bone Joint Surg Am 1989 Dec; 71(10): 1542-1548. 2. Wittenberg G, Kueppers V, Tschammler A, et al. Long-term results of vena cava filters: experiences with the LGM and the Titanium Greenfield devices. Cardiovasc Intervent Radiol 1998 May-Jun; 21(3): 225-229. 3. Thomas JH, Cornell KM, Siegel EL, et al. Vena caval occlusion after bird’s nest filter placement. Am J Surg 1998 Dec; 176(6): 598-600.
All IVC Filters have the potential to cause IVC thrombosis [3,4]. Further, patients with IVC filters require lifelong anticoagulation. Other uncommon complications of permanent filters include IVC perforation, filter migration etc. [5-8].
4. Starok MS, Common AA. Follow-up after insertion of Bird’s Nest inferior vena caval filters. Can Assoc Radiol J 1996 Jun; 47(3): 189-194.
Fourth generation IVC filters were developed to overcome the complication of IVC thrombosis as these filters can be removed after the period of greatest chances of occurrence of PE is over, usually six weeks. Further, as the filter is removable, patients do not require lifelong anticoagulation with its attendant expenses and complications. These filters are further classified as removable or retrievable. Difference is that the retrievable filters can be either left inside or removed depending on the continued indication for the filter. Removable filters have a tethering catheter and the filter must be removed within six weeks of insertion.
5. Athanasoulis CA, Kaufman JA, Halpern EF, et al: Inferior vena caval filters: review of a 26-year single-center clinical experience. Radiology 2000 Jul; 216(1): 54-66. 6. Awh MH, Taylor FC, Lu CT. Spontaneous fracture of a VenaTech inferior vena caval filter. AJR Am J Roentgenol 1991 Jul; 157(1): 177-178. 7. LaPlante JS, Contractor FM, Kiproff PM, Khoury MB. Migration of the Simon nitinol vena cava filter to the chest. AJR Am J Roentgenol 1993 Feb; 160(2): 385-386. 8. Teitelbaum GP, Jones DL, van Breda A, et al. Vena caval filter splaying: potential complication of use of the titanium Greenfield filter. Radiology 1989 Dec; 173(3): 809-814.
Patients of polytrauma or those requiring urgent surgery and also have DVT, require prophylactic coverage for prevention of PE as anticoagulation is contraindicated [9-12]. Such patients are ideally suited for the fourth generation IVC filters.
9. Gosin JS, Graham AM, Ciocca RG, Hammond JS. Efficacy of prophylactic vena cava filters in high-risk trauma patients. Ann Vasc Surg 1997 Jan; 11(1): 100-105. 10. Greenfield LJ, Proctor MC, Michaels AJ, Taheri PA. Prophylactic vena caval filters in trauma: the rest of the story. J Vasc Surg 2000 Sep; 32(3): 490-5; discussion 496-497.
Anticoagulation was contraindicated in the first patient due to recent head injury with concomitant intracranial hemorrhage. The DVT was extending to his IVC and hence, he had a real threat of developing life threatening PE. As the patient is a young man with a long life ahead of him, a conventional IVC filter would have meant possible IVC thrombosis with subsequent bilateral chronic venous Apollo Medicine, Vol.1 September 2004
11. Langan EM 3rd, Miller RS, Casey WJ 3rd, et al. Prophylactic inferior vena cava filters in trauma patients at high risk: followup examination and risk/benefit assessment. J Vasc Surg 1999 Sep; 30(3): 484-488. 12. Rogers FB, Shackford SR, Ricci MA, et al. Prophylactic vena cava filter insertion in selected high-risk orthopaedic trauma patients. J Orthop Trauma 1997 May; 11(4): 267-272. 70