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Optional inferior vena caval filters: where are we now?

  • Vascular-Interventional
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Abstract

With the advent of newer optional/retrievable inferior vena caval filters, there has been a rise in the number of filters inserted globally. This review article examines the currently available approved optional filter models, outlines the clinical indications for filter insertion and examines the expanding indications. Additionally, the available evidence behind the use of optional filters is reviewed, the issue of anticoagulation is discussed and possible future filter developments are considered.

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Authors and Affiliations

  1. Department of Academic Radiology, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland

    A. N. Keeling & M. J. Lee

  2. Department of Radiology, University of California, San Diego, CA, 92103-8756, USA

    T. B. Kinney

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  1. A. N. Keeling
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  2. T. B. Kinney
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  3. M. J. Lee
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Correspondence to M. J. Lee.

Appendices

Appendix 1

Permanent caval filter indications modified from Grassi et al. [43]

ABSOLUTE

  • Contraindication to anticoagulation with proven PE or significant DVT

  • Anticoagulation failure (10%):

    • Breakthrough PE

    • Inability to achieve adequate anticoagulation

  • Anticoagulation complication:

    • Major hemorrhage, approx. 10–26% risk

    • Heparin-induced thrombocytopenia (HITS), 5–15%

    • Heparin-induced osteoporosis

    • Heparin-induced skin necrosis

RELATIVE

  • IVC/iliofemoral thrombus, free floating DVT with no PE

  • Progression/extension of DVT despite adequate anticoagulation

  • Anticoagulation therapy problematic in patient with PE: syncope/unsteady gait/poor compliance

  • Massive PE with residual DVT in patient at risk for further PE

  • Recurrent PE with filter in place (place 2nd filter)

  • DVT with severe cardiopulmonary disease

  • Recent DVT undergoing major surgery

  • Pregnancy with proximal DVT (may need supra-renal placement)

  • DVT thrombolysis (controversial) [64]

Appendix 2

Contraindications for permanent caval filter placement modified from Grassi et al. [43]

ABSOLUTE

  • Young patient with long life expectancy

  • Obstructive thrombus along all access routes

  • Early pregnancy

RELATIVE

  • Uncorrectable severe coagulopathy

  • Bacteraemia/untreated infection

Appendix 3

Clinical indications for optional filter placement

  • Same as permanent [45].

    However, in selected cases, retrievable filters maybe used for relative indications, e.g.:

    1. 1.

      Time-limited indication for caval filtration, recent or near-term surgery with DVT [64]

    2. 2.

      Prophylaxis: high risk of thromboembolism [52]

      • Trauma, major (extensive pelvic/long bone fractures)

      • Spinal paralysis/traumatic brain injury-prolonged immobile.

      • Major surgery with significant VTE risk

        • Bariatric surgery

        • Hypercoagulable states

        • Remote history of DVT/PE

      • Advanced malignancy

      • Venous reconstructions

    3. 3.

      Free floating DVT [64] or large burden of proximal DVT

    4. 4.

      PE with marginal cardiopulmonary reserve [64]

Appendix 4

Optimal filter characteristics [62]

  • Small calibre, flexible delivery device

  • High efficacy in trapping emboli, without impeding blood flow

  • Secure fixation, without injuring vessel wall

  • Repositioning/removal possiblea

  • MR compatible

  • Low cost

  • Nonthrombogenic

  • No associated mortality, minimal morbidity

    aNew feature of optional/retrievable devices, all other features permanent and retrievable

Appendix 5

Criteria for successful placement [89]

  • Delivery system advanced to placement level

  • Ideal position: apex of filter at or just below level of renal veins

  • Filter deployed and fixed at intended position

    • No migration/embolisation

    • No IVC penetration

  • Filter configuration conferred protection from PE

    • Complete opening

    • No additional device needed

    • No/minimal tilt <15°

Early complications [43]

  • IVC penetration (0–41%, but clinically significant penetration rare)

  • Access site thrombosis (0–6%, threshold = 1%)

  • Insertion complications (arterial puncture, arteriovenous fistula, pneumothorax, air embolism, haematoma, infection, haemorrhage, 5–50%)

  • Death (0.12%, threshold <1%)

Late complications [43]

  • Breakthrough PE (0.5–6%, threshold 5%)

  • Recurrent DVT (20.8%, permanent) [8]

  • Thrombotic occlusion of IVC (2–30%, threshold 10%)

  • Filter fracture and embolisation (2–5%, threshold 2%)

  • Migration (0–18%)

  • Vena caval stenosis

  • Venous insufficiency (5–59%, at 6 years)

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Keeling, A.N., Kinney, T.B. & Lee, M.J. Optional inferior vena caval filters: where are we now?. Eur Radiol 18, 1556–1568 (2008). https://doi.org/10.1007/s00330-008-0923-z

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