Inferior Vena Cava Filter Placement in Patients with Venous Thromboembolism without Contraindication to Anticoagulation

The identification of associated adverse events further favor the judicious use of IVC filters. A retrospective review of the long-term complications of IVC filters based on imaging data showed a 14% fracture rate, 13% IVC thrombosis rate, and a 48% perforation rate.¹⁴ Multiple studies have shown that the associated complication rates of retrievable filters are higher than those of permanent filters; such an association is concerning given that retrievable filter usage exceeds permanent filter usage.^14,15 The increase in retrievable filter usage is likely attributable to their attractive risk-benefit calculation. In theory, retrievable IVC filters should be perfect for patients who have conditions that increase VTE risk but create temporary contraindications, such as trauma or major surgery, to anticoagulation. However, anticoagulation is preferred over IVC filters in the long term because the complication rates of IVC filters increase with dwell time.¹⁶ Given the reports of adverse events and concern that IVC filters are not appropriately removed, the Food and Drug Administration recommends removing retrievable IVC filters once the risk of filters outweighs the benefits, which appears to be 29-54 days after implantation.¹⁷ However, successful retrieval rates are low, both because of the low rates of removal attempts and because of the interference of complications, such as embedded or thrombosed filters, with removal.^10,18 As an example, in a retrospective review of all patients who received an IVC filter at an academic medical center over the period of 2003-2011, nearly 25% of patients were discharged on anticoagulation after IVC filter placement.¹⁰ This suggests that their contraindication to anticoagulation and need for IVC placement have passed by the time of discharge. Nevertheless, clinicians attempted filter retrieval in only 9.6% of these patients, representing a significant missed opportunity of treatment with anticoagulation rather than IVC filters.¹⁰

Factors such as filter plan documentation, hematology involvement, patient age ≤70 years, and establishment of dedicated IVC filter clinics are correlated with improved rates of filter removal; these correlations emphasize the importance of a clear follow-up plan in the timely removal of these devices.^18,19

IVC filter placement is inappropriate in the vast majority of patients with VTE who can be anticoagulated. However the ACCP does acknowledge that a small subset of patients – specifically, those with severe or massive PE – may fall outside this guideline.⁷ Clinicians fear that these patients have low cardiopulmonary reserve and may experience hemodynamic collapse and death with another “hit” from a recurrent PE. This recommendation is consistent with the evidence that in unstable patients with PE, IVC filter placement is associated with decreased in-hospital mortality.²⁰ Data remain limited for this situation, and the decision to place an IVC filter in anticoagulated but unstable patients is an individualized one.

In stable patients admitted to the medical service with VTE and who can be anticoagulated, there is little evidence that placement of an IVC filter will improve short- or long-term mortality. Hospitalists should anticoagulate these patients with a vitamin-K antagonist, heparin product, or novel oral anticoagulants.