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

The “Things We Do for No Reason” (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent “black and white” conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion. https://www.choosingwisely.org/

A nticoagulation is the cornerstone of acute venous thromboembolism (VTE) management. Nonetheless, the use of inferior vena cava (IVC) filters in addition to anticoagulation is increasing, with wide variation in practice patterns and a growing recognition of filter-related complications. Rigorous randomized controlled data demonstrating that IVC filters, particularly the increasingly commonly placed retrievable filters, provide a mortality benefit are sparse. Given our review of IVC filter use and the lack of evidence demonstrating that IVC filters provide a mortality benefit, we recommend using anticoagulation alone for stable medical service patients admitted with acute VTE. In nuanced cases, hospitalists should engage in multidisciplinary care to develop individualized treatment options.

A 65-year-old woman with a history of diabetes mellitus, metastatic breast cancer, and peptic ulcer disease presents to the Emergency Department for the evaluation of right thigh swelling, chest pain, and dyspnea after a transcontinental flight. Physical examination is notable for a pulse of 114 beats per minute, blood pressure of 136/93 mm Hg, respiratory rate of 14 breaths per minute, oxygen saturation of 95% on room air, and swelling of the right thigh. Computerized tomography imaging demonstrates multiple bilateral pulmonary emboli. Emergency department physicians begin anticoagulation and inform you that they have ordered the placement of a retrievable inferior vena cava (IVC) filter.

Acute venous thromboembolism (VTE) accounts for more than 500,000 hospitalizations in the United States each year.¹ Although the management of VTE centers around anticoagulation, the concurrent use of IVC filters has increased over the past several decades.² Several observational studies have attempted to quantify IVC filter usage and have shown that overall filter placement has increased at an impressive rate. Within two decades, the number of patients undergoing IVC filter placement has increased nearly 25 times from 2,000 in 1979 to 49,000 in 1999.² Recent Medicare data show that claims for IVC filter placement procedures have increased from 30,756 in 1999 to 65,041 in 2008.³ IVC filter placement rates are higher in the US than in other developed countries; one review projected that in 2012, the IVC filter placement rate in a given population in the US is 25 times higher than that in a similar population in Europe.⁴