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PurposeTo compare the Celect and Denali filters in terms of complex filter retrieval and indwelling complications after a 2-month indwelling time.Materials and MethodsIn this prospective, randomized trial, 153 subjects were assessed for eligibility between May 2016 and July 2018. A total of 136 participants were randomly assigned to receive either Celect (n = 68) or Denali (n = 68) filter placement in the infrarenal inferior vena cava. Tilt angles at placement and retrieval and rates of overall filter retrieval, indwelling complication, and complex retrieval were compared.ResultsOf 136 participants (mean age, 62 ± 12.8 years, 55 male), 24 (17.6%) were lost to follow-up. The mean indwelling time of filter was 60.4 ± 7 days and there was no significant difference in the baseline characteristics between the two groups. Filter retrieval was successful in all participants (112/112, 100%). Significantly higher rates of filter tilt > 15° (n = 8) and strut penetration (n = 14) were found with the Celect filter than with the Denali filter (1 significant tilt and 1 penetration) (P = 0.033 and 0.001, respectively). No filter fractures were observed and there was no significant difference in tip embedment, filter fracture, filter migration, or mean fluoroscopy times. There were 3 cases of complex retrieval (1 for Denali vs. 2 for Celect, P = 0.500), for which the loop-snare technique was used.ConclusionDenali filters demonstrated significantly lower rates of tilt angle > 15° and strut penetration. However, there was no significant difference in the complex filter retrieval rate between the Celect and Denali filters.

Background The benefit of adding a vena cava filter to anticoagulation in treating cancer patients with venous thromboembolism remains controversial. We initiated this study as the first prospectively randomized trial to evaluate the addition of a vena cava filter placement to anticoagulation with the factor Xa inhibitor fondaparinux sodium in patients with cancer. Methods Sixty-four patients with deep vein thrombosis (86 %) and/or pulmonary embolism (55 %) were randomly assigned to receive anticoagulation with fondaparinux sodium with or without a vena cava filter. Endpoints included rates of complications by treatment arm, recurrent thromboembolism, complete resolution of thromboembolism, and survival rates. Results No patient had a recurrent deep vein thrombosis; two (3 %) patients had new pulmonary emboli, one in each randomized cohort. Major bleeding occurred in three patients (5 %). Two patients on the vena cava filter arm (7 %) had complications from the filter. Median survivals were 493 days in the anticoagulation only arm and 266 days for anticoagulation + vena cava filter ( p  < 0.57). Complete resolution of venous thromboembolism occurred in 51 % of patients within 8 weeks of initiating anticoagulation. Conclusions No advantage was found for placement of a vena cava filter in addition to anticoagulation with fondaparinux sodium in terms of safety, recurrent thrombosis, recurrent pulmonary embolism, or survival in this prospective randomized trial evaluating anticoagulation plus a vena cava filter in cancer patients. Favorable complete resolution rates of thrombosis were observed on both study arms.

PurposeTo investigate the long-term outcomes of using vena cava filters to prevent symptomatic pulmonary embolism (PE) in major trauma patients who have contraindications to prophylactic anticoagulation.MethodsThis was an a priori sub-study of a randomized controlled trial (RCT) involving long-term outcome data of 223 patients who were enrolled in Western Australia. State-wide clinical information system, radiology database and death registry were used to assess long-term outcomes, including incidences of venous thromboembolism, venous injury and mortality beyond day-90 follow-up.ResultsThe median follow-up time of 198 patients (89%) who survived beyond 90 days was 65 months (interquartile range 59–73). Ten patients (5.1%) died after day-90 follow-up; and four patients developed venous thromboembolism, including two with symptomatic PE, all allocated to the control group (0 vs 4%, p = 0.043). Inferior vena cava injuries were not recorded in any patients. The mean total hospitalization cost, including the costs of the filter and its insertion and removal, to prevent one short- or long-term symptomatic PE was A$284,820 (€193,678) when all enrolled patients were considered. The number of patients needed to treat (NNT = 5) and total hospitalization cost to prevent one symptomatic PE (A$1,205 or €820) were, however, substantially lower when the filter was used only for patients who could not be anticoagulated within seven days of injury.ConclusionLong-term complications related to retrievable filters were rare, and the cost of using filters to prevent symptomatic PE was acceptable when restricted to those who could not be anticoagulated within seven days of severe injury.

Objectives Inferior vena cava filter (IVCF) placement is indicated when there is a deep vein thrombosis and/or a pulmonary embolism and a contraindication of anticoagulation. Due to the increased risk of recurrent deep venous thrombosis when left in place, IVCF removal is indicated once anticoagulant treatment can be reintroduced. However, many temporary IVCF are not removed. We aimed to analyze the removal rate and predictors of filter non-removal in a university hospital setting. Methods We collected all the data of consecutive patients who had a retrievable IVCF inserted at the Saint-Etienne University Hospital (France) between April 2012 and November 2019. Rates of filter removal were calculated. We analyzed patient characteristics to assess factors associated with filter non-removal, particularly in patients without a definitive filter indication. The exclusion of this last category of patients allowed us to calculate an adjusted removal rate. Results The overall removal rate of IVCF was 40.5% (IC 95% 35.6–45.6), and the adjusted removal rate was 62.9 % (IC 95% 56.6–69.2%). No major complications were noted. Advanced age ( p < 0.0001) and cancer presence ( p < 0.003) were statistically significant predictors of patients not being requested to make a removal attempt. Conclusions Although most of the filters placed are for therapeutic indications validated by scientific societies, the removal rate in this setting remains suboptimal. The major factors influencing IVCF removal rate are advanced age and cancer presence. Key Points • Most vena cava filters are placed for therapeutic indications validated by scientific societies. • Vena cava filter removal rates in this setting remain suboptimal. • Major factors influencing IVCF removal rate are advanced age and cancer presence.

Objective The utilization of inferior vena cava filters (IVCF) has evolved over time. We explored the indications, complications, and outcomes of patients undergoing IVCF placement. Methods We performed a single institution, retrospective review of CPT codes for IVCF placement between 2018 and 2022. Patient characteristics and location were collected. Indications for IVCF placement were categorized. Procedural details were noted and immediate and long-term complications. IVCF removal, total IVCF days, and removal complication were analyzed. Overall mortality, cause of death, and if death occurred the same admission were included. Results An analysis of 347 patients undergoing IVCF placement was performed. Mean patient age was 65 years-old (+/– 16 years), 167 patients (48%) were male, and 28% with current malignancy at time of IVCF placement. 8% of patients had prior DVT, 22% prior PE, 3% prior IVCF. 84% were inpatient on floors, 12% in the ICU, and 4% ambulatory. IVCF were typically placed prior to a surgery with contraindication to anticoagulation (41%), gastrointestinal bleed (15%), failure of anticoagulation (10%), brain bleed (9%), and during venous thrombectomy (8%). The operations included spine procedures (17%) other orthopedic procedures (19%), abdominal procedures (32%), and bariatric interventions (6%). Retrievable filters were placed in 99% of patients. Immediate postoperative complications occurred in 6% of patients. Worsening edema within the same admission, DVT, and filter strut migration in 12% of patients. 29% of patients underwent IVCF removal, of which 10 were unsuccessful and resulted in the filter remaining in place despite an attempt to retrieve it. All-cause mortality at any time point was 21%, with 42% of mortalities occurring during the same admission as the IVC filter placement. Of these mortalities, 4 (1.2%) were secondary to VTE complications. Mortality at 30 days was 8.3% and at 1 year was 15.7%. Death during the admission of IVC filter placement was positively correlated with older age (p = 0.010) and current malignancy was associated with higher mortality (OR 2.2, p < 0.001). Spine surgery patients were 3.8 times more likely to undergo IVCF removal (p = 0.002) as well as patients undergoing ambulatory IVCF placement (p = 0.001). Conclusion IVCF placement has utility in younger patients undergoing elective operations, particularly spine procedures, with contraindication to anticoagulation. Older patients and those with current malignancy are unlikely to benefit given the higher mortality.

Background The likelihood of inferior vena cava filter penetration increases with prolonged implantation. Despite the generally low risk associated with an ALN inferior vena cava filter (ALN IMPLANTS CHIRURGICAUX, Ghisonaccia, France), we present a case in which penetration occurred 43 days after implantation. At present, no consensus is available on the standardized approach for filter removal in such cases. In this report, we describe a secure and reliable method involving surgical access to the abdomen and transcatheter filter removal while directly observing the inferior vena cava. Case presentation A 72-year-old Japanese male patient presented to our institution with complaints of pain and subsequent edema in his left lower limb. Contrast-enhanced computed tomography (CT) revealed thrombi spanning from the left common iliac vein to the external iliac vein, as well as in the right pulmonary artery and inferior vena cava. Upon admission, we promptly inserted an ALN inferior vena cava filter and initiated anticoagulation therapy. Follow-up contrast-enhanced CT performed on day 13 after filter implantation demonstrated disappearance of thrombi in the pulmonary artery and inferior vena cava, and the patient was discharged on day 14 following implantation. However, due to the presence of a residual thrombus in the left common iliac vein, we decided against removing the inferior vena cava filter at that time. Contrast-enhanced CT performed on day 43 after implantation revealed signs suggestive of filter penetration with extension into the abdominal aorta, necessitating immediate filter removal. To address this, we performed transcatheter removal of the filter through open abdominal surgery. Conclusions An ALN inferior vena cava filter, initially considered to pose a low risk of penetration, unexpectedly exhibited penetration during the brief indwelling period. Although a definitive consensus concerning the optimal removal approach for such cases remains elusive, our experience indicates that transcatheter removal via laparotomy represents a secure and reliable method.

Purpose This study was designed to assess the incidence, magnitude, and impact upon retrievability of vena caval perforation by Günther Tulip and Celect conical inferior vena cava (IVC) filters on computed tomographic (CT) imaging. Methods Günther Tulip and Celect IVC filters placed between July 2007 and May 2009 were identified from medical records. Of 272 IVC filters placed, 50 (23 Günther Tulip, 46%; 27 Celect, 54%) were retrospectively assessed on follow-up abdominal CT scans performed for reasons unrelated to the filter. Computed tomography scans were examined for evidence of filter perforation through the vena caval wall, tilt, or pericaval tissue injury. Procedure records were reviewed to determine whether IVC filter retrieval was attempted and successful. Results Perforation of at least one filter component through the IVC was observed in 43 of 50 (86%) filters on CT scans obtained between 1 and 880 days after filter placement. All filters imaged after 71 days showed some degree of vena caval perforation, often as a progressive process. Filter tilt was seen in 20 of 50 (40%) filters, and all tilted filters also demonstrated vena caval perforation. Transjugular removal was attempted in 12 of 50 (24%) filters and was successful in 11 of 12 (92%). Conclusions Longer indwelling times usually result in vena caval perforation by retrievable Günther Tulip and Celect IVC filters. Although infrequently reported in the literature, clinical sequelae from IVC filter components breaching the vena cava can be significant. We advocate filter retrieval as early as clinically indicated and increased attention to the appearance of IVC filters on all follow-up imaging studies.

Intimal hyperplasia (IH) is a major risk for inferior vena cava (IVC) filter retrieval failures and potentially fatal vascular trauma to the IVC or caudal vena cava (CVC) wall post-retrieval. However, demonstrating neointimal formation in humans presents challenges due to the difficulty in obtaining quantitative pathological evidence from the IVC. Here, it was hypothesized that the mismatch between the diameter of the CVC and the filter would correlate with increased IH. Radial force (RF) exerted by filter struts at various CVC diameters was tested in vitro. In vivo, Bama miniature swine were randomly fitted with IVC filters of 32 mm–20 mm diameter, and a three-dimensional digital subtraction angiography model was used to determine the oversizing ratio (OR). After dwelling times of 2, 3, and 4 weeks, the macroscopic CVC wall and intima in the areas adjacent to IVC filter struts were observed. The proliferation and thickness of IH and presentations of vascular smooth muscle cells (VSMCs) were evaluated. Masson trichrome staining was used to determine the production of collagen fiber. The RFs of the IVC filter consistently increased with the OR, suggesting a correlation coefficient ( R 2  = 0.74, p  < 0.001). Notable response in the CVC wall after filter placement, characterized by vessel wall injury, VSMCs dedifferentiation, proliferation, and extracellular matrix secretion, which tended to increase and change over time. Increased ORs and dwelling time correlated linearly with greater IH thickness (adjusted R 2  = 0.456, p  < 0.001). Moreover, restricted cubic splines (RCS) analysis revealed that ORs had a non-linear relationship with the IH thickness after adjusting for the IVC filter dwelling time (nonlinear p  = 0.047, p  < 0.001). A linear correlation was also noted between increased ORs and dwelling time with the collagen area fraction (adjusted R 2  = 0.860, p  < 0.001). Furthermore, RCS indicated a consistently higher risk of increased collagen fiber content when the OR exceeded 100.75% (nonlinear p  = 0.047, p  < 0.001). IH developed in response to CVC injury, VSMCs proliferation, and secretion of the extracellular matrix collagen fiber. RFs increased with increased ORs. Increased ORs and dwelling time correlate linearly with greater IH thickness and increased production of collagen fiber.

BACKGROUND:Public awareness of inferior vena cava (IVC) filter-related controversies has been elevated by the Food and Drug Administration (FDA) safety communication in 2010. OBJECTIVES:To examine population level trends in IVC filter utilization, complications, retrieval rates, and subsequent pulmonary embolism (PE) risk. DESIGN:A retrospective cohort study. SUBJECTS:Patients receiving IVC filters during 2005–2014 in New York State. MEASURES:IVC filter-specific complications, new PE occurrences and IVC filter retrievals were evaluated as time-to-event data using Kaplan-Meier analysis. Estimated cumulative risks were obtained at various timepoints during follow-up. RESULTS:There were 91,873 patients receiving IVC filters between 2005 and 2014 in New York State included in the study. The average patient age was 67 years and 46.6% were male. Age-adjusted rates of IVC filter placement increased from 48 cases/100,000 in 2005 to 52 cases/100,000 in 2009, and decreased afterwards to 36 cases/100,000 in 2014. The estimated risks of having an IVC filter-related complication and filter retrieval within 1 year was 1.5% [95% confidence interval (CI), 1.4%–1.6%] and 3.5% (95% CI, 3.4%–3.6%). One-year retrieval rate was higher post-2010 when compared with pre-2010 years (hazard ratio, 2.70; 95% CI, 2.50–2.91). Among the 58,176 patients who did not have PE events before or at the time of IVC filter placement, the estimated risk of developing subsequent PE at 1 year was 2.0% (95% CI, 1.9%–2.1%). CONCLUSIONS:Our findings suggest that FDA communications may be effective in modifying statewide clinical practices. Given the 2% observed PE rate following prophylactic IVC filter placement, large scale pragmatic studies are needed to determine contemporary safety and effectiveness of IVC filters.

PurposeAlthough recommended placement of IVC filters is with their tips positioned at the level of the renal vein inflow, in practice, adherence is limited due to clinical situation or IVC anatomy. We seek to evaluate the indwelling and retrieval complications of IVC filters based on their specific position within the infrarenal IVC.Materials and MethodsRetrospective, single institution study of 333 consecutive infrarenal vena cava filters placed by interventional radiologists in patients with an average age of 62.2 ± 15.7 years was performed between 2013 and 2015. Primary indication was venous thromboembolic disease (n = 320, 96.1%). Filters were classified based on location of the apex below the lowest renal vein inflow on the procedural venogram: less than 1 cm (n = 180, 54.1%), 1–2 cm (n = 96, 28.8%), and greater than 2 cm (n = 57, 17.1%). Denali (n = 171, 51.4%) and Celect (n = 162, 48.6%) filters were evaluated. CT follow-up, indwelling complications, and retrieval data were obtained.ResultsFollow-up CT imaging performed for symptomatic indications occurred for 38.3% of filters placed < 1 cm below the lowest renal vein, 27.1% of filters placed 1–2 cm, and 36.8% placed > 2 cm (p = .16). There was no difference in caval strut penetration, penetration of adjacent viscera, time to penetration, filter migration, or tilt (p = .15, .27, .41, .57, .93). No filter fractures occurred. There was no difference in the incidence of breakthrough PE or complex filter retrieval (p = .83, .59). Only one retrieval failure occurred.ConclusionsThis study suggests filter apex location within the infrarenal IVC, including placement > 2 cm below the level of the renal vein inflow, is not associated with differences in indwelling or retrieval complications.Level of evidenceLevel 3 non-randomized controlled follow-up study.