Inferior vena cava filters: use or abuse?

Excerpt

Use of inferior vena cava filters (IVCFs) has increased exponentially over the last two decades. Although the insertion rates have risen universally, the current amount of filter usage varies significantly across different health systems, and it is estimated to be 25-fold superior in the USA than in Europe [1‐3]. Such huge expansion seems mainly related both to availability of the retrievable devices and to filter placements beyond absolute indications, for example primary prevention of life-threatening pulmonary embolism (PE) in patients at high risk for venous thromboembolism (VTE). However, solid evidence is lacking in this setting and guideline recommendations, mostly based on expert consensus, are rather inconclusive or conflicting [4‐7]. Furthermore, with regard to filter placement as a measure of secondary prophylaxis in VTE patients, two randomized controlled trials (RCTs) fail to demonstrate that neither permanent nor retrievable filters can impact VTE-related mortality when used in addition to anticoagulant therapy [8, 9]. Therefore, current clinical practice guidelines recommend using IVCFs only for acute treatment of proximal lower extremity deep venous thrombosis (DVT) or PE in patients with an absolute contraindication to anticoagulation [10‐13], such as patients with active uncontrollable bleeding, high risk of major bleeding or requiring urgent major surgery. Findings from a large observational study support this approach, showing that IVCF use significantly reduces the short-term risk of death only among patients with acute VTE who have a contraindication to anticoagulation because of active bleeding [14]. On the other hand, results of a recent meta-analysis including five RCTs and six prospective observational studies in the setting of primary or secondary prevention of PE confirm that IVCF placement is associated with an overall 50% lower incidence of subsequent PE at the cost of approximately a 70% increase in the risk of subsequent DVT and no significant effect on overall mortality [15]. …