IVC Filters: Rate of Insertion, Indications, Effects on Prognosis, Evidence Basis for Current Practices. Paul D. Stein, MD

Transcription

1 IVC Filters: Rate of Insertion, Indications, Effects on Prognosis, Evidence Basis for Current Practices Paul D. Stein, MD Professor Department of Osteopathic Medical Specialties College of Osteopathic Medicine Michigan State University, East Lansing, Michigan

2 Open Procedures John Hunter Femoral vein ligation 1784 Bottini IVC ligation 1893 Homans Femoral vein ligation 1929 Fatal recurrent PE 5-8% Oschner, DeBakey IVC ligation 1943 Operative mortality 14% Recurrent PE 6% Fatal recurrent PE 2% Venous insufficiency 33% DeWeese, Hunter IVC suture plication 1958 Operative mortality 10% IVC occlusion 31% Moretz clip Adams/DeWesse clip Miles clip IVC clip Operative mortality 12% Recurrent PE 4% Fatal recurrent PE 1.7% IVC occlusion 33% Greenfield LJ. Arch Surg 1992;127: Jones TK et al. Ann Thorac Surg 1986;42:48-55

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5 Permanent Filters Mobin Uddin umbrella Greenfield stainless steel filter Greenfield titanium filter 28F (9.3 mm) sheath 12F (4 mm) sheath 1969 Fatal recurrent PE <1% Occlusion 60% 1973 Occlusion 2% with or without anticoagulants Insertion site thrombosis 30%-41% 1989 Bird s Nest 1984 Venatech/LGM 1988 Simon Nitinol 1989 Greenfield LJ. Arch Surg 1992;127:

6 Mobin-Uddin Umbrella 1969

7 Greenfield Filter (1973)

8 Lazar J. Greenfield

9 Permanent Filters Vena Tech LGM

10 Retrievable Filters Recovery July 2003 Gunther Tulip Oct 2003 OptEase March 2004

11 Retrievable Filters Optease IVC Filter - Günther Tulip Celect IVC Filter From Cook Medical Filtre Veine Cave ALN

12 No. of VC Filters In Patients with PE 50,000 40,000 30,000 20,000 10,000 0 NHDS ( ) Retrievable Approved Year Updated from: Stein et al. AJM; 2011;124:

13 Indications for IVC Filter in PE Definite Contraindication to anticoagulation Recurrent PE despite anticoagulation Possible Severe PE in whom recurrence may be fatal PE with continuing DVT by ultrasound

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15 Nationwide Inpatient Sample (NIS) Healthcare Cost and Utilization Project (HCUP) Agency for Healthcare Research and Quality (AHRQ) Samples approx 20% of US nonfederal, short-term hospitals About 1000 hospitals 5 to 8 million hospital stays HCUP Nationwide Inpatient Sample

16 The Nationwide Inpatient Sample ,110,320 PE Stein et al. AJM; 2012;125:

17 In-hospital All-cause Mortality (%) Unstable PE VC Filter No VC Filter Anticoagulants* Thrombolytics** Embolectomy*** *Stein et al. AJC 2010:106: **Stein et al. AJM 2012;125: ***Stein & Matta. AJM 2012;125:

18 Stable PE High Risk Stein et al. AJM; 2012;125: Stein & Matta. AJM 2012;125:

19 Stable PE Low Risk In-hospital All-cause Mortality (%) VC Filter 7.9 No VC Filter Stein et al. AJM; 2012;125:

20 Low Risk Stable PE with DVT n= 721, In-hospital All-cause Mortality (%) VC Filter 5.3 No VC Filter Stein et al. AJM; 2012;125:

21 Unstable Patients PE attributable In-hospital Case Fatality Rate Stein et al. AJM; 2012;125:

22 Embolectomy PE attributable In-hospital Case Fatality Rate Stein et al. AJM; 2012;125:

23 Stable Low Risk No Thrombolytic Therapy & No Embolectomy PE attributable In-hospital Case Fatality Rate Stein & Matta (unpublished data)

24 2,110,320 PE ( ) Stable No Lytics 95.3% Unstable 3.4% Stable and Lytics 1.3% Stein et al. AJM; 2012;125:

25 Proportion That Received Filters Stein et al. AJM; 2012;125:

26 Distribution of Vena Cava Filters n= 325,730 ( ) Stable Low Risk 91.4% Unstable 6.0% Stable High Risk 2.6% Stein et al. AJM; 2012;125:

27 Stable Patients With PE 50,000 Number of VC Filters Inserted 40,000 30,000 20,000 10,000 Retrievable Approved Years Stein & Matta (Unpublished)

28 Unstable PE n= 72,240 No IVC Filter 73% IVC Filter 27% Stein et al. AJM; 2012;125:

29 Retrievable Filter Complications (n=284) IVC or filter thrombosis 6.0% Filter migration, often asymptomatic 3.9% Filter tilt 7.7% Leg edema, moderate 0.7% Total 18.3% Stein et al Am J Cardiol 2004; 94:

30 Embolized OptEase IVC Filter

31 Retrievable Filter Complications (n=144) IVC Thrombosis 2.1% New DVT 4.9% Filter Migration 1.3% Total 8.3% Janjua et al. J Invasive Cardiol 2010; 22:

32 Half of retrievable IVC filter complications occurred after 3 months Janjua et al. J Invasive Cardiol 2010; 22:

33 Retrievable IVC Filters n= 3,230 Attempted Retrival 41% Janjua et al. J Invasive Cardiol 2010; 22:

34 Indications for Retrievable IVC Filter with PE Based on In-Hospital Case-Fatality Rate Data, Nationwide Inpatient Sample (n=2,110,320 PE) Unstable patients (shock or on ventilatory support). Stable high-risk patients (administered thrombolytic therapy or embolectomy) Stein et al. AJM; 2012;125: Stein & Matta. AJM 2012;125:

35 Pulmonary Embolism Routine IVC filter insertion in unstable patients or stable high-risk patients would save 1800 lives/year

36 Pulmonary Embolism Avoidance of unnecessary IVC filters in stable low-risk patients would save $133 million/year