Inferior Vena Cava Filters- Are they Followed up? By Dr Nathalie van Havre Dr Chamica Wijesinghe Dr Kieren Brown

Transcription

1 Inferior Vena Cava Filters- Are they Followed up? By Dr Nathalie van Havre Dr Chamica Wijesinghe Dr Kieren Brown

2 Introduction Trousseau (1868) first described interruption to inferior vena cava (IVC) to prevent pulmonary embolism Bottini (1893) Performed the first filter insertion (1) Transcutaneous placement of Filters were done in 1967 (Mobin Uddin filter) (2) 1 Becker DM, Philbrick JT, Selby JB. Inferior vena cava filters. Indications, safety, effectiveness. Arch Intern Med. 1992;152(10): Mobin-Uddin K, Smith PE, Martinez LD, et al. A vena cava filter for the prevention of Pulmonary embolism. Surg Forum 1967; 18:209.

3 Indications There are no definitive guidelines to the use of IVC filters Generally used when Absolute contraindication to therapeutic anticoagulation Failure of anticoagulation when there is acute proximal venous thrombosis Also used in Prophylactic placement in those undergoing spinal, neurosurgical, bariatric surgery Traumatic injuries Chung J, Owen RJ. Using inferior vena cava filters to prevent pulmonary embolism. Can Fam Physician. 2008;54(1):49-55 Crowther MA. Inferior vena cava filters in the management of venous thromboembolism. Am J Med. 2007;120(10 Suppl 2):S13 S17

4 IVC Filters Non Retrievable filters Retrievable Filters

5 Complications The incidence of complications related to IVC filter placement is 4% to 11%. Deep Vein thrombosis at site of insertion Filter migration/embolization Filter erosion through IVC wall IVC thrombosis/obstruction Filter Fracture Recurrent DVT post phlebitic syndrome Joels CS, Sing RF, Heniford BT. Complications of inferior vena cava filters. Am Surg 2003; 69:654 Streiff MB. Vena caval filters: a comprehensive review. Blood. 2000;95(12):

6 Mater Adult Hospital

7 Perioperative Medicine at the Mater Hospital Established since 2010 Comprise of a Consultant Physician 2 Perioperative Medical Registrars Medical Resident

8 Perioperative involvement Local Orthopaedic Urology Gynae oncology Plastic surgery General surgery ICU transfers Urology Out reach Elective Urgent POM Pre admission clinic Chart review Perioperative period Communication with GP post discharge

9 Methodology Retrospective study on patients with IVC filter insertion done at Mater adult Hospital Brisbane Total of 40 patients Time period Data collected on Indication for insertion Follow up post insertion Removal of retrievable IVC Anticoagulation Complications Obtained Ethics Approval

10 Use at Mater Adult Hospital Indications Indication Acute Haemorrhage while on anticoagulation for VTE Number of Patients 15 Perioperative VTE where anticoagulation was contraindicated 12 High risk patients for perioperative VTE 2 Recurrent VTE despite anticoagulation 8 Permanent contraindication for anticoagulation for VTE 2 Other 1

11 Indications 29 patients had IVC filters inserted for temporary indications. (72.5%) 19 of the 24 retrievable IVC filters were inserted for temporary reasons (79%)

12 Types of Filters Used Non retrievable filters 14 (35%) Birds nest filter Greenfield Trap eaze Nitinol Retrievable filters 24 (60%) Gunther tulip Bard G2x 6 FG optease IVC Unknown 2 (5%)

13 Gunther Tulip

14 Bard G2x

15 Follow up post IVC filter insertion Follow up Number of patients % Specialist out patient clinic in 3/12 IVC filter not discussed Specialist out patient clinic in 3/12 IVC filter discussed Palliative care No follow up 4 10

16 Removal of IVC Only 21% of retrievable IVC filters were removed (5 patients)

17 Complications documented at MAH 2 episodes documented Recurrent PE despite IVC filter and anticoagulation Recurrent Bilateral DVT and IVC thrombosis. (failed attempt of removing the filter)

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19 Anticoagulation post IVC filter If an IVC filter is placed and the anticoagulant contra-indication resolves, anticoagulation should be resumed Becker DM, Philbrick JT, Selby JB. Inferior vena cava filters. Indications, safety, effectiveness. Arch intern Med. 1992;152(10):

20 Anticoagulation Anticoagulation 32 (80%) No anticoagulation 8 (20%) 5 were palliative care patients. Type of anticoagulation Warfarin 21 Therapeutic clexane 9 Prophylactic clexane - 2

21 Conclusion 72.5% had IVC filters for temporary indications. 52.5% of patients were either not followed up post IVC filter insertion or did not have a discussion regarding removal. Only 21% of retrievable IVC filters were removed Majority of patients were on effective long term anticoagulation 2 Documented complications of IVC filter (5%)

22 Discussion How do we optimize IVC filter management post insertion? Filter Registry (1) 1 Rogers FB, Shackford SR, Miller JA, Wu D, Rogers A, Gambler A Improved recovery of prophylactic inferior vena cava filters in trauma patients: The results of a dedicated filter registry and critical pathway for filter removal. Trauma Acute Care Surg Feb;72(2):381-4.

23 Acknowledgement Radiology Department for supply of list of IVC filter placements Dr Huong Huynh for assistance with data collection

24 THANK YOU!