23 – What are the indications for use of an IVC filter in patients undergoing orthopaedic procedures?

23 – What are the indications for use of an IVC filter in patients undergoing orthopaedic procedures?

Justin Kleiner, Paul Tornetta III.

Response/Recommendation: Inferior vena cava (IVC) filters may be considered for patients who have a high risk of venous thromboembolism (VTE) and in whom chemical anticoagulation is contraindicated. IVC filters should not be used on a routine basis for deep venous thrombosis (DVT) prophylaxis if chemical prophylaxis is available.

Strength of Recommendation: Low.

Rationale: VTE is a significant concern in patients undergoing orthopaedic procedures. VTE may result in morbidity and mortality through pulmonary embolism (PE), post-thrombotic syndrome, and symptomatic DVT1–6. Without anticoagulation, risk of VTE after orthopaedic surgery has been estimated from 40% – 80%7,8. Anticoagulation protocols are designed to balance the benefits of reducing these complications with the risks of bleeding. In patients with contraindication to pharmacologic anticoagulation or particularly high risk of VTE, orthopaedic surgeons may consider the prophylactic use of IVC filter.

For most patients, the rate of PE after orthopaedic surgery is low, estimated at approximately 0.5%9–13. Many comorbidities are known to increase the risk of VTE, including advanced age, cancer, obesity, Glasgow coma scale (GCS) < 8, and multiple long bone fractures10,14–22. The risk of VTE is higher still in patients with prior history of VTE or familial clotting disorders23,24. In these high-risk groups, VTE risk may approach 10 – 15%, with 5% developing PE after orthopaedic procedures24.

In nonrandomized trials, IVC filters have proven effective in reducing the risk of PE in high-risk patients. In patients with prior VTE undergoing elective arthroplasty, IVC filter reduced the risk of PE from 5.5% to 0.8%24. Similarly, in a group of high-risk spine surgery patients, defined as fusions > 5 levels, anesthesia time > 8 hours, and prolonged immobilization, 3.6% developed PE in the IVC group vs. 13.1% in a group of matched controls25–27. These reports were retrospective and were not controlled for modern chemical anticoagulation. More recently, in trauma patients with contraindication to anticoagulation, the placement of IVC filters significantly reduced the risk of symptomatic PE after injury from 14.7% to 0%28.

In deciding whether to employ a filter, surgeons must also consider the risks associated with the placement of IVC filters. Filter migration, puncture site, hematoma, have been reported29–32. In addition, IVC filters are associated with increased risk of long-term complications such as post-thrombotic syndrome. Historically the rate of complication associated with IVC filter placement has been estimated at 12%, with up to 20% of IVC filters unable to be removed.2 These risks, however, are decreasing as technology and technique are improving, with recent cohorts demonstrating much lower complication rates with filter retrieval24,33,34. Technological advances and systematic improvements in monitoring and an increased rate of planned removal have lowered, but not eliminated the risks of filter placement. Filters may be unable to be removed for various reasons including a clot load distal to the filter as well as technical difficulties.

Data is less supportive regarding the utility of IVC filters in patients also receiving pharmacologic anticoagulation. Most studies demonstrating reduced PE risk have included patients also receiving medical anticoagulation, but these standards have also changed over time. Most recently, the Prevention of Recurrent Pulmonary Embolism by Vena Cava Interruption (PREPIC) – 2 trial was unable to demonstrate decreased PE risk after IVC filter placement in patients admitted with VTE who received chemical anticoagulation30,31.

In summary, IVC filters have been shown to decrease rate of PE in patients at high risk of VTE undergoing orthopaedic surgery who cannot tolerate anticoagulation. Placement and retrieval of IVC filter is associated with some risks bordering on 10% with inability to remove the filter being the highest risk. IVC filter placement should not be used routinely for VTE prophylaxis, particularly in patients who can receive VTE prophylaxis within 24 – 48 hours. The use of IVC filters should be limited to patients who either have a known VTE or are high risk for clot formation and cannot receive prophylaxis. The use of IVC should also be considered in patients who developed VTE despite being on chemical anticoagulation.

References:

1.        Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e278S-e325S. doi:10.1378/chest.11-2404

2.        Bass AR, Mattern CJ, Voos JE, Peterson MG, Trost DW. Inferior vena cava filter placement in orthopedic surgery. Am J Orthop (Belle Mead NJ). 2010;39(9):435-439.

3.        Lieberman JR, Hsu WK. Prevention of venous thromboembolic disease after total hip and knee arthroplasty. J Bone Jt Surg Am. 2005;87(9):2097-2112. doi:10.2106/jbjs.d.03033

4.        Lieberman JR, Pensak MJ. Prevention of venous thromboembolic disease after total hip and knee arthroplasty. J Bone Jt Surg Am. 2013;95(19):1801-1811. doi:10.2106/jbjs.l.01328

5.        Sahni A, Lem V. Inferior vena cava filters: a concise review. Hosp Pr. 2011;39(3):71-78. doi:10.3810/hp.2011.08.582

6.        Haas SB, Barrack RL, Westrich G, Lachiewicz PF. Venous thromboembolic disease after total hip and knee arthroplasty. J Bone Jt Surg Am. 2008;90(12):2764-2780.

7.        Ploumis A, Ponnappan RK, Bessey JT, Patel R, Vaccaro AR. Thromboprophylaxis in spinal trauma surgery: consensus among spine trauma surgeons. Spine J. 2009;9(7):530-536. doi:10.1016/j.spinee.2009.01.008

8.        Xiao S, Geng X, Zhao J, Fu L. Risk factors for potential pulmonary embolism in the patients with deep venous thrombosis: a retrospective study. Eur J Trauma Emerg Surg. 2020;46(2):419-424. doi:10.1007/s00068-018-1039-z

9.        Lieberman JR, Bell JA. Venous Thromboembolic Prophylaxis After Total Hip and Knee Arthroplasty. J Bone Jt Surg Am. 2021. doi:10.2106/jbjs.20.02250

10.      Bohl DD, Maltenfort MG, Huang R, Parvizi J, Lieberman JR, Della Valle CJ. Development and Validation of a Risk Stratification System for Pulmonary Embolism After Elective Primary Total Joint Arthroplasty. J Arthroplast. 2016;31(9 Suppl):187-191. doi:10.1016/j.arth.2016.02.080

11.      Parvizi J, Smith EB, Pulido L, et al. The rise in the incidence of pulmonary embolus after joint arthroplasty: is modern imaging to blame? Clin Orthop Relat Res. 2007;463:107-113. doi:10.1097/BLO.0b013e318145af41

12.      Raphael IJ, McKenzie JC, Zmistowski B, Brown DB, Parvizi J, Austin MS. Pulmonary embolism after total joint arthroplasty: cost and effectiveness of four treatment modalities. J Arthroplast. 2014;29(5):933-937. doi:10.1016/j.arth.2013.09.033

13.      Mont MA, Jacobs JJ, Boggio LN, et al. Preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Am Acad Orthop Surg. 2011;19(12):768-776. doi:10.5435/00124635-201112000-00007

14.      Lex JR, Evans S, Cool P, et al. Venous thromboembolism in orthopaedic oncology. Bone Jt J. 2020;102-b(12):1743-1751. doi:10.1302/0301-620x.102b12.bjj-2019-1136.r3

15.      Della Valle CJ, Steiger DJ, Di Cesare PE. Thromboembolism after hip and knee arthroplasty: diagnosis and treatment. J Am Acad Orthop Surg. 1998;6(6):327-336. doi:10.5435/00124635-199811000-00001

16.      Berber O, Vasireddy A, Nzeako O, Tavakkolizadeh A. The high-risk polytrauma patient and inferior vena cava filter use. Injury. 2017;48(7):1400-1404. doi:10.1016/j.injury.2017.04.038

17.      Akeda K, Matsunaga H, Imanishi T, et al. Prevalence and countermeasures for venous thromboembolic diseases associated with spinal surgery: a follow-up study of an institutional protocol in 209 patients. Spine (Phila Pa 1976). 2014;39(10):791-797. doi:10.1097/brs.0000000000000295

18.      Schizas C, Neumayer F, Kosmopoulos V. Incidence and management of pulmonary embolism following spinal surgery occurring while under chemical thromboprophylaxis. Eur Spine J. 2008;17(7):970-974. doi:10.1007/s00586-008-0668-z

19.      Sabharwal S, Zhao C, McClemens E, Kaufmann A. Pediatric orthopaedic patients presenting to a university emergency department after visiting another emergency department: Demographics and health insurance status. J Pediatr Orthop. 2007. doi:10.1097/BPO.0b013e3181425653

20.      Rockson HB, DiPaola CP, Connolly PJ, Stauff MP. Venous Thromboembolism Prophylaxis for Patients Having Elective Spine Surgery: When, Why, and How Much. J Bone Jt Surg Am. 2019;101(13):1220-1229. doi:10.2106/jbjs.18.00849

21.      Khatod M, Inacio MC, Bini SA, Paxton EW. Prophylaxis against pulmonary embolism in patients undergoing total hip arthroplasty. J Bone Jt Surg Am. 2011;93(19):1767-1772. doi:10.2106/jbjs.j.01130

22.      Forsythe RM, Peitzman AB, DeCato T, et al. Early lower extremity fracture fixation and the risk of early pulmonary embolus: filter before fixation? J Trauma. 2011;70(6):1381-1388. doi:10.1097/TA.0b013e318215b928

23.      Agarwal S, Rana A, Gupta G, Raghav D, Sharma RK. Total Knee Arthroplasty in a Diagnosed Case of Deep Vein Thrombosis – Our Experience and Review of Literature. J Orthop Case Rep. 2017;7(1):16-19. doi:10.13107/jocr.2250-0685.668

24.      Ahmed O, Kim YJ, Patel M V, Luu HH, Scott B, Cohen K. Efficacy and Safety of Mechanical IVC Filtration for Preventing Pulmonary Embolism in High-Risk Orthopedic Patients Undergoing Total Hip or Knee Arthroplasty. J Arthroplast. 2021;36(7):2586-2590. doi:10.1016/j.arth.2021.02.042

25.      Rosner MK, Kuklo TR, Tawk R, Moquin R, Ondra SL. Prophylactic placement of an inferior vena cava filter in high-risk patients undergoing spinal reconstruction. Neurosurg Focus. 2004;17(4):E6. doi:10.3171/foc.2004.17.4.6

26.      McClendon  Jr. J, Oʼshaughnessy BA, Smith TR, et al. Comprehensive assessment of prophylactic preoperative inferior vena cava filters for major spinal reconstruction in adults. Spine (Phila Pa 1976). 2012;37(13):1122-1129. doi:10.1097/BRS.0b013e31824abde2

27.      McClendon  Jr. J, Smith TR, O’Shaughnessy BA, Sugrue PA, Thompson SE, Koski TR. Time to Event Analysis for the Development of Venous Thromboembolism After Spinal Fusion ≥ 5 Levels. World Neurosurg. 2015;84(3):826-833. doi:10.1016/j.wneu.2015.03.068

28.      Ho KM, Rao S, Honeybul S, et al. A Multicenter Trial of Vena Cava Filters in Severely Injured Patients. N Engl J Med. 2019;381(4):328-337. doi:10.1056/nejmoa1806515

29.      Strauss EJ, Egol KA, Alaia M, Hansen D, Bashar M, Steiger D. The use of retrievable inferior vena cava filters in orthopaedic patients. J Bone Jt Surg Br. 2008;90(5):662-667. doi:10.1302/0301-620x.90b5.19743

30.      Partovi S, Davidson JC, Patel IJ. Implications and limitations of the PREPIC2 study-the interventionist’s perspective. Cardiovasc Diagn Ther. 2016;6(3):259-261. doi:10.21037/cdt.2016.01.03

31.      Mismetti P, Laporte S, Pellerin O, et al. Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism: a randomized clinical trial. Jama. 2015;313(16):1627-1635. doi:10.1001/jama.2015.3780

32.      Slullitel PAI, Díaz Dilernia F, Stagnaro J, et al. Are there any risk factors for developing complications with the use of retrievable vena cava filters in orthopaedic surgery? Rev Fac Cien Med Univ Nac Cordoba. 2018;75(2):119-127. doi:10.31053/1853.0605.v75.n2.17746

33.      Pan Y, Zhao J, Mei J, Shao M, Zhang J, Wu H. Evaluation of nonpermanent inferior vena cava filter placement in patients with deep venous thrombosis after lower extremity fracture: A single-center retrospective study. Phlebology. 2016;31(8):564-572. doi:10.1177/0268355515597632

34.      Power JR, Nakazawa KR, Vouyouka AG, Faries PL, Egorova NN. Trends in vena cava filter insertions and “prophylactic” use. J Vasc Surg Venous Lymphat Disord. 2018;6(5):592-598.e6. doi:10.1016/j.jvsv.2018.01.018

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