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:
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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
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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