How did the treatment of deep venous thrombosis (DVT) and pulmonary embolism (PE) evolve to include use of inferior vena cava (IVC) filters?

Updated: Oct 31, 2020
  • Author: Gary P Siskin, MD; Chief Editor: Kyung J Cho, MD, FACR, FSIR  more...
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Answer

Deep venous thrombosis (DVT) and pulmonary embolism (PE) represent two points on the continuum of a single disease process. The reported annual incidence of DVT in the United States includes a wide range (250,000-20,000,000 cases of lower-extremity DTV involving treatment or hospitalization), and the disease constitutes a major healthcare burden.

Most commonly, DVT develops within the deep veins of the lower extremities, but it can also involve, or arise solely from, the veins of the pelvis or the upper extremities. The most feared complication of DVT is PE. PE frequently results in hospitalization, and it is associated with high morbidity and mortality rates. Currently, PE is the third leading acute cardiovascular cause of death in the United States. Death is associated with serious underlying disease in approximately 50% of patients with PE.

Systemic anticoagulation with intravenous heparin followed by oral warfarin remains the mainstay of treatment for DVT and for prevention of PE. However, studies have shown that as many as 33% of patients develop a second PE while receiving adequate anticoagulation therapy.

In addition, anticoagulation therapy is associated with hemorrhage, which precludes its use in certain groups of high-risk patients, including patients at high risk for falling, hemorrhagic stroke, central nervous system (CNS) metastasis, or bleeding diathesis. Although heparin can be used during pregnancy, warfarin crosses the placenta and has been shown to have significant adverse effects on the developing fetus.

The concept of interrupting the flow in the inferior vena cava (IVC) to prevent PE originated in the 1930s-1940s with the performance of ligation of the common femoral vein and superficial femoral vein. These methods were used in parallel with anticoagulation methods when heparin and warfarin became available in 1935 and 1948, respectively. Phlebotomy with clot removal was also performed if thrombus was present at the common femoral vein level. A high incidence of limb edema was associated with femoral vein ligation.

Later, ligation of the IVC was performed, initially in patients harboring thrombi above the superficial femoral veins. Eventually, it replaced lower-level venous ligation. The operative mortality rate of 2-15% was not significantly different from that for femoral vein ligation, but a lower rate for recurrent PE was reported. The optimal level of ligation was located immediately below the renal veins to prevent thrombosis caused by venous stasis between the interrupted IVC and the renal veins. However, 10-16% of these patients had immediate lower-extremity swelling.

In the 1960s, various methods of partially interrupting the flow in the IVC were developed to lessen the effect of venous stasis. The procedures provided emboli trapping with preservation of blood flow through the lumen. The procedures included suture plication and the use of caval clips (Moretz clip, Miles clip, Adams-DeWeese clip). The rates for operative mortality and recurrent PE were similar to those for caval ligation, yet the rate for limb edema was reduced. Despite the fact that these procedures partially interrupted flow in the IVC, caval occlusion rates of 30-40% were reported.

In 1967, the Mobin-Uddin umbrella filter (see Design Features) was developed as a replacement for surgical ligation, caval plication, and caval clips, as well as partially to interrupt the flow in the IVC and to prevent PE. Since then, several filters have been introduced. Currently, filters represent the standard of care when partial interruption of IVC flow is indicated to prevent the occurrence of PE.


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