Recurrent Pulmonary Emboli With IVC Filter Placement

Question

What is the best course of treatment for a patient with recent pulmonary embolus (PE) and gastrointestinal (GI) bleeding (resulting from anticoagulation) who has a recurrent PE despite recent inferior vena cava (IVC) filter placement?

Magdalene Szuszkiewicz, MD

Response from Gerald W. Smetana, MD

The patient with both recent bleeding and thrombotic events poses a great challenge to clinicians. The rationale for an IVC filter is that it would potentially reduce the risk of morbid or fatal pulmonary embolus without exposing a patient at risk for bleeding complications to anticoagulation. Common clinical scenarios in which this might be appropriate include recent GI or brain metastases in a patient with cancer. However, few data exist in the literature regarding the efficacy of this approach. So, it is difficult to know how commonly the scenario in this patient occurs: recurrent pulmonary embolism shortly after IVC filter placement.

In a study of 400 patients with proximal deep vein thrombosis (DVT), investigators randomly assigned patients to IVC filter or no filter.^[1] In addition, all patients received either unfractionated heparin or low-molecular-weight heparin (in this regard, they differed from the patient in this question). Although more pulmonary emboli occurred at 12 days in the no-IVC group (4.8% vs 1.1%), there were no significant differences in rates of mortality or pulmonary emboli at 2 years. There were, however, significantly more recurrent DVTs in the IVC filter group at 2 years (20.8% vs 11.6%). This study suggests a low risk of recurrent PE even among patients who were anticoagulated simultaneously. It is likely that recurrent PE rates would be higher among patients such as those in this question who were not anticoagulated due to a contraindication. Clinical lore suggests that recurrent PE is more likely the longer a patient has an IVC filter, due to the development of collateral veins in the abdomen that allow a clot to bypass the filter.

In this patient, an early failure of the IVC filter with a recurrent PE suggests the possibility that the filter was not placed correctly (technical failure), or that the source of recurrent embolism was from an upper-extremity thrombosis. If reevaluation of the filter suggests that it has migrated or was not placed correctly, I would reconsult interventional radiology to see whether the placement could be optimized.

No low-risk options exist for this patient. I would reassess the risk of recurrent bleeding. If the GI bleed was from a self-limited etiology that has been treated effectively, such as an arteriovenous malformation that was cauterized, I would favor resumption of full-dose anticoagulation as the risk of recurrent PE and death would likely be greater than the risk of recurrent bleeding. If the patient has an active GI bleed for which endoscopic treatments are not available, I would consider angiographic or surgical treatment of the bleeding source to allow future anticoagulation. The degree to which one should consider such aggressive approaches would, of course, depend on the comorbidities and overall life expectancy of the patient.

Cite this: Gerald W Smetana. Recurrent Pulmonary Emboli With IVC Filter Placement - Medscape - Jun 22, 2004.

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