Samuel Z. Goldhaber, MD

Disclosures

November 30, 2016

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Hello. This is Dr Sam Goldhaber from Brigham and Women's Hospital and Harvard Medical School, speaking for the Clot Blog at theheart.org on Medscape. I'm talking to you from the European Society of Cardiology meeting in Rome.

Today I'm going to speak about the use of inferior vena cava (IVC) filters in the management of pulmonary embolism and deep vein thrombosis (DVT).[1] IVC filters have a long history of waxing and waning popularity. I think, at the moment, the use of IVC filters is at an all-time low in terms of its popularity. Healthcare providers are shunning the use of IVC filters, but I'd like to use this Clot Blog to put IVC filter use in perspective.

First of all, no more than 1000 patients have ever been studied in randomized controlled trials of vena cava filters. This is a big problem if we want to model our practices using evidence-based medicine. We have to then rely on registries of patients, but the registries and the randomized trials are quite limited.

The two randomized trials, both called PREPIC [Prévention du Risque d'Embolie Pulmonaire par Interruption Cave],[2,3,4] studied patients and randomized them to IVC filters vs no IVC filters, in a population where many of us would not insert an IVC filter. In these randomized controlled trials, all of the patients were eligible for full-dose anticoagulation. That's clearly not the group of patients that we're focusing on when we're considering placing a vena cava filter.

Let me start [by stating] the general consensus recommendations.[5,6] If a patient is having active major bleeding and has a pulmonary embolism or a DVT, that is a consensus recommendation for placing a vena cava filter. And if a patient has been on full-dose anticoagulation and suffers a new DVT or a new pulmonary embolism despite full-dose anticoagulation, that is also recognized as an indication for a vena cava filter even today—even with filters at a low point in their popularity.

I do want to point out some other areas where I think vena cava filters play a role. Certainly, there is very suggestive observational evidence in patients with massive pulmonary embolism that filters might help improve their survival. This requires further study. This observation may also apply to patients with large, dangerous submassive pulmonary embolism both with moderate or severe right ventricular dysfunction and an elevation of the cardiac biomarker, troponin, indicating right ventricular microinfarction.

I also think that patients who undergo open surgical pulmonary embolectomy should have vena cava filters inserted because they've been at death's door and can't afford the risk of suffering another pulmonary embolism, and they cannot be fully anticoagulated in the early postoperative stage. I think the most controversial area is those patients who are at high risk for bleeding and at high risk for clotting—they're often cancer patients; they should be considered under certain circumstances for placement of at least a retrievable IVC filter—for example, particularly if they're undergoing cancer chemotherapy, which in itself is a potent risk factor for pulmonary embolism and DVT.

So, in summary, the use of vena cava filters has fallen in popularity; filters are getting a bad street name. I think this is a bit unfair, and we have to come back to a more balanced approach. We now almost always insert a retrievable IVC filter, so we should consider filters for patients who might need protection for several months and then have the filter retrieved. We should give special thought and consideration to inserting filters in patients with massive pulmonary embolism, particularly if they are not going to undergo thrombolytic therapy; and also in patients who undergo open surgical pulmonary embolectomy, so they can have the filter in place during the postoperative period, when they cannot immediately be fully anticoagulated. And we should think of high-risk cancer patients and high-risk surgical patients, who have a great potential for developing venous thromboembolism yet who are at extraordinarily high bleeding risk, for placement of at least a retrievable vena cava filter.

This is Dr Sam Goldhaber, signing off for the Clot Blog.

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