Greenfield filter; umbrella; inferior vena cava filter; IVC filter
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Introduction
Indication(s):
- high risk of pulmonary embolism in a patient with contraindication(s) to anticoagulation[5][11]
- may reduce rick of pulmonary emboli after major trauma if anticoagulation cannot be started within 7 days of injury[9]
- massive or submassive pulmonary emboli with hemodynamic compromise, especially if residual thrombus in a lower extremity[10]*
- other situations where benefit may exceed risk[11]
* no benefit over anticoagulation alone even for proximal DVT[4][5]
Clinical significance
- the effective span of a Greenfield filter is about 7-10 years due to development of collateral circulation around the filter
- these collaterals, however, will be smaller caliber vessels than the inferior vena cava & may themselves provide a filter of a sort
- decreased mortality from pulmonary embolism (1.7% vs 4.9%)[3]
- no significant effect on overall mortality[3]
Procedure
- umbrella device inserted into the inferior vena cava by means of a catheter introduced into the femoral vein
- once in place, the umbrella opens, providing a filter to prevent emboli originating in the large veins of the lower extremities (i.e. femoral vein) from lodging in the pulmonary vasculature (i.e. pulmonary embolism)
Complications
- pulmonary embolism occurs in 2.5% of patients despite placement of a Greenfield filter
- filter migration
- fracture & embolization of the filter itself
- to the heart
- embolization of struts[6] (CT images)
- inferior vena cava perforation[2]
- 10-fold risk of recurrent deep vein thrombosis (6.1% vs 1.6%)[3]
- 18% increased risk for mortality at 30 days vs no filter[7]
- increased risk for 30-day & 1-year mortality in elderly patients with pulmonary embolism vs no IVC filter (RR=1.5 at 1 year)[8]
Management
References
- ↑ Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 778
- ↑ 2.0 2.1 FDA MedWatch Inferior Vena Cava (IVC) Filters: Initial Communication: Risk of Adverse Events with Long Term Use http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm221707.htm
Nicholson W et al Prevalence of Fracture and Fragment Embolization of Bard Retrievable Vena Cava Filters and Clinical Implications Including Cardiac Perforation and Tamponade Arch Intern Med. Published online August 9, 2010 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/20696949 <Internet> http://archinte.ama-assn.org/cgi/content/full/2010.316 - ↑ 3.0 3.1 3.2 3.3 Muriel A et al Survival Effects of Inferior Vena Cava Filter in Patients with Acute Symptomatic Venous Thromboembolism and a Significant Bleeding Risk. J Am Coll Cardiol. Published online March 6, 2014 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24576432 https://content.onlinejacc.org/article.aspx?articleid=1841604
Morris T Do IVC Filters Prevent Death from Pulmonary Embolism? J Am Coll Cardiol. Published online March 6, 2014 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24613334 https://content.onlinejacc.org/article.aspx?articleid=1841471 - ↑ 4.0 4.1 Mismetti P 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 PMID: https://www.ncbi.nlm.nih.gov/pubmed/25919526
- ↑ 5.0 5.1 5.2 Medical Knowledge Self Assessment Program (MKSAP) 17, 18, 19. American College of Physicians, Philadelphia 2015, 2018, 2022
- ↑ 6.0 6.1 Flannery LD, Shabani N (CT images) Embolization of Struts from an Inferior Vena Cava Filter. N Engl J Med 2018; 378:e21. April 12, 2018 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29641958 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMicm1710700
- ↑ 7.0 7.1 Turner TE, Saeed MJ, Novak E et al Association of Inferior Vena Cava Filter Placement for Venous Thromboembolic Disease and a Contraindication to Anticoagulation With 30-Day Mortality. JAMA Network Open. 2018;1(3):e180452 Not indexed in PubMed https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2687385
Secemsky EA, Carroll BJ, Yeh RW. Inferior Vena Cava Filters and Mortality. Is It the Underlying Process, the Patient, or the Device? JAMA Network Open. 2018;1(3):e180453 Not indexed in PubMed https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2687383 - ↑ 8.0 8.1 Bikdeli B, Wang Y, Minges KE et al Vena Caval Filter Utilization and Outcomes in Pulmonary Embolism: Medicare Hospitalizations From 1999 to 2010. J Am Coll Cardiol. 2016 Mar 8;67(9):1027-35. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26940921
Bikdeli B, Wang Y, Jimenez D et al. Association of inferior vena cava filter use with mortality rates in older adults with acute pulmonary embolism. JAMA Intern Med 2018 Dec 10; PMID: https://www.ncbi.nlm.nih.gov/pubmed/30535318 https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2717952 - ↑ 9.0 9.1 Ho KM, Rao S, Honeybul S et al. A multicenter trial of vena cava filters in severely injured patients. N Engl J Med 2019 Jul 25; 381:328. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31259488 https://www.nejm.org/doi/10.1056/NEJMoa1806515
- ↑ 10.0 10.1 Ahmed O et al. Meta-analysis of the usefulness of inferior vena cava filters in massive and submassive pulmonary embolism. Am J Cardiol 2020 Aug 1; 128:54 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32650924 https://www.ajconline.org/article/S0002-9149(20)30459-8/fulltext
- ↑ 11.0 11.1 11.2 Kaufman JA et al. Society of Interventional Radiology clinical practice guideline for inferior vena cava filters in the treatment of patients with venous thromboembolic disease. J Vasc Interv Radiol 2020 Oct; 31:1529. PMID: https://www.ncbi.nlm.nih.gov/pubmed/32919823 https://www.jvir.org/article/S1051-0443(20)30531-5/fulltext
- ↑ 12.0 12.1 Leong S et al. Complex inferior vena cava filter retrievals: Success rate and predictors of adverse events at a large specialized referral center. AJR Am J Roentgenol 2023 Mar; 220:389. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36169541 https://www.ajronline.org/doi/10.2214/AJR.22.28142