A recent national cohort study of Medicare beneficiaries with pulmonary embolism (PE) as their principal discharge diagnosis found that placement of inferior vena cava filters (IVCFs) rose significantly from 1999 to 2010 — from 19.0 to 32.5 per 100,000 beneficiary-years.
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As most of the IVCFs placed today are retrievable, the authors suggested that availability of retrievable filters might have made IVCFs “more palatable” to referring physicians and thus contributed to their growing use.
At the same time, no mortality benefit for IVCFs has been established in randomized trials, and the new cohort study found that mortality associated with PE hospitalization declined over the study period regardless of whether patients had an IVCF placed. However, many leading institutions, including Cleveland Clinic, continue to implant the filters.
“Most of us feel there is a benefit,” says John R. Bartholomew, MD, Section Head of Vascular Medicine at Cleveland Clinic.
The IVCF trade-off
An IVCF can be a lifesaver for the patient who cannot be anticoagulated due to contraindications or who has experienced recurrent deep vein thrombosis or PE despite adequate anticoagulation.
But these benefits must be balanced against IVCFs’ rare but potential risks, which include device migration, embolization, perforation and filter fracture. Potential complications from filter placement include hematoma, pneumothorax and placement in the wrong vessel.
The coordination conundrum
In 2010 and again in 2014, the FDA expressed concern that IVCFs, which are intended for short-term use, were not always being removed after the risk of blood clots had been resolved. According to Dr. Bartholomew, the problem persists and may contribute to unnecessary complications.
“Someone needs to decide whether the filter should come out — and, if so, when,” he says. “Anticoagulation is usually stopped after three months in most patients with unprovoked clots. Unfortunately, follow-up of patients with filters is often poor, because the physician who put in the filter may not still be taking care of the patient, and coordination of care is lost.”
One solution: A dedicated clinic
Cleveland Clinic has taken a proactive approach to protect these patients by establishing an IVC Filter Retrieval Clinic.
A nurse calls every patient who has received an IVCF through Cleveland Clinic’s Miller Family Heart & Vascular Institute and requests that they make an appointment to be evaluated by a vascular medicine physician to determine whether the filter may be removed or should be left in place. Patients with filters implanted at other institutions are welcome as well.
“Some patients need the filter permanently, and some filters cannot be retrieved because they have become embedded,” Dr. Bartholomew notes. “But if the patient can be fully anticoagulated and the filter is no longer needed, it should come out.”
No substitute for planning
As a physician who recommends IVCFs but does not implant the filters himself, Dr. Bartholomew understands how easy it is for patients to get lost to follow-up. But he says it’s incumbent on physicians to ensure that appropriate follow-up occurs. This may mean sending a reminder to the patient’s personal physician or scheduling a follow-up appointment on the day the filter is implanted.
“All patients with retrievable IVCFs should be evaluated for filter removal,” he says. “At the time the filter is being put in, the doctor should make sure the patient has a structured follow-up in two or three months and a plan for when the filter should be removed.”