SAN DIEGO – In the hands of experienced vascular surgeons, the use of retrievable inferior vena cava filters was less common than with other specialists, except in trauma or bariatric cases, and superior vena cava filter placement was very rare.
Those are two key findings from what is believed to be the first survey to questions vascular surgeons about vena cava filter (VCF) placement safety and practice patterns.
Dr. Mark Friedell
"VCF use has skyrocketed over the past 20 years with percutaneous insertion, low-profile retrievable devices, relative and prophylactic indications, and other interventionalists now placing filters," Dr. Mark Friedell said at the annual meeting of the American Venous Forum.
However, in August 2010 the Food and Drug Administration released a communication indicating that it had received 921 reports of adverse events with inferior vena cava (IVC) filters since 2005. The communication, which went out to implanting physicians and clinicians responsible for the ongoing care of patients with IVC filters, recommended that patients be referred for removal of retrievable filters when feasible and clinically indicated.
Dr. Friedell, director of surgical education for Orlando Health, and his associate, Dr. Peter Nelson, assistant professor of vascular surgery at the University of Florida, Gainesville, sent a 17-question survey about VCF practices to all 276 members of the Southern Association for Vascular Surgery, an organization composed exclusively of board-certified vascular surgeons. Of the 276 members, 126 responded, for a response rate of 46%.
When asked about the IVC, respondents cited the Greenfield filter as their preferred permanent device (31%), followed by a variety of retrievable devices. Half of the respondents said that they rarely placed retrievable filters, 26% said that they placed them selectively, and 24% said that they usually placed them. They cited the Bard as their preferred retrievable filter (45%).
Despite the fact that 52% and 46% of respondents placed vena cava filters in trauma and bariatric patients, respectively, filters were placed for prophylactic indications less than 50% of the time by 63% of respondents.
When asked how often they removed retrievable filters, 64% estimated that they did so less than 25% of the time and 78% estimated that they did so less than 50% of the time.
There were few major complications, including one case of atrial perforation and one case of migration to the heart. There were also 12 cases of IVC thrombosis (4 with TrapEase filters); 3 cases of strut emboli (all Bard filters), and 9 cases of severe tilting (eight Bard filters).
"Experienced vascular surgeons appear more conservative with filter use in the management of venous thromboembolism than other specialists, because there are fewer retrievable and more permanent filters placed, fewer prophylactic filters except in trauma and bariatrics, and probably fewer filters placed altogether," Dr. Friedell said. "The interest in retrievable filters reflects a preference for a low-profile, potentially removable device. However, retrievable filter removal is uncommon, both in the literature and in the [Southern Association for Vascular Surgery] experience."
Until more experience is accrued with retrievable devices – particularly since the removal rate is low – he said that "they should not be used as permanent filters, and they should be removed as soon as possible. Ideally, filters should be placed by those who can provide complete care to the VTE patient, including the management of anticoagulation."
Dr. Friedell said that he had no relevant financial disclosures.