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Greenfield filter; umbrella; inferior vena cava filter; IVC filter

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] 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) 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] 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 - ventricular tachycardia - cardiac tamponade - sudden death - 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: - IVC filters can be safely retrieved in > 99% of patients at specialized centers [12] - among patients who survive to retrieval, 94% of retrievals are successful, & complications of retrieval are rare (4%) [13]

References

  1. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 778
  2. 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 PMID: 20696949 http://archinte.ama-assn.org/cgi/content/full/2010.316
  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: 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: 24613334 https://content.onlinejacc.org/article.aspx?articleid=1841471
  4. 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: 25919526
  5. Medical Knowledge Self Assessment Program (MKSAP) 17, 18, 19. American College of Physicians, Philadelphia 2015, 2018, 2022
  6. 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 PMID: 29641958 http://www.nejm.org/doi/full/10.1056/NEJMicm1710700
  7. 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. 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: 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: 30535318 https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2717952
  9. 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: 31259488 https://www.nejm.org/doi/10.1056/NEJMoa1806515
  10. 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: 32650924 https://www.ajconline.org/article/S0002-9149(20)30459-8/fulltext
  11. 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: 32919823 https://www.jvir.org/article/S1051-0443(20)30531-5/fulltext
  12. 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: 36169541 https://www.ajronline.org/doi/10.2214/AJR.22.28142
  13. Ferro EG, Mackel JB, Kramer RD et al. Postmarketing surveillance of inferior vena cava filters among US Medicare beneficiaries: The SAFE-IVC study. JAMA 2024 Nov 6; [e-pub]. PMID: 39504004 PMCID: PMC11541742 (available on 2025-05-06) https://jamanetwork.com/journals/jama/fullarticle/2825899