Abstract
Background
The use of both temporary and permanent inferior vena cava (IVC) filters continues to rise yet randomized data regarding efficacy and complication rates are limited, especially in cancer patients. Temporary IVC filters are associated with higher costs and can have more long-term complications than permanent IVC filters. In this study, we examined the use of temporary and permanent IVC filters in the cancer population, a group at high risk for venous thromboembolism (VTE) as well as complications of anticoagulation.
Methods
This single-institution study included patients with active malignancy receiving adjuvant chemotherapy or considered for future chemotherapy that received an interventional radiology (IR) placed temporary (N=179) or permanent (N=207) IVC filter from 2009 to 2013. Patients were followed prospectively from the time of filter placement. The database included patient demographics, type of malignancy, indication for filter placement, time to filter retrieval, complications of placement/retrieval, rates of VTE recurrence and cause of death (if applicable).
Results
Patient demographic information is shown in Table 1. The most common reasons cited for filter placement included a contraindication to anticoagulation from bleeding (36%), recent or upcoming procedure (19%), thrombocytopenia (17%), and surgical prophylaxis (8%). 21% of filters were placed in patients with no contraindication to anticoagulation or failure of anticoagulation. Of these, 35% of the temporary filters were not removed. IVC filters were most frequently placed in patients with underlying hematologic malignancies (22%), gastrointestinal malignancies (22%) and lung cancer (16%). The majority of patients had stage III or IV cancer (62%).
Of the 179 temporary filters placed, 60% were not retrieved. The most common reasons for failure of filter retrieval included: progressive disease/clinical deterioration (51%), continued contraindication to anticoagulation (23%) and loss of follow-up (8%). Only 2% of filters could not be removed because of mechanical reasons. Of the 81 attempted filter removals, 5 had in-filter thrombus, 4 had surrounding fibrin sheaths, 4 had filter tilt, 1 had IVC in-growth, 1 had broken struts and 1 had a procedure-related infection.
The rate of recurrent VTE in all patients studied was 23% (21% in temporary filter group, 24% in permanent filter group), including 20 pulmonary emboli (PE) and 14 thromboses within the IVC filter. The majority of recurrences occurred off of anticoagulation (58%). Only 34% could be maintained on therapeutic anticoagulation. By study end, 72% of patients had died, most commonly due to progressive cancer. Median time from filter placement to death was 2.9 months (range: 0.1-64.7 months). Seventy-five patients (19%) died within 30 days of filter placement. They were more likely to have stage IV disease (78% vs. 54%). Of these 75 patients, three experienced recurrent VTE, two with lower extremity DVTs and one with an IVC thrombus. Data on filter costs were also collected. Costs were attributable to the placement and retrieval procedures when applicable ($10,983.00 and $8,824.00, respectively) as well as the device itself ($1,576.00).
Conclusions
Malignancy-associated thrombosis is common and associated with a high rate of recurrence. While most recurrent VTE after IVC filter placement were deep vein thromboses, a relatively large number of PE's occurred after filter placement as well. A significant number of patients with malignancy-associated thrombosis who underwent IVC filter placement had no contraindication to anticoagulation or recurrent VTE while on anticoagulation. Better prospective studies are needed to assess the safety and efficacy of IVC filters in the setting of hemodynamic compromise, extensive clot burden or for surgical prophylaxis, especially in the oncology population. In this cohort, the majority of filters were placed in patients with advanced cancer with likely short life expectancies, suggesting the patient selection for filter placement could be optimized. Finally, the cost of filter placement and retrieval is substantial, further emphasizing the need for better prospective data to identify the subset of patients who will derive the most benefit from filter use.
Disclosures
Stein: Incyte Corporation: Membership on an entity's Board of Directors or advisory committees, Research Funding. Lewandowski:Cook Medical: Consultancy; Boston Scientific: Membership on an entity's Board of Directors or advisory committees.
A New Catheter Technique to Correct Severe IVC Filter Tilt during Placement
