when do you use ivc filters? - new cardiovascular … a3/1630 wang/when...when do you use ivc...
TRANSCRIPT
When do you use IVC
filters?
Jeffrey Wang MD
Horizon Vascular Specialists
Director of Vascular Research
Shady Grove Adventist Hospital
DVT and PE
DVT in the U.S.: • Symptomatic PE is the most important acute
complication of DVT
– 600,000 new DVT cases a year
– Responsible for 200,000 deaths (more than combined deaths from AIDS and breast cancer)
– Leading cause of preventable in-hospital mortality
• Diagnosis is confirmed in only 20-30% of ER patients with clinically suspected DVT
Sources:
• Society of Vascular Surgeons website, www.vascularweb.org, 1-6-06
• Schreiber, D. Deep venous thrombosis and thrombophlebitis.
www.emedicine.com/emerg/topic122.htm, last updated October 2005.
2414-001 9/11 Slide #
2
Symptoms
• Dyspnea 78%
• Pleuritic chest pain 59%
• Cough 43%
• Leg pain 27%
• Hemoptysis 16%
• Palpitations 13%
• Wheezing 14%
• Angina like pain 6%
Signs
Tachypnea (20/min) 73%
Crackles 55%
Tachycardia (>100/min) 30%
Leg swelling 31%
Loud P2 23%
DVT 15%
Wheezes 11%
Diaphoresis 10%
Temperature (≥38.5°) 7%
Pleural rub 4%
Fourth heart sound 24%
Third heart sound 5%
Cyanosis 3%
Homans' sign 3%
Anticogaulation
• First line treatment of DVT and PE is
antigoagulation
• IVC interruption is an option if
anticoagulation is not possible
History
• 1893 Bottini-Ligates IVC
• 1959 Moretz- External clip of IVC
• 1973 Greenfield 1st IVC filter
Vena Cava Filter Indications
• Deep Venous Thrombosis and or
Pulmonary embolism
• Significant risk for falling
• Pt not able to tolerate anticoagulation
• Pt unable to tolerate additional PE
• New DVT or PE while on therapeutic
anticoagulation
Clinical Scenarios
• 84 yo female s/p right hip pining 1 wk
ago presents with right poplitial DVT
• 65 yo male with bilateral PE in ICU on
ventilator on pressors. O2 Sat 85%
• 68 yo female with GI Bleed and Left
Femoral DVT
• 72 yo male with atrial fibrillation on
therapeutic anticoagulation. Develops
a new right popliteal DVT. INR is 2.5
Some Other Controversial Indications
• BMI > 55 undergoing gastric bypass – There is data to suggest that prophylactic
filters reduce the amount of PEs
• Prior history of PE undergoing major orthopedic surgery – No evidence that once anticoagulation
treatment has been completed that there is additional benefit
• Oncologic Disorder with thromboembolic event – Effective in preventing PE but doesn’t seem
to convey a survival benefit
Some Other Controversial Indications
• Trauma and paraplegia or
quadriplegia
– There is a reduction in fatal PE, but higher
rate of recurrent DVT
– EAST recommends prophylactic filter in
high risk trauma patients
– ACCP does not recommend prophylactic
filters in the same group
• Hypercoagulable state
– Not appropriate for prophylaxisis
List of available IVC filters
Retrievable
• Celect (Cook)
• Gunther Tulip (Cook)
• Denali(Bard)
• Optease(Cordis)
• ALN (ALN)
• SafeFlo (Rafael)
• Option (Rex)
• Crux (Crux)
Permanent
• Simon Nitinol (Bard)
• Vena Tech (Braun)
• Vena Tech LP (Braun)
• Greenfield (BSCI)
• Trapease (Cordis)
• Bird’s Nest (Cook)